Wednesday, 7 March 2012

Electronic Health Records

Known Unknowns 

In life, there are 'known unknowns and unknown unknowns' as Donald Rumsfeld once put with questionable eloquence. For those practicing in emergency medicine, this aphorism resonates, particularly in the busy first few minutes of a patient's arrival in a resuscitation bay. With the roll out of the summary-format Personally Controlled Electronic Health Record (PCEHR) due later this year, consideration should be given to the reasons for its inception and whether a more comprehensive Electronic Medical Record system could prove a critical step in improving patient care.

The first few minutes of a gravely ill patient's admission to an Emergency Department are a period of controlled chaos. People, in varying degrees of distress or consciousness, are borne in, with a cursory history from paramedics or a relative. "He has some cardiac history, but can't remember the last time he came to hospital".

Doctors and nurses in small teams swarm around the bed and with a flurry of examinations, investigations and interventions occurring in parallel begin to assess the patient. Amid a background din of chirping machines, the quiet flow of instructions and the hiss of the oxygen, attempts are made at obtaining a history. Between coughs or gasps, or muffled through an oxygen mask, patients give some account of their current illness and, to varying degrees, a precis of their medical history. A slightly fuzzy picture begins to emerge of why this person is here, and what state they are truly in. And then, we wait for the chart to arrive from medical records or send to GPs or other hospitals for information.

Unfortunately, this often where the information flow stops. The story given often lacks critical information. Patients are unconscious, or often not in full command of their faculties at times like these due to pain, drugs or hypoxia. Others can simply not recollect (or have not been informed) of results of important investigations and aspects of their medical history. "I had a heart test a year ago at another hospital, but I don't remember what they found". "My GP changed my blood pressure medication this week, but I'm not sure which one is new".

It is these known unknown that can be critical to developing a diagnosis and guiding the direction of emergency care and the answers to these known unknowns that are frustratingly sometimes out of reach of the emergency clinician. The answer lies with a comprehensive electronic medical records system.

Medical records contain valuable medical information for the treating clinician, including detailed notes of previous presentations and admissions, discussions of multidisciplinary care plans, discussions with patients and carers, detailed investigation results and importantly, description of specialist consultations and advice. To any emergency clinician at the bedside, but particularly to junior doctors who staff our emergency departments, these are critical details that allow for informed diagnosis, enhanced, safer immediate care and timely disposition.

Present systems

Presently, state health departments have a number of e-health systems employed throughout their hospitals; for example, to access pathology or radiology results and reports. Increasingly, these are being integrated across state-wide facilities; that is, results from one public hospital can be viewed from a station at another public hospital. This distribution does not extend private sphere, nor are private investigation results available publicly.

There are also information systems with their own electronic medical record systems employed by different departments within the same hospital. These do provide a source of readily accessible clinical information. Unfortunately, there is little or no integration between these systems. Clinical notes written in the Emergency Department cannot be viewed electronically at another campus, off-site by a GP, or even on the Medical ward of the same hospital. In emergency situations, often notes from other hospitals must be located in medical records and pages faxed to the treating facility. GP surgeries have being using electronic record and prescription systems for some time, but again their distribution is only practice-wide with no capacity to electronically share information. 

A comprehensively distributed medical record system would go some way to reducing these redundancies and improving patient care. Confused purposes and limited scope mean that PCEHR appears unlikely to be able to meet this need.  


The Federal Government announced a $466.7 million (now $760 million) investment over two years for a national PCEHR system.  The PCEHR will 'not hold all the information held in your doctor's records but will complement it by highlighting key information'. The premise behind the system is to allow better patient interaction with their health records to encourage patient empowerment and participation in their own health care, and to provide a summary of key health information to clinicians in the shared care setting.

In effect, the PCEHR will produce a dot-point summary of a patient's medical history, medications and allergies, and some investigation results (if entered) and possibly letters from specialists (again, if entered). Information will be added to the record by the patient, or at the clinician's discretion. The concern for clinicians is that the completeness, accuracy and relevance of the data be maintained, so that ultimately, it does provide benefit in clinical decision making. At present, a summary-style care record has not proven to be useful in this regard. 

The PCEHR bears resemblance in many aspects to the HealthSpace Summary Care Record (SCR) system adopted in the UK in 2007, which has been assessed as not meetings its objectives of patient empowerment, or of improving information sharing. An important feature of the PCEHR, like the UK's HealthSpace, is that it will be an 'opt-in' system. Results from the UK show very poor uptake - between 2007 and 2010, only 172,950 people opened a basic account, and 2,913 people opened an advanced account (only 0.13% of those invited). Among reasons for its poor uptake was a requirement for patients to enter medical details, a perception that it would be of limited value to clinicians, and the level of technological expertise to derive full benefit from its features. It is likely that uptake in the Australian context will be similar, raising concerns as to its power as a healthcare-wide tool. 

If as it appears at present, a summary-style system does not appear to confer significant benefit to patients and is under-powered as a decision making adjuvant for clinicians; then the cost in personal privacy, not to mention its high infrastructure and implementation cost, may outweigh the benefits of the PCEHR. 

Where's the chart?

It is generally recognised that the implementation of a comprehensive, widely distributed electronic medical records system will deliver true benefits to clinicians and patients. Some have argued that the PCEHR is a 'stepping-stone' to this eventuality, but it may prove a diversion instead. 

At the crux of this issue is the question of purpose. Who are we developing national e-health system for? At a time of an ever increasing burden of chronic disease, engaging patients with their own long term health care is laudable and based in good evidence. But, in a system where patients are cared for by a number of different clinicians, and are expected to traverse the interface between primary care, private specialists and hospitals and the public system with increasing frequency, the capacity of an e-health system to share important clinical details, results and specialist interpretations is of far more value to clinicians and ultimately, to the patient. 

State- or nation-wide IT systems have a track record of being cumbersome, costly and unreliable (witness the Queensland Health payroll issues). It is understood that the infrastructure and logistic costs of implementing a full electronic medical records system would likely be significantly higher that of the PCEHR, but the long term benefits may justify the expenditure. 

We will see PCEHR deployed in July 2012, and no doubt enjoy some good outcomes from it. But there should be continued commitment to develop a comprehensive, widely distributed electronic medical records system if we want to unlock the real potential of e-health. 

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