This address was delivered on behalf of the Minister of Health and Ageing by Mr. Ken Ticehurst, Chair of the Liberal Party Backbench Committee on Health and Aging. The Minister was unable to attend at short notice.

BETTER RECORDS MAKE BETTER DOCTORS

Jump to audio presentation

It's good that the Australian Medical Association has organised this E-Health Forum because doctors are at the heart of the health system and there can be no integrated IT-based patient health record while most doctors' case notes remain on cardboard cards.

Doctors can hardly be blamed for focusing on their patients' treatment rather than their patients' records and their practices' administrative systems. From day one at medical school, doctors are conditioned to be clinicians rather than administrators. Intellectually, doctors understand that case notes are an integral part of patient treatment and not an unavoidable afterthought but instinctively many find it hard to take the administrative side of patient care as seriously as the clinical one. Few doctors would accept the use of 19th century technology in patient treatment when there's better available, yet many give archaic reporting and filing systems scarcely a second thought.

Australian doctors like to think of themselves as the worlds best. For up-front diagnosis and treatment, this is almost certainly true. It's not so clearly the case for follow up care and the management of complex, chronic conditions because that involves creating patient records and communications systems which enable each professional to follow the work of his or her predecessors and which mean that each patient-professional relationship no longer has to start from scratch.

It's hard to remember the time when people still received hand-written statements of fees from their doctors. These days, it would be regarded as verging on the unprofessional not to have computerised accounting systems. Why then is it not regarded as equally substandard to have 19th century paper-based patient record-keeping systems, especially when these are far more important for actual patient care than statements of account?

No doubt some doctors feel that making notes on a keyboard and glancing at a screen could detract from personal contact with their patients. In fact, a well set-up computer system can be a teaching resource, improving doctors' ability to explain particular conditions or procedures to patients. Like the rest of us, doctors tend to grumble about the cost of doing business but electronic record systems are not as expensive as the negligence claims which are harder to defend without complete and clear medical records.

Still, I remain fundamentally optimistic about the eventual take-up of E-Health because doctors, while no more inclined than anyone else to change the habits of half a lifetime, are so professionally committed to the best possible patient care.

For the proponents of an integrated IT-based health record system, the challenge is to persuade doctors of its importance for the professional care of patients. As soon as doctors realise that an integrated health record system will make them better doctors, there will be a steady take up of E-Health measures. Events such as this Forum should help promote doctors' understanding that continuing improvements in record keeping is as much a part of maintaining professional standards as continuing medical education.

An integrated IT-based patient record system should mean fewer medical mistakes, fewer duplicated tests and more effective team care. In other words, it should be good for doctors and good for patients as well as good for taxpayers.

The 1994 Quality in Health Care study concluded that 20 per cent of avoidable deaths in hospital were due to communication problems or poor record keeping. If these figures are right, the ability of doctors and other health professionals to access their patient's file by entering a few commands on keyboard could help prevent nearly 3000 deaths a year. Even if these figures over-dramatise the problem, it's clear that better medical record keeping could significantly improve the quality of health care.

A recent US study estimated that an integrated health record system could save between eight and 22 per cent of total health care costs by eliminating duplicated tests, shortening hospital stays and improving care for chronically ill patients. A $7 billion saving which is a low-side extrapolation of these estimates to Australia sounds wildly optimistic but even a 1 per cent saving would liberate $800 million a year for deployment towards better health outcomes.

An ageing population will require more complex health care using a wider range of health professionals and a greater diversity of health institutions. The time has long passed when patients' health care was the province of just one family GP and perhaps the local public hospital yet, without an integrated health record system, effective and efficient team care will be almost impossible. Queues will be longer and costs will be higher as health professionals under pressure keep asking the same questions and ordering the same tests.

Over the two years to 2004, there were 10 million Australians who consulted three or more GPs. A Commonwealth Fund survey showed that patients who consulted three or more doctors were almost twice as likely as those consulting one family doctor to experience a medication error or a medical mistake and 60 per cent more likely to have been sent for duplicate tests.

This is why better records are so important for health care quality. It's not just a question of patient convenience or of improved efficiency, important though these are. Ultimately an effective IT based health record system is necessary to ensure the continued professional excellence of Australia's health system.

Five years ago, the Health Ministers' Council first committed all Australian governments to the development of an integrated IT-based health record system. Over the past decade, the Commonwealth Government has paid some $600 million in IT-linked GP Practice Incentive Payments. Over the past 18 months, the Government has committed $60 million to the Broadband for Health initiative, designed to ensure that every general practice and pharmacy has access to business-grade connectivity. So far, the Government has committed more than $110 million to developing HealthConnect, including $9 million in half-funding the National Electronic Health Transition Authority which aims to standardise usage and facilitate interoperability of Federal, State and private health IT systems.

Progress, or at least progress that patients would notice, has been disappointingly slow. The computers on GPs' desks are sometimes little more than expensive paperweights. Under 50 per cent of GPs use a system such as Medical Director for recording the outcomes of consultations. Only 4 per cent of GPs have the capacity to generate patients' Medicare rebate electronically from the surgery though this functionality has been theoretically available for at least three years. Only about 2000 Medicare smart cards have been issued in Tasmania and these can access patients' immunisation records only from kiosks in Medicare offices. Only 35,000 privately-insured episodes of hospital care (out of more than 2 million in any year) have yet resulted in one integrated patient bill, despite the $13 million the Government has so far spent on the ECLIPSE computer system to allow this to happen.

Despite numerous pilot projects, the goal of automatically copying all health records to a secure central data base, sorting and indexing them, and making them available in a useful and accessible form to patients and authorised health professionals remains as elusive here as it is overseas. Because of cost, privacy, and integration concerns, it's never seemed in doctors', patients' or institutions' self-interest to push E-Health, even though it's clearly in the national interest. Despite strong official commitment to E-Health, it's always been a worthy second order issue, the interest of many but the preoccupation of none, at least until the formation of NeHTA.

It's not the role of Government to design-in-detail and custom-build a functioning E-Health system. Government's role is to establish the right regulatory environment, perhaps to provide some modest carrots and sticks towards best practice, but not to build systems which will be a boon for IT companies but are invariably over or under-engineered for their users. The Government's chief role might be to put the onus on providers to develop and use E-Health systems. HealthConnect, like the internet itself, is likely to emerge as more and more health professionals, health providers and their patients see the benefit of sending, receiving and storing information on line.

As it happens, several Commonwealth Government-sponsored demonstration projects are now sufficiently functional to show how useful a full HealthConnect system could be for doctors and their patients. In the Eastern Goldfields district of Western Australia, about 30 doctors now have a secure on line communication system with pathology and radiology services and hospitals in Kalgoorlie. This is providing low cost internet phone services as well as easy transfer of clinical data. In the area around Katherine in the Northern Territory, the local aboriginal health service is using electronic records, accessible with patient consent at a number of different clinics, to treat itinerant patients.

An AMA forum will not be surprised to learn that some of the most promising initiatives have not come from government.

Ozdocsonline was originally formed by four GPs in Leichardt in Sydney who were worried that their fee charging practice might lose patients to a nearby bulk-billing clinic. The system currently involves up to 100 doctors and more than 2000 registered patients. Patients can describe their symptoms through a secure web access point and receive medical advice without playing phone tag or spending time in a crowded waiting room. Fees, paid by credit card, are usually less than the gap between the AMA recommended fee and the Medicare rebate.

Complete Primary Care is a health record system designed by two Port Macquarie GPs to provide more effective treatment to older patients. The system facilitates the use of Enhanced Primary Care items, allied health consultations and home medication reviews without the dreaded paperwork which doctors often say makes these items hard to use. The system offers better business potential for doctors and better clinical outcomes for patients.

As I said at the outset, there will be no functioning E-Health system without the involvement of doctors. Doctors need to appreciate that professional practice can no longer be oblivious to the potential of information technology. Doctors can't leave information technology to secretaries and accountants or to governments. Government still has a crucial role but it's more to provide the right balance of requirements and incentives to promote best professional practice rather than to design and build complete medical technology systems.

For its part, the Commonwealth Government is currently talking to banks and other financial service organisations about enabling patients to access their Medicare rebate simply by swiping their card at doctors' surgeries. It should not be necessary for patients to carry bank account details with them and for receptionists to have to enter these details for every transaction when no other financial transaction is so cumbersome. The Government expects to have more user-friendly arrangements in operation by the middle of next year.

Convenient financial systems are as much part of quality health services as well-equipped premises. Hence, the Government intends to consult with the AMA and the College of General Practitioners about a timetable for requiring GPs to offer Medicare card swipe facilities as part of practice accreditation and access to Practice Incentive Payments. Once the appropriate systems are in place, it's not unreasonable to expect change that patients will notice and appreciate within months rather than years.

Again, as I suggested at the outset, it's hardly professional to keep case notes that can't easily be accessed by other members of a care team or, sometimes, that can't even be read by anyone other than the original author. On this score too, the Government intends to consult with the AMA and the professional colleges about swiftly making it a requirement of continuing accreditation to have accessible case notes.

The Government also believes that some of the privacy fears surrounding health information could be reduced (if not entirely eliminated) if patients had immediate access to their own health records (and had the capacity to mask anything they did not want others to see). Ideally, patients would not regard an integrated health record as an opportunity for health authorities to know more about them but as chance for them to know more about themselves. An accessible health record means that patients would no longer have to ask their doctor about when they had their last tetanus shot or when they last took a particular medicine.

The Department of Health is working with the Department of Human Services to investigate the feasibility of converting the existing Medicare Benefits Schedule and Pharmaceutical Benefits Scheme data into information that patients could readily follow and then making it securely available on the internet. If people can access their bank account details via the internet, there's no reason why they shouldn't be able to view their health records in much the same way. It ought to be possible to link patients' verified health data to their Medicare and PBS details so that people who were happy to let treating professionals have potentially life-saving knowledge about them could readily make it available.

Giving people more access to health data could promote a greater sense of patients' own role in health care and an understanding that health care involves what we do for ourselves as much as the treatments we receive from our doctors. Patients who could access their Medicare and PBS data, plus their immunisation status and safety net eligibility on the net might start to ask why summaries of their consultation and procedure case notes could not also be made available. They might start to demand the ability to keep pathology and radiology results in an accessible data base rather than in a cupboard at home. Notwithstanding the notorious length of time systems engineering always seems to take, I'd be disappointed if at least some health data can't be made available on-line to patients within 18 months.

Just over two years ago, the first scripted speech I made as Health Minister was about the importance of creating an E-Health system. At that time, in my inexperience, I declared that it must be possible to bring about such a self-evidently worthy goal within five years. Despite the hard lessons since, I'm more convinced than ever of the importance of this project for the long-term good of the health system. It may never be the most pressing task for the people running our system but it may be the most important practical measure policy-makers can pursue to make it more efficient and more responsive to patients.

Additional comments by Ken Ticehurst:
One of the key messages the Minister made was that the country is relying on medical practitioners to adopt new types of information technology. There are challenges with data entry however I have been using voice dictation technology. This can be linked with mobile phones and voice dictation devices. It is possible to send voice messages over the phone or internet.

Keeping track of contact information is much simpler with Personal Information System.

Broadband is being more widely rolled out, with Telstra upgrading the CDMA network.

The power of the internet has to be harnessed by the profession to support mobile access to records and support the provision of patient information. I have developed an early warning system for lightening used over the whole country and delivered on the internet.

A key challenge to the profession is to simplify the billing process. The ability to use swipe cards to allow patients to pay the gap and have the balance move to their bank account would be very useful.

Finally look after your data, regular backups are essential.