Is hospital-to-GP our most important HIE use case?

What single element of our highly fragmented healthcare system, if fixed, might deliver the greatest short-term return for providers, patients and system economics overall?

---

You think you’ve heard a lot of crazy things after 10 years reporting on digital health and then you hear someone say something that completely throws your sense of understanding and balance about what is actually going on at the coalface.  

At last week’s Wild Health summit in Melbourne, a very senior hospital virtual ED doctor and administrator told a very senior and influential audience of system movers and shakers that even if her patient discharge summaries made it to their patient’s GP – this might happen if her patient gave her the right GP to enter into her Cerner EMR – the summary itself was formatted in such a way as to be confusing to just about anyone who got it.  

In fact, she wasn’t entirely clear, based on the summary construct, who it was being written to – the patient, the GP or someone else.  

She recently got the following complaint about one of her summaries: 

“I’m very confused, because your discharge summary says the doctor is Dr X, [this was the clinical director of the whole VED service] but then it says that you saw them [that was because she had signed bottom right because she was the doctor that actually saw the patient]. 

“And then it said the history of present illness, and that was great, but then it said information to patients. But was that to me or to the patient?” 

Our virtual ED doctor explained that she can’t change in any way the format of the discharge summary. It’s hardwired into the EMR.  

She then asked the audience: “Am I writing that to the patient so that they can see the data? Am I writing it to the GP so they can action the data? Am I writing it to the next specialist so they can see the data?” 

She pointed out that all this potential confusion was being dumped directly into the patient’s My Health Record, which probably wasn’t helping. She had earlier pointed out that she and most of her peers found the My Health Record confusing because of the format and nature of the data in it. She said that the information was definitely not designed for ED doctors to get a good idea quickly about a patient. 

“I just need a one-page summary, not 36 pages of last month’s individual pathology results.” 

Inadvertently or not, this high-level ED clinician laid bare for everyone in the room that what is probably our most important system nexus if we really intend to meaningfully pivot the system to managing chronic care properly in the community – that of communication between our hospitals and our GPs – is still a raging bin fire of occasional hits-but-mostly-misses, notwithstanding years of attempts at making it much better. 

“I think one thing that’s being lost in this is we’re writing lots of communication, but it’s having to be sent to multiple people. From a hospital standpoint, my question is, what do you want? What can I give you? And how can I give it to you in a way that matters?” 

It seems like a logical and important question from someone at the coalface who desperately wants to help. 

But who is going to facilitate this VED clinician’s desire for far more effective hospital to GP (and patient somehow) communication?  

I had initially thought: “Hang on, you’re in charge of most of this, can you really not make a dint in this problem?”  

Many reading this will recognise this ED clinician’s dilemma I suspect – no she can’t.  

It’s too complex and too big a problem that has for too long been sidelined in our use cases for system interoperability. 

This clinician isn’t the shy retiring type. She is particularly smart, resourceful and committed.  Admitting the problem in the way she did to the audience she did must have been the result of quite a bit of exasperation because in the state hospital system you don’t really wanting to be sticking your head up too far above the parapet. 

So who does fix this problem? 

The question opens the door to a world of fragmentation, technical complexity, politics and bureaucracy that currently competes vigorously to prevent what feels like is an obvious core system problem that should not be that hard to be solve.  

Let’s say that this ED clinician got the attention of the powers-that-be and they set in motion some process to get that discharge summary reformatted in this particular instance of Cerner in the manner she thought was much smarter.   

Would that help? 

Likely not. 

After all a big part of the problem here is the question: who am I writing this discharge summary to?  

Who is going to sort that out before you get to reformatting the EMR form?  

Do we need two forms, or more, going to different parties?  

How do they get there? 

And then, if you sort out the problem, in this instance, in Cerner, what about all the other instances in the state? What about all the other ones in the country? What about all the locations where Cerner isn’t used? 

And even if you cracked these problems, Victoria has over 70 hospital jurisdictions, all with some individual power to decide on processes like patient discharge formatting, depending on how they think they should do it in their network and region.  

And that’s just in Victoria. 

Is there another way around a seemingly wicked problem like this? 

How could we nationally simplify and make useful the vital communication that needs to be conducted between GPs, their patients and hospitals in a much more comprehensive, uniform and effective manner? 

Before we start, we have another problem. 

Some people think (or at least openly argue) that we are doing a pretty good job already with meaningful real-time communication between hospitals and GPs. 

At an international digital health meeting earlier this year in Australia someone cleverly put together a panel of about six of our state and territory e-health leaders.  

It was a great and informative panel and there is obviously a lot of interesting work being done, some of it aimed at the above problem, but most of it aimed at internal communication in the states between hospitals. 

Near the end of the session a frustrated ex-RACGP digital health expert committee rep stood up and took the panel to task for the parlous state of hospital discharge summaries and the level of effective communication between hospitals and GPs. 

The panel was polite but almost wholly political. Most asserted they were doing a pretty good job under the circumstances and a few quoted statewide initiatives specifically aimed at solving the problem which they thought were impressive. 

In NSW and some other states, the part of the system which deals with communicating between hospitals and GPs in real time is based on secure messaging between EMR systems in some hospitals in the state directly to local GPs.  

Secure messaging is a 1980s technology attempting to talk to 1990s server-bound GP management systems often with inaccurate directory data on GPs which, of course, is hard to keep up to date.  

The secure messaging point-to-point solution in most states is hit-and-miss at best. One problem is that even if the message does manage to make it to a particular GP practice, it doesn’t actually make it to the right GP in the practice for a variety of reasons. Or the GP doesn’t even know how to look for it or when to.  

The GP in the audience was unimpressed. He sensed he was being gaslit.  

He was. 

It’s arguable, however, that at least some of those on the panel were not aware they were doing it.  

They were all well-meaning, competent and committed technologists. Some probably believed their own rhetoric.  

But all live within the highly febrile political framework of state healthcare. That means that no matter where you are in the system, if you say or do something that the health minister doesn’t like, you can suddenly have the eye of Sauron on you. 

Hardly anyone speaks out from within the system in the states. You go down pretty far into the system and there is a generalised fear about what you say and how you present yourself.  

It’s not a good dynamic if you want system change. 

The fact that even those state health ministers understand that without much better communication and data sharing between hospitals and GPs, hospitals are likely to continue to experience severe overcrowding, ramping and dysfunction, and cost the state more than their state can possibly afford in building new tertiary capacity moving forward, does not trump the politics of state versus federal healthcare funding priorities. 

States are not funded to fix this problem and while we do see them occasionally tip their hat to it and suggest it’s important and they’re helping, substantively, they just aren’t. 

A big part of this dysfunctional dynamic comes down to state politicians using hospitals as a political chess pieces, especially near elections.  

Also, health secretaries and e-health heads don’t have a lot of room to move on effective whole-of-system reform because states quite simply aren’t in charge of the whole system. They just look after hospitals, and while they know they are all going to go broke at some point in the near future by continuing in this merry way, politics is a blind short-term game – it will be someone else’s problem one day. 

I can already hear the objections, anger even, screams and groans from the many dedicated and good people trying to help within the state systems. There are a lot who are trying and who do care. 

But please everyone, look at the scoreboard.  

Listen to the ED clinician above talk about what is really happening here today.  

We are a long way behind in the last quarter – more than the third quarter – by a lot and from a state perspective we don’t have a strategy to win. 

This problem obviously gets exacerbated and blurred quite a bit near an election. State politicians start behaving like they are running the whole healthcare system and they make promises about general practice they simply can’t or won’t keep. Promises which outside of an election they aren’t interested in and which they largely have no ability to keep anyway because they don’t fund GPs or formulate policy around them. 

The Queensland election is pretty good example of this. No payroll tax for GPs, a huge brain fart with consequences across the whole state tax system and with massive ATO consequences for general practice not contemplated, and 50 new “fee” bulk-billing GP centres – the go-to political solution these days.  

Who is going to pay for this?  

I’ve digressed here to try to make a point.  

For GPs and hospitals to communicate effectively you need hospitals to really want to do that, to be paid to do that, or to be vertically integrated into the GP funding paradigm somehow so it is actually their problem to fix, with a means of fixing it.  

That isn’t how federation rolls unfortunately and short of breaking up federation as far as health is concerned (Kevin Rudd wanted to try and look how far he got), not a lot is likely to change. 

Is there another way?  

Is there hope for this virtual ED clinician who seems to be in hospital discharge summary purgatory?  

And for all the GPs at the butt end of a badly connected system with very confusing documents being sent when they are sent? 

Maybe. 

In a Health Services Daily webinar a couple of weeks back on the national health information exchange (HIE), we got a ton of good questions, but none better from a smart GP which went a bit like this: 

“Forget trying to send me a summary of what happened to my patient in hospital last week and landing it somewhere I can’t find and when I can, I don’t understand it anyway … can’t you just fix my patient management system so I can see what happened to them for myself when I need to?”  

In other words, a system where a GP can poll their local hospital EMR or other database around the country and decide for themselves what was going on, no matter how badly formatted the hospital discharge notes might have ended up being. 

A couple of years ago that might have been a crazy person’s question – someone fantasising. 

Today, if we manage to get a working national HIE up and running, the fantasy might just be possible. 

We’ve got a lot to do before we get a working national HIE of course – fix the My Health Record so you can actually access it securely via the web, legislate for technology standards for web-based data sharing for all software platforms, including our antiquated GP patient management platforms, and include rules on all this for the providers using the platforms, build the HIE (minor challenge?) … and a lot more. 

But if we did do all that then it feels feasible that we might get some cut-through against the dysfunctional political framework and money issues that are currently a big barrier to doing something which should be simple – making GPs talk meaningfully with their local hospital. 

Is this going to be quick?  

Not really.  

The Australian Digital Health Agency puts the main goals for an HIE being met within a seven-year timeframe, and it’s government doing big IT remember, so that’s probably a pretty optimistic estimate. 

Also, we’ve been at the My Health Record for nearly 10 years and it’s not doing much. 

So nobody is cracking the champagne here any time soon.  

What we do have is a plan, a lot of alignment and quite a few people in government departments and agencies with energy and intent. 

It’s a long journey and everyone, including the states, are going to need to all to get on the train and resist the temptation to make their way to the last carriage and throw out anchors for short-term political wins.  

What we can say is that a lot of government departments and agencies are aligning with the idea of the HIE – the states are there, albeit nervously, and all looking at it with a different lens, so we will see.  

The idea has a lot of momentum, in part, because it cuts out a lot of the politics of funding and money – the federal government is going to pay for most of it, the others just have to co-operate as much as they can and everyone should benefit. 

During our HSD national HIE webinar another very good question to the ADHA, which is charged with building the HIE, was “what are your key clinical use cases for building the HIE”. 

If you read the recently released HIE ADHA architecture and roadmap document – you really should have a quick go no matter who you are the pecking order – you might struggle to work out what the key use cases are which justify moving on a new piece of digital health infrastructure probably a lot more complex and risky than the My Health Record.   

It’s a bit of a dense document trying to cover all bases which is good and bad.  

Good because it does provide a lot of thinking about where we are and where we want to go and all the myriad elements that might need to be aligned to get there.  

Bad because important things like “what will change at the coalface for our ED clinician above if we do this” aren’t really articulated that well.  

But if the HIE cracked just this single use case nut that our ED clinician so articulately outlined as being such an ongoing mess for everyone – GP talks to hospital effectively in real time when they need to – this new giant project would surely be worth it.