PCEHR-Benefits

PCEHR Benefits I do not think anyone will use it. There will not be sufficient, comprehensive data to make it worthwhile. That is before you get into the "can I trust it" question and this is the real worry.

(Terry Hannan). I think this PCEHR Concept of Operations document provides a line in the sand for ACHI to comment on. Until now we have no 'definitions' from NEHTA or DoHA so now we can pool our collective knowledge to attempt to guide these departments as to waht is the best course for e-Health which includes that used by patients (i.e all of us-one for every member of the population) and includes 'entities' such as a PCEHR. ACHIs role as an informatics professional peer group MUST at minimum document what the College as a group considers the best way to proceed. In the end if they do not listen then ther eis little we can do. Doing nothing is worse. I hope these comments fit in with Enrico's original comments of not being entirely negative. Has anyone considered what happens to all this when the Opposition comes to power with a leader who has more doubts about e-health than climate change? A former health minister in the now oppostion stated publically that "it has nothing to do with patients it is about the money and gettign re-elected"! ACHI as a College must document why e-Health is essentail as per __the IOM study in 1991__. "The computer-based patient record the ESSENTIAL technology for health care."

As discussed in previous section. The benefits will be greatly diminished if there is not large take up. Opt out rather than opt in will help with this process. It is likely to cause more pain in the short term, however benefits will be realised in the longer term. It is not a case as to whether we should have an PCEHR; rather how it is best built, implemented and maintained in the longer term. Andrew C

(Paul Clarke) This document has not properly considered benefits in any depth nor how they may be practically achieved. It would be hoped that the Department will conduct a comprehensive and detailed cost-benefits analysis once the full scope of the PCEHR is determined and that this analysis be used in conjunction with completion and review of the detailed planning and specification (including detailed functioanl and technical specifications - note the recent review of the NHS EHR implementation (report dated 18 May 2011) has highlighted the failure to complete the detailed planning and specification prior to implementation of the detailed care record systems) of the PCEHR (which are substantial and critical pieces of work yet to be completed) to enable an informed decision making process by the Government on not only whether or not to proceed with the PCEHR as scoped but also whether it is prudent to contemplate or enact any alternative options / approaches if the costs, technical complexity or risks are considered to far outweigh the benefits of the PCEHR as finally scoped and presented for final approval before proceeding. It should be noted that a cost benefits analysis should accordingly consider a range of strategic and technical options to the recommended approach (as scoped) which should be at least considered in terms of their strategic value, ability to satisfy the primary objectives, costs, benefits, impact assessment - technical, stakeholder, implementation, adoption etc, comprehensive risk assessment, timeframe to deliver.

Having said that, the benefits outlined in the table are largely centered around access to the PCEHR information, improvements in care delivery and provider productivity and efficiency related benefits, however, realisation of these benefits will be problematic, given the following: a. the value of the PCEHR in terms of provision of care delivery is highly dependent on the scope, quality, accuracy, comprehensiveness and integrity of the data held and the utility of the information within a broad range of clinical scenarios / patient settings b. the comprehensiveness of the data held in the PCEHR cannot be guaranteed (due to the opt-out option afforded to patients) and the broad summary data intended to be drawn on to populate the PCEHR, there is questionable value to clinicians (as opposed to detailed medical records that clinicians already hold and rely on for care delivery) c. From a medico-legal perspective, the liability of providers that make clinical decisions based on data held in the PCEHR (compared with their own comprehensive medical records) and also for the providers of informatation that will populate the PCEHR is uncertain across a range of scenarios, eg if there was critical information missing, wrong information or inaccurate information stored in a PCEHR record that the provider was unaware of and the provider made clinical decisions on care delivery to the patient based on exactly what information was held in the PCEHR, and this resulted in a patient adverse event. The Department will need to seek legal advice on medico-legal liability for the providers and users of the information, once the final scope and detailed specification of the PCEHR has been completed. c. there appears to be no consideration of the impact of the PCEHR on clinical providers in their provision of care in a time-constrained, fee for service patient consultation setting - in particular given the requirements of providers to populate and review PCEHR data in a patient consultation as envisaged in the CONOPS document - this is a major assumption that would need to be properly tested (investigated fully through broad consultation with all stakeholder provider groups) as there is no analysis of teh willingness of providers to do this nor any mention of any financial compensation for the additional time required of providers to do this. d. there are many references in the literature that substantiate the significant benefits of provider based EMR's in terms of patient care and safety when implemented in conjunction with electronic clinical descision support. The PCEHR, as currently scoped is a summary based record (as opposed to a comprehensive provider based EMR) and there has been no reference to teh impmlementation of clinicial decisison support as part of this project. Currently, there is no reference in the literature to any PCEHR implementations that have delivered any quantifiable patient care delivery and safety benefits e. quantification of the benefits identified in the CONOPS will be difficult. Achievement of the benefits is predicated on provider care delivery process changes. It would be recommended that a comprehensive benefits assessment (as part of the proposed cost-benefits analysis - see above) be conducted to identify exactly what stakeholder and provider operational changes / workflow changes need to be made to realise the productivity, efficiency and care delivery benefits proposed and to complete the necessary planning and costing of this for due consideration. f. timely access to clinical information across the full range of clinical settings is an important benefit for time-starved clinical providers, however, there is currently no detailed technical architecture of the PCEHR. It is not clear how PCEHR longitudinal data will be sorted, archived and accessed efficiently over by providers over time - particularly for chronically ill patients with complex conditions, multiple morbidities, numerous treatments, interventions etc and hence a large amount of data will potentially be stored ' over time - fast, efficient access, navigation and presentation of the most clinically relevant and important information is critical in a patient consultation setting g. Patient benefits do not appear to include the assurance of privacy, security and confidentiality of information held within the PCEHR over time, however these are benefits that should be properly evaluated. The PCEHR project must include systems and processes to ensure that all access to, manipulation, processing and use of information held within the PCEHR systems is appropriately authorised and fully monitored and any breech or unauthorised access, manipulation, deletion, merging, copying / replication, transmission or encryption of PCEHR information must be detectable and the source identifiable for prosecution or remedial action. Most importantly, in the event of a breech, there needs to be appropriate action taken to maintain patient confidence in the PCEHR system through formal commitment to make any reasonable operational changes to PCEHR systems promptly and effectively to mitigate or avoid any further breeches of the same type The benefits of privacy, security and confidentiality of PCEHR information to the patient should be properly evaluated over time. This should consider a range of metrics that evaluate the effectiveness and efficiency of the detection, remedial action and notification processes, such as incidence of breeches, severity / type of breeches, number of successful prosecutions / enaction of remedial action, number of unresolved / outstanding breeches, number of notification of breeches, amount of compensation ($) paid to patients, costed amount of actions taken to improve / rectify deficiencies in PCEHR handling of privacy, security and confidentiality of data accessed or stored in the PCEHR systems etc. Data concerning breeches should be made publicly available (via website). In addition, all patients impacted by a specific breech should be properly notified (with appropriate details concerning the nature of and action taken to remedy / rectify the breech) h. The benefits realisation and flow will be heavily dependent on: (i) the timeframe for delivery of the scoped functionality. The roll-out of the PCEHR system will take many years to be fully functional with the richness of data intended (at least 2020, according to Paul Madden, DOHA CIO - refer to Australian IT Section - 24/5/2011). Given that there is currently no detail regarding the functional specification of the PCEHR, it is currently unclear what level of functionality is required (or should) be delivered and in what (realistic) timeframe this can and should be delivered to provide an acceptable positive impact on adoption by patients and providers (ii) the adoption rate of the PCEHR system by patients and providers will impact on the realisation of benefits and the quantum of benefits over time - this needs to be properly modelled as part of the cost-benefits analysis (referred to above). (iii) many of the required clinical feeder systems (that are referred to in the CONOPS document to be connected to the PCEHR systems) do not currently exist or will require substantial modification to enable them to be interfaced to the PCEHR systems. This will require a substantial number of sub-projects that are critical to the delivery of a fully functional PCEHR to be delivered as part of the overall project. In addition, this does not appear to be costed and will need to be incorporated into the detailed planning and finalisation of scope yet to be completed.

DM - It is worth noting there is actually a cost benefits study, for the PCEHR, which was used by NEHTA / DoHA to define the $477M that was to be invested over two years. Of course that business case is 'secret' as is the usual form with these things.

It is also worth noting that earlier business cases developed by NEHTA had a heavy dependence (over 50% of total) for benefits on Clinical Decision Support - and that is not being provided by the PCEHR - indeed is a problem specifically for the feeder systems.

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