Ep54: My Health Record in Practice

Ep54: My Health Record in Practice
Date:
9 December 2019
Category:

Fellows of the RACP can claim CPD credits via MyCPD for listening to this episode and reading the resources below.

How many times have you thought “things would be so much more efficient if we had shared electronic health records?”  Australia, now has the My Health Record covering 90% of the population with individual profiles.

It is proposed that this will improve safety especially for people with chronic and complex health care needs. It could reduce medication mismanagement and duplication of pathology and diagnostic imaging tests and help improve health literacy among the public.  And at the point of care it might prove safer for the previously unseen patient who arrives at emergency unable to say anything about what allergies they have or what medications they’re already on.

But that’s only if everyone is putting information up there. It’s been a long process getting health providers to upload data the My Health Record routinely, and the uptake differs wildly between primary, secondary and tertiary care.

In this podcast we visit each of these settings and hear what the different expectations are of this new tool, what are the benefits gained, and how well it fits into the workflow of a consultation. The RACP received support from the Australian Digital Health Agency for production of this podcast.

Credits

Guests

A/Professor Nicholas Buckmaster FRACP (Gold Coast University Hospital)
Dr Ron Granot FRACP (East Neurology and Clinical Advisor for Healthshare Digital) 
Professor Meredith Makeham FRAGCP (Chief Medical Adviser Australian Digital Health Agency, Macquarie University)

Production

Written and produced by Mic Cavazzini. Tracks licenced from Epidemic Sound include ‘Far away star’ – Lishiod, ‘Straight out of the basement’ – SINY, ‘Leaving Serengeti’- OOyy, ‘Struck by You’ – Seroa, ‘Little Liberty’ – Paisely Pink. Image courtesy of Australian Digital Health Agency.

Editorial feedback for this episode was kindly provided by members of the RACP’s Podcast Editorial Group; Ilana Ginges, Paul Cooper, Michael Herd, Marion Leighton, Li-Zsa Tan, Rebecca Grainger, Andrew Whyte, Alan Ngo, Jenae Valk, Joseph Lee, Seema Radhakrishnan, Lisa Mounsey, Phillipa Wormald, Pavan Chandrala, Andrea Knox, Rhiannon Mellor, Atif Slim and Leah Krischock. Thanks also to RACP staff Sandra Dias and Krista Le Claire.

References

These references and more can be found at the curated collection
My Health Record Physician Toolkit

Registering a practice for MyHealth Record

Healthcare Provider Registration (short version)
Practice manager registration guide
Handbook for Practice managers
Conformant Practice Software
Resources for Specialist Practices [Melbourne Hand Surgery]

Using MyHealth Record

Clinical Software Simulators [MyHealth Record]
My Health Record online training
RACP introductory webinar
MyHealth Record webinars


Other Reading

My Health Record implementation in private specialist practice [Tomlinson, MJA]
Why doctors hate their computers [New Yorker- Atul Gawande]
My Health Record: think about the status quo before opting out [Monash Lens]
My Health Record: on a path to nowhere? [Insight+]
the My Health Records Act 2012
Shaping the future of UK healthcare: Closing the digital gap
[Deloitte]
Promoting an overdue digital transformation in healthcare
[McKinsey and Co]

Information from the Australian Digital Health Agency about a pilot study of MyHealth record in general practice

71 GPs in total participated. Using the Medcast SupportQI methodology, a three-arm pragmatic, educational trial was developed and implemented. The three arms included a deprescribing intervention, a pathology-ordering intervention and a diagnostic-imaging intervention. All three arms explored and reinforced the role of MHR in realising the potential health care benefits and integration of MHR into clinical practice. 

Utilising a responsive evaluation framework, participants were invited to undertake pre-and post-intervention interviews regarding their attitudes, expectations and experiences of this MHR-based education intervention. In addition, changes in practitioner knowledge, skills and intended behaviours were assessed using pre/post case scenario surveys and a practitioner post-intervention audit. The results were combined in a mixed-methods approach.  

Based on the results of the post-education intervention analysis, there was good evidence that there was uptake of an ‘is this needed’ step in participants’ clinical reasoning and increased attention to reducing unnecessary health care expenditure. In addition, a change in behaviour of participants in the prescribing arm and pathology arm was evident through the self-reported qualitative data.”

 A definitive randomised controlled trial is currently underway to confirm findings.

Transcript

MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast about the culture of medicine. I’m Mic Cavazzini, for the Royal Australasian College of Physicians.

If you’ve listened to the show before, you’ll know that in about every second interview someone says “we need better integration of primary, secondary and tertiary care” or “things would be so much more efficient if we had shared electronic health records.”  Well finally, we’ve got one. At least in Australia, anyway, with My Health Record.

It’s actually been around since 2012, when it was launched as the Personally Controlled Electronic Health Record. It was rebranded in 2016 and then in January this year there was something of a Rapture- when millions of new profiles were created and coverage of the population reached 90%.

So how is My Health Record, or the MHR, going to change healthcare delivery? The go-to example is that of the previously unseen patient who arrives at hospital unable to say anything about what allergies they have or what medications they’re already on. If there’s an up-to-date shared health record to consult, the uncertainty evaporates, or at the very least you have an idea which other providers you can call for more information. To run over some of the data collected from different healthcare settings, here’s Professor Meredith Makeham, Chief Medical Adviser to the Australian Digital Health Agency.

MEREDITH MAKEHAM: So the information that flows in there is different from every connected setting.  From general practice we have shared health summaries, from hospitals we have ‘discharge summaries’, from pharmacy we have ‘dispensed medicines records’, from private pathology and imaging we have those reports going in.  And from specialists, specialist reports, specialist letters and things called event summaries where you can—it’s basically like a template, you can create whatever information you need in there. 

We have three new document types sitting in My Health Record that have just appeared over the last year or so. One of them is called ‘medicines view’.  That’s a document that when you click on it, it pulls every bit of medicines information from the record, allergy and medicines information all pulled into one place.  Now for a person who’s meeting a patient for the first time, that is incredibly useful.  We’ve just this month released a similar thing for pathology and diagnostic imaging, so that My Health Record will search all of the documents sitting in it from wherever they come from, so that you can see a patient’s history of what pathology and imaging they’ve had.

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MIC CAVAZZINI:
The principle of centralised health records is great, and that’s something every doctor I’ve spoken to agrees on. But it’s been painstaking work getting doctors and other providers to actually use the My Health Record routinely.

The Australian Digital Health Agency initially focused its attention on General Practitioners, as they were going to be the best advocates of the program to consumers. Many practice management software platforms used in the GP setting have been upgraded to be conformant with the MHR. Practices are also incentivised with up to $50,000 a year to upload patient data, and to meet other eHealth standards for clinical coding and secure messaging. The result of this is that 92% of GP practices are now registered for My Health Record, and about three quarters of those are uploading letters and patient data.

In hospitals the Agency has partnered with electronic medical record providers like Epic and Cerner and now about three quarters of Australian public hospitals have been plugged in. Discharge letters will be transferred to the MHR automatically, unless a patient requests otherwise, and a lot of lab and imaging reports are going up as well.

For private hospitals, community pharmacies and private pathology and imaging, about half of organizations are uploading data to My Health Record. Lagging far behind are specialists in private practice. I couldn’t get a hold of the latest data but a chart from two years ago shows that fewer than 4% of specialists had registered. [Figures submitted to senate estimates in mid December now put this at 8%]

For today’s podcast I spoke to doctors from three different healthcare settings to find out what they get out of My Health Record in daily practice and what they expect from it. We’ll go back to Meredith Makeham later, but let’s start with a visit to Gold Coast University Hospital.

Queensland actually had a boost on most of the country in regards to digital transformation. For a couple of years now, over half of public hospitals in that state have had a digitally integrated EMR built on the Cerner architecture. An application called the Viewer gives GPs access to highly granular real-time data captured in the hospitals. My Health Record allows information to flow back the other way. Here’s an impression from Associate Professor Nick Buckmaster.

NICK BUCKMASTER:       Okay, my name is Nick Buckmaster.  I’m a general physician with long standing interest in e-health, and I have been the senior responsible owner within the Queensland Health, My Health Record expansion program for about the last three years. 

MIC CAVAZZINI:               Tell us what the user experience is like—like how it’s making an impression. 

NICK BUCKMASTER:       I think there’s still a little way to go to make it a really easy experience.  But in my own group of patients, patients coming in, in general medicine and into our aged care service, people are really very sketchy frequently as to what the medications are.  Just even simply having the list of medications that have been recently prescribed makes a huge difference. 

MIC CAVAZZINI:               So even if nothing has been uploaded by a provider, a consumer’s profile will contain two years of historic information from the MBS and the PBS.  So that’s all federally subsidised prescriptions and interactions with healthcare.  It doesn’t include over the counter drugs or those supplied in hospital.  But is that in itself a useful enough picture for—if you are naive to a patient’s background?

NICK BUCKMASTER:       I can tell you that within my chronic disease clinic, it can be a really good starting point.  It really does make our time much more efficient, and we’re much less likely to miss something along the way. 

MIC CAVAZZINI:               And the MBS and the PBS records have a six week lag obviously from when they’re updated from Medicare, and they don’t tell you about the regime or dosage that a patient’s on.  But there’s another page called the ‘prescription and dispense view’ where these details can be uploaded in real time by the prescribing doctor.  Then there’s another tool which will allow pharmacists to write up non-prescription drugs and complementary medicines.  Is this kind of information more for the patient’s benefit, or are you finding it useful in practice for providers?

NICK BUCKMASTER:       Well, in fact, the dispense view is probably the most useful view of all, when there’s a disparity between what is prescribed and what is dispensed.  That in itself is additional information as it gives a picture at times where there may be some gaps in adherence.  And once again, obviously, the information at the moment is a little patchy, but as time goes on, there’s a much better longitudinal history of medications.  And you can then again ask the patient “Well, why did you stop this particular medication?”, or “Why did your GP stop that?”.  And sometimes it can be because of quite alarming side effects, which otherwise you might not have been aware of, that could harm the patient.

MIC CAVAZZINI:               Now, as well as the displays we’ve described, there’s a page called the ‘medicines information view’, which is a summary of all of the sources we’ve described.  There’s another page called the ‘medicines preview’, which allows you to search all the meds ever associated with that patient by medicine name or active ingredient or provider.  But a few of the practitioners in a Facebook group of MHR users made comments like “It’s clunky and arranged like a teenager’s floordrobe”.  Some have even taken to using the hashtag #myshoebox. How will does it fit into the clinical encounter?  Is it easy to integrate seamlessly into your consultation in secondary care?

NICK BUCKMASTER:       I agree with many of my colleagues that at this stage the tools are relatively clunky at times.  Having a simple list of medications without any explanation behind particular medication being changed, or for that matter being started, does mean that it still remains a relatively complex piece of work.  Although there are event summaries that are uploaded, potentially by specialists, that’s not happening terribly frequently as yet.  But I can tell you that when you have that information from one of your colleagues, it is absolute gold.  I personally believe that if we are to be effective clinicians, we have to use e-health.  And just as it’s a responsibility to write to the GP, you should be uploading the event summary of that letter.  And the likelihood of you finding information that is going to be useful in your patient care is now reaching a tipping point in my mind.

MIC CAVAZZINI:               Finally, let’s talk about the other tool, useful tools on there, the pathology reports.  I’ve read quite a few gripes about the way these are handled in My Health Record.  Reports don’t show up or they don’t contain all the information.  Have you noticed some of these sort of patchiness in terms of lab results?

NICK BUCKMASTER:       Once again, at this stage, unfortunately, My Health Record shows a snapshot of a set of pathology results, whereas a modern pathology system will show the correct normal ranges for a particular age group, may well show trends over time, and so on.  But no discharge summary has ever been really good at pathology and radiology reports.  We’re very pleased in my local area in southeast Queensland that one of the major pathology companies is now uploading reports from the private sector including GPs.

MIC CAVAZZINI:               So a patient can consent to all or just some of the pathology reports being uploaded to My Health, and once the lab has done these tests, they will automatically become available to the patient after seven days.  So this means that the requesting physician needs to make sure to see, to book in the patient within that timeframe to be able to explain the results.  In this Facebook poll, a pathologist wrote, “I’ve had zero benefit.  I’ve had many patients finding out their pathology results before being seen, including malignant results.  It’s not often you will get public oncology patients back within a week”.  That seemed that seemed to highlight a good design aspiration with My Health Record that’s being corrupted by the broader systems pressures. 

NICK BUCKMASTER:       I think the system needs to change, because at the end of the day, if it’s a malignant result, and the patient’s waiting past that seven days for an answer, and don’t forget, that’s when the result is finalised.  So in other words, it’s often four or five days already after the patient has had their procedure.  So we’re then talking 11 days before the patient might will see something in their My Health Record.  I think we are obliged to counsel our patients if they’re something of that sort.  We could well say, “Look, we happen to have a big problem with getting you back in that time.  But I’m going to send a letter to your GP, and your GP will let you know the result if I can’t do it myself. We’ve got too used to using the system as an excuse for what is not best practice patient focused care. 

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MIC CAVAZZINI:
The rollout of My Health Record has been critiqued by some observers for its patchwork design and costs of 2 billion dollars since 2012. But examples from around the world show that the technical hurdles are far from trivial, and there’s always a ticket price to enter the digital age.

The Australian National Audit office predicts that government spending will be recouped several times over by the year 2027, through time efficiencies for providers, reduced duplication of tests and scans, improved population health outcomes and enabling of further digital health innovations.

It's often suggested that healthcare is a decade behind other industries in terms of digitisation. As Professor of eHealth Tim Shaw says, our medical technology is in the space age but as far as information technology is concerned, we’re pulling the rocket to the launch pad with a horse and cart.

And it’s a running joke that the only reason fax machines are still produced is due to the conservativism of medics and the fragmentation of the health system. Private practitioners, in particular, have a reputation for being overly attached to their manila folders, but neurologist Ron Granot says that these stereotypes are unfair.

RON GRANOT: So a lot of people say doctors are Luddites, and doctors are lazy, but in fact, it’s not. It’s inertia, because the costs of switching are significant.  So you have to have a pull to make sure that switching from one piece of software to another piece of software is worth your while.

MIC CAVAZZINI: Dr Ron Granot himself is no Luddite. He’s designed an app that sends a questionnaire to patients before they turn up to the clinic. This runs through the usual history; “When did you first notice the symptoms? What makes them go away?” The notes are then summarised in your practice management software so you can cut straight to the chase at the initial consultation.

That’s if you’re using one of the two main software platforms. But there are around two hundred different players in this space—and they all have their own architecture. This is the big problem for disseminating My Health Record among providers. No one wants to log into another online portal to get there—you need the interoperability to be seamless. 

I’ve linked to a page on the Agency’s website that shows which platforms are conformant with the MHR. Some will upload letters and prescription lists; others only allow you to view a patient’s record. Several products that are most used by specialists are undergoing targeted development. Despite all this, Dr Ron Granot has some fundamental reservations about the way My Health Record has been designed.

RON GRANOT: So full disclosure for my side, I haven’t registered for My Health Record.  And that’s because I haven’t seen any need to. So if it was solving a major problem that I had, I would have, and I certainly know of—I’ve seen all those individual screens, and I’ve seen how to download and upload files into the record.  It’s fishing through a series of different folders to find the bit of data that you’re interested in. 

But from my perspective, even for new patients, the vast majority come in with all the requisite information that I need anyway.  And to me, from a neurologist perspective, I need to see source images, as much as the reports and so on.  But most of the big players are all online, digitised and allow for direct access, or at worst, they’re easy, they’re a phone call away, and they’ll be sent across. 

MIC CAVAZZINI:               I can imagine you see a few elderly patients, many with multi-morbidities—

RON GRANOT:  Absolutely.

MIC CAVAZZINI:               —getting scripts from their cardiologist and their rheumatologist as well as from you.  Can this not be a useful summary of the different therapies and so on that are coming together with all these different…?

RON GRANOT:  Patients spend probably five to 10 minutes before they see me either filling in better consult, or a piece of paper.  So if they’re self-dosing, they’ll know exactly what they’re taking.  The majority of those that don’t know will come with a family member who is completely aware.  If they don’t know, then we’ll simply call up their chemist who’s providing that Webster-pack and get that data.  And I would say I would do that in one in 20 or less patients.  So there’s not a lot of black holes.  So I don’t need to worry about whether prescribing data and dispensation data in the My Health Record is indeed up to date. 

MIC CAVAZZINI:               You feel like it’s a due diligence that you need to do regardless of what might be on a record. 

RON GRANOT:  Absolutely. 

MIC CAVAZZINI:               You describe quite a high level of health literacy among your patients.  Could that also be a reflection of operating in the eastern suburbs where level of education might be higher? 

RON GRANOT:  Absolutely, they may well be that, and as I said, I only speak from my perspective.  A lot of patients have a lot of copies of a lot of their correspondence, investigation results, latest blood tests, x-ray reports, and caregivers are also involved.  So I can certainly imagine that some patients will have less understanding of the medication they’re taking, and quite possibly not be taking what they’re prescribed anyway.  So again, the PBS data may then look blank, whereas in fact they’re meant to be on a whole host of medications they’re not actively taking. 

MIC CAVAZZINI:               Well, there is now a view within the My Health Record called ‘prescription and dispense’ where you can see if the patient has filled a script that you wrote, as long as the pharmacist is registered to the system as well.  That sounds like a step towards the Kaiser model of care that we keep hearing about from California.

RON GRANOT:  Sure. 

MIC CAVAZZINI:               Can you not see a good step in that direction?

RON GRANOT:  The data that it provides, while useful, is hidden in such a way that the time it takes to say, “Are you taking your tablets?”, “No”, “Why aren’t you taking your pills? Let’s discuss that” is a much more effective way than trying to sleuth through a four-month old record to see, “Oh, well, that hasn’t been dispensed in months.  So I don’t see—again, there’s no drive, there’s no upside for me.  And if there is I’m very happy to listen to it and change my practice.  I’m very happy to be evidence driven.  But as we know, with increasing time pressures on practitioners, you’ve got to find the most efficient way. 

When you’re selling a product, any product to any client, what you don’t want to do is have a very steep learning curve, and need to spend a long time trying to convince someone that what your product is doing is useful.  Either out of the gate, your product is going to give me some benefit that is very obvious and make it worth my while, or else the product dies. 

And in fact all the biggest tech players, so Microsoft had Health Vault.  Google Health had this sort of patient centric medical record.  And the answer was they all failed after literally hundreds of millions of dollars of capital intensive investment, because no one was using them.  Not patient wise, but doctor wise.  So electronic medical records on the doctor’s side alone, if anything they’re a ball and chain rather than a productivity tool.

MIC CAVAZZINI:               I was privy to some views in a GP forum where they said you’re not going to have people queuing up like they do outside the Apple Store. 

RON GRANOT:  That’s right.  The question, what is My Health Record replacing? And if it’s replacing the folder of paper that my new patients are coming with, then it’s not replacing a hell of a lot.  It’s a no brainer, therefore, that to introduce such technology into the marketplace, the governments have to put in practice incentive payments, because otherwise, why would you spend time training effort, to install a tool that slows you down?

MIC CAVAZZINI:               I think what you’ve highlighted for me is something that I hadn’t thought about before, why is there this difference between GPs and private clinics and hospital.  You, as private clinicians and as neurologists, see specific patients for a specific condition, who will then become your patients over a long period of time, and so you can see everything that they interact with, and that’s what you trust.  I guess at different levels of the health system, that contact won’t be so regular.

RON GRANOT:  Correct. 

MIC CAVAZZINI: And, you know, all that infiormation won’t be on that provider’s EMR. But—it’s sad to say—but you’re not going to take one for the team and spend a bit of extra time uploading stuff to it just in case some other provider down the track might need to use that, because you don’t know that anyone down the track is going to …

RON GRANOT:  So what you’re saying is we’ll do a huge effort for edge cases.  All time is a resource.  And so that’s a poor use of a resource for edge cases.  Most patients will represent to the same emergency department they’ve presented at before and had previous admissions at.  There are edge cases no doubt, and with grey nomads, and so on and so forth, they may be an issue, but the issue is small.  It’s not solving a major problem for the majority of practitioners for anything like the majority of the time. 

Could there be a solution created for the hyper-acute circumstances?  Absolutely, and it would potentially be a useful one.  So if you show me that effort equals substantial reward, even in patient care, beyond what I currently do, very, very happy to listen.  At that point, if it’s still taking one for the team, then I think the government should step in and offer to subsidise that ,which they are not wont to do, having not modified item rebates and so on for many a year, particularly in the specialist space, quite the opposite.

MIC CAVAZZINI:               And apart from the interface, which could be integrated as well as you like into your current practice management software, which information is missing in there that would make it worth your while?

RON GRANOT:  So the ideal of a centralised record is only a good one if you design a system which is ultimately connected to all end user databases, in other words, the medical record software and so on, so that whenever changes are made, it’s reflected in a central database.  That sort of instant flow of information is only a good thing.  If that’s then checked cross so that there are flags in the database whereby ‘drug X prescribed’, ‘drug X dispensed’, ‘drug X due’, ‘not dispensed any longer’, ‘red flag’—sends across to GP and to patient and says “Your script is due for refill. Why aren’t you filling it?” and then interacts with the patient to find out why. Fantastic solution.  It will improve efficiency, it will reduce errors, everyone will use it because it’s a better consultation.  But the devil is in the detail and it’s always the execution. 

So I wouldn’t even say that the execution is poor because it was designed to do this idealised central repository, and they just couldn’t pull it off.  It was not designed to be that, and therefore isn’t that.  So the execution is what it was meant to be, fantastic.  You’ve delivered the specs for piece of software, but it’s not a needed solution.  If you solve my problem as a practitioner then I will use your solution, if I have to pay for it.  If it saves me time, then I will pay for it.

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MIC CAVZZINI:
 I don’t know what proportion of specialists are “doubting Thomases” like Ron Granot. I emailed all of those in my orbit and got responses from 7 working mostly in public hospitals and 5 working mostly in private practice.

One person objected to the My Health model outright based on privacy concerns. The rest thought it would be useful to varying degrees. Only three of them had already actually seen what the MHR looked like, and a couple more came back to me afterwards to say they’d never noticed it sitting in the background of their hospital EMR.

Notably, none of those in private practice had signed up their organization on My Health Record. For a start, all five had software compatibility issues, and there was also some trepidation about the registration process. There are a couple of authentication steps, and a practice must identify a ‘responsible officer’ in whose name the practice is registered. This person must also ensure that staff are appropriately trained to comply with security policies.

There are guides and policy documents at the My Health Record website, but one of the most useful accounts comes from Dr Jill Tomlinson of the Melbourne Hand Surgery in an article for the MJA. Dr Tomlinson has also provided some very helpful templates at her practice website. She told me in a personal communication that “the implementation wasn’t terribly difficult” and since she signed on in 2017 the process has been streamlined. Dr Tomlinson says the main frustration was finding that other providers weren’t sharing diagnostic and medication data on there. It would save her a few phone calls and a lot of time if everyone was on the same page.

I guess it helps to manage the wider expectations. Dr Granot and others in health tech dream of a central repository that pipes in discrete measures from any other EMR. Something that would allow real-time signalling between providers and to patients and easier harvesting of big data for population analyses.

But My Health Record wasn’t designed as the ring to bind them all. It’s been developed with the consumer as the primary manager of the reports it collects. US surgeon and write Atul Gawande makes a similar observation in his essay ‘Why doctors hate their computers’. In the last few years the US has been transitioning most of its hospitals to a single Epic platform, and Dr Gawande writes; “While some sixty thousand staff members use the system, almost ten times as many patients log into it to look up their lab results, remind themselves of the medications they are supposed to take, [or read their doctor’s notes] in order to better understand what they’ve been told.”

The Americans have experienced the same challenges we have in trying to build something that will be all things to all people. Atul Gawande complains about thirteen tabs on the side of the screen with nearly identical labels: “chart review,” “results review,” “review flowsheet.” But the alternative solution is equally annoying—you only have five tabs to look over but you need to click deeper and deeper to get where you want.

It’s the same with data entry fields. I hate those drop-down menus where you have to scroll through options in a tiny pop-up window. But free fields can become problematic too if users don’t engage with them in the way the designers intended. Gawande gives the example of Epic’s patient problem list; “Three people will list the same diagnosis three different ways. Or an orthopedist will list the same generic symptom for every patient, which is sufficient for billing purposes but not useful to colleagues who need to know the specific diagnosis…The problem lists have become a hoarder’s stash.” 

It remains to be seen how exactly specialists will use the events summaries and other entries within My Health Record’s. Every clinician has their own unique workflow, and the art of medicine doesn’t always mesh with the tech of medicine.

In general practice too there are champions as well as sceptics of the MHR. One noteworthy story was published by the RACGP. A patient underwent some pre-operative ECGs which were dutifully uploaded to the record by the GP. That same evening, the patient experienced sudden chest paints and was taken to emergency, where a treating physician saw these report, ruled out medication issues and PE, and was able to discharge the patient rather than keep them overnight for more testing and observation.

Let’s hear again from Professor Meredith Makeham, who’s a General Practitioner on top of her role at the Australian Digital Health Agency.

MEREDITH MAKEHAM: My practice personally as a GP, I use My Health Record a lot to access information that I wouldn’t have otherwise been able to see.  So I work in a university setting, and we’ve got a lot of students, post graduates, from all over the country.  I can click into My Health Record, and did do last week in my practice, and be able to see a Queensland discharge summary—I’m based in Sydney—pathology results and imaging results. 

And of course, one of the best examples we’ve had recently would probably be the Townsville floods and what happened up there.  So many people were displaced and disconnected from their regular GPs and they regular pharmacies. And one of the pharmacists up there had an amazing story of helping people in an emergency centre that was set up nearby to them, and they talked about the way My Health Record really came into its moment, it really shone, because suddenly they were able to package up care packages of medicines for these people that were displaced.  That really did avoid patient harm in that terribly difficult emergency situation up there. 

MIC CAVAZZINI:               Yeah, maybe we can point to a couple of examples from GPs on a Facebook group.  So one of them said, “I love being able to look at a patient’s medication dispensing history, especially if they’re new patients, and discharge summaries are hard to come by when working regionally”. Do you have any systematic data …

MEREDITH MAKEHAM: Yeah, and I mean, the discharge summary one is a beautiful example.  The majority of patients these days really have about three GPs.  So often, in my experience, what happens is it might go to their regular GP that lives near them, but you’re their GP in the work setting.  And so you’ve got no access to that information traditionally.  But through My Health Record, you’ll have access to it as well.  So it’s incredibly helpful for discharge summary. 

And often patients can’t even remember where they had various tests and imaging done, or even sometimes which hospital they were in.  Someone took blood out of their arm while they were lying on a bed feeling sick, they’ve got no idea what bloods were done.  So being able to very quickly see that through My Health Record, it’s a great time saver, but it’s really, I think that it contributes so much to patient safety in the long term.

MIC CAVAZZINI:               I polled my editorial group and other friends in the profession, I managed to get responses from 12 specialists.  But only three of them reported that they were aware they had some access to the MHR through that.  And even the one that said, “Yes, my hospital’s got a good connection.  But I don’t really need to use it because for my patients, all the data is in the EMR anyway”.

MEREDITH MAKEHAM: I think what people need to remember is we don’t know what we don’t know.  And through clicking on that My Health Record button, I may be able to find stuff that I didn’t know about, and that’s going to be an improvement for my patient in terms of my ability to make a sensible and safe clinical decision in real time with them then and there.  So it helps me to avoid delays.  It helps me to coordinate care.  We have a very rigorous benefits measurement program running at the moment as well with academic partners around the country.  There’s a great study that’s been done at Wollongong University that was also randomised, and they taught GPs how to use the My Health Record to de-prescribe unnecessary medications, and not order pathology tests that had already been done.  And those results were quite impressive [research unpublished at date of podcast].

So we found that the use of the My Health Record contributed to not ordering pathology, somewhere in the vicinity of 15 to 20%, and that the My Health Record led to a medicine being cut off the list that wasn’t necessary.  [See References above for more detail on this study]

So those sorts of things actually have massive benefit for people that don’t have to go through unnecessary tests, but also, of course, the economic benefit to the whole society.  We’re not paying for tests that are needed and medications that aren’t needed.  And of course, the medication safety benefits of not being on things you don’t have to be on.

MIC CAVAZZINI:               I wonder if the, I mean, it’s hard to tell now how much of the recalcitrance, the slow uptake among specialists is just awareness, or whether there are different design needs for health practitioners working in different settings.  So I got a sense that general practitioners find the My Health Record useful because they’re trying to coordinate information coming from all these different specialists and labs.  And both in primary and secondary care, you can get anyone walking in through the door—and they can be undifferentiated patients, and the MHR fills, helps fill that picture.  By contrast, I guess it if you’re working in tertiary care and a patient is referred to you, they’re already a known entity.  So I wonder if private specialists don’t find it is useful just by nature of the kind of work they do.

MEREDITH MAKEHAM: Look, I’d probably challenge that actually, Mic.  I’ve got a lot of colleagues in different specialty areas who do often complain about the quality of information they receive when they get a referral from some of my good general practice colleagues, and they might not actually have an up to date or accurate medication list, or the allergies or any of those tests that you’re referring to.

And look, it’s not for me, the general practitioner, to know which tests et cetera, should have already done and sent to the specialist necessarily.  So that specialist looking at My Health Record might be able to see that certain tests they were about to order have already been done, for example.  I think there are a lot of use cases where a specialist receiving a referral for the first time would really love some of the information that’s available in My Health Record. 

MIC CAVAZZINI:               There was also the gripe that the pathology on there, for example, is a simplified, and the scans are a very simplified report whereas …

MEREDITH MAKEHAM: Oh, no, that’s a myth.

MIC CAVAZZINI:               So Ron Granot, who’s a neurologist, wants to see the scans himself, he doesn’t want to just read the report. For the pathology, specialists want to see—dig down into the data, they want to see the normal ranges, whereas …

MEREDITH MAKEHAM: Oh no, it’s got all of that, it’s got all of that.  That’s misinformation. Just to clarify, you do have the complete report with all the normal ranges as you’re used to seeing on it in pathology.  For diagnostic imaging, depending on the diagnostic imaging provider, the report itself may have some images embedded in it. But it’s not a repository of all of the full images that are collected say for a CT and MRI scan, and people who need to have that level of detail, would at least have knowledge that the test has been done.  They’ll have the immediate report from that radiologist, and they’ll know where it was done and when.  That’s a great head start to then go and get those more detailed images if that’s what’s needed.

MIC CAVAZZINI:               Yeah.  And some of this is less to do with perhaps the functionality of it and maybe some of the other systems pressures. Like, so in this Facebook conversation between largely GPs there was a comment that “If you complain that there’s no info, maybe you should upload a summary for the next practitioner,”  and the response from another doctor was, “That’s easy to say when one is salaried”.  So it suggests that time is the greatest resource, and how they spend it really depends on the setting they’re in. 

MEREDITH MAKEHAM: Yeah, look, Mic, I couldn’t agree more, especially speaking as a busy GP.  I don’t have time to go out of my practice software and jump around in multiple different systems and log into different things and look at things.  You want it to be seamless, user friendly, sitting in the software that you’re using to treat your patient that’s sitting with you at that time.  Look, I’d say that that saving time for clinicians is one of the primary benefits that we’re observing and measuring through the use of the My Health Record system. 

So of course, it’s dependent upon the way your practice is set up, who’s in your clinical care team, what sort of vendor system you’re actually using.  But the My Health Record system currently has 36 million clinical documents sitting in there.  There are 11.8 million Australians that have got My Health Records right now with clinical documents sitting in them.  So yeah, there’s a lot of information that I think would be a great benefit to private specialists, and specialists working in public settings.

MIC CAVAZZINI:               Once they’ve had a positive experience, hopefully this view will change, but some of the comments have also reflected on “Well, it’s just a patient facing portal.  But it’s not that useful to clinicians”, or “The government designed this because they’re interested in collecting big data”, which is, of course useful for public health and the health system, “but it’s not that useful to providers”.  Of course, it had to be designed as a patient facing portal given it was an opt-in system. 

The sort of, perhaps cynical, argument I want to ask is whether with that experience, that seven years of waiting for people to opt in, and then it was flipped anyway; with 20/20 hindsight, would it have been better to start from day one as an opt out system, and to design at a more granular level, with all of these providers with all of these different needs, who want all the different interoperability. You know, built all that in and spend the money on that from day one, so that the provider engagement wasn’t such a hurdle as it is, as it has been?

MEREDITH MAKEHAM: You know, it’s a really interesting question and probably reflects a whole lot of stuff that’s really not specific to My Health Record.  It’s the way we think about digital things we do in our life.  You know, how much control and what our level of concern is around privacy and security, all of those sorts of factors play into whether a society is willing to accept having something created for them, and knowing that it’s got particular privacy and security protections around it. 

A lot of people that I spoke to in my general practice setting who weren’t opposed to the system, in my experience, it was just simply, they just didn’t have time.  That was the main thing that people told me.  You know, you had to log on to MyGov and create an account and all of this process that you would of course have to go through.  And at the point that we actually did flip it over, about a quarter of Australians already had a My Health Record.  So there was a healthy number. 

But we know that until you’ve got about over 50% of the population in, it doesn’t work as well.  People don’t bother to look, because most people don’t have a record.  So I think that it’s just made life so much easier for people who want a My Health Record to just have that thing created for them and know that their information is flowing in there in the background.  It’s bit like an insurance policy.  You don’t know when you’re going to need it.

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MIC CAVAZZINI:
So there you have it, give My Health Record a go. You’ll probably find some useful information in there, or at the very least make another provider’s day a little easier by uploading your notes. Maybe they should build one of those ‘buy me a coffee’ widgets into the top of each clinical document, so they can thank you for it. Hopefully it won’t take much more incentivisation than that to get a critical mass of users and information on board.

Many thanks to Meredith Makeham, Nick Buckmaster and Ron Granot for contributing to this episode of Pomegranate Health. The views expressed are their own and may not represent those of the Royal Australasian College of Physicians. The RACP received support from the Australian Digital Health Agency to develop this podcast.

I suggest you visit the My Health Record website to learn more about how to register for and use the MHR. There are actually some clinical software simulators too, and if you’re still having trouble you can request assistance from the Agency. I’ve linked to some of the key resources at racp.edu.au/podcast.

Many people kindly listened to drafts of this podcast to make it better, and they have been thanked individually at the website. If you have any feedback, please send an email to podcast@racp.edu.au. I’m Mic Cavazzini. I hope to hear from you

Comments


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29 Oct 2020

Rosalie Schultz

For Aboriginal people who often speak languages other than English, move between health services and across state borders, and have high burden of disease managed by a range of different specialists My Health Record is fantastic. Providing greater benefit to more disadvantaged people it is a progressive service and despite the teething problems I believe can assist us to provide more coordinated and person centred services.

11 Dec 2019

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