Transcript E-health

E-Health:
The Foundations
NHHRC & COAG and Why E-health is
important: How to get on with it!
Royal Australasian College of Medical Administrators
TC / Melbourne, 16/7/2010
National E-Health Transistion Authority
www.nehta.gov.au
12 April 2017
Professor Mukesh Haikerwal
•General Medical Practitioner
•Professorial Fellow, Flinders University
•Head Clinical Unit, National Clinical Lead,
E-Health: National
Shaping the
future Transition
of healthcare
-a
E-Health
Authority
clinician’s view
•De-Commissioned
Commissioner,
National Health & Hospitals Reform
Commission
•Chair, Finance and Planning, World
Medical Association
•Past President, Australian Medical
Association
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12 April 2017
NHHRC: The 4 Pillars
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Joining up the Dots
Communications
between care
centres within the
Hospital or
Community
sector and the
GP or other
Primary Carer
National E-Health Transistion Authority
E-Health: Enabler for Australia’s Health Reform. Booz & Company, 27/11/2008.
http://www.nhhrc.org.au/internet/nhhrc/publishing.nsf/Content/discussion-papers
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12 April 2017
COAG OUTCOMES: 2010 REFORM?
Major element
Primary health care:
transfer of funding
and policy
responsibility to CW
Primary health care:
transfer of funding
and policy
responsibility to CW
(ctd)
Details
Classes of service have been agreed for transfer from July 2011 including (Clause B10):
Community health centre PHC services
Primary mental health care services: more common mild to moderate mental illnesses
Hospital avoidance programs that do not relate to patients being treated in acute care
Primary and secondary prevention programs for early intervention and care coordination
that focus on the management of patients with chronic disease in the community;
Cancer screening programs for cancer delivered in a PHC setting
Immunisation
Funding and other arrangements related to PHC transfer:
There is to be consultation with local governments (B37a)
States are required to maintain current level of effort in these services until July 2012
(B37d) (Note: 1 year after the transfer date of July 2011)
Variations include: Victoria has not agreed to transfer immunisation, and Tasmania is still
considering its position on transfer of primary mental health services (B37b & c)
Funding for the transfer of PHC services from states is included in the dedicated share of the
GST retained by the CW (C3b)
CW will not substantially alter delivery mechanisms for transferred services for 5 years after
July 2011 unless relevant state agrees (B7)
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COAG OUTCOMES: 2010 REFORM?
12 April 2017
Major element
Aged care transfer of
funding and policy
responsibility to CW
Details
CW will take full responsibility for a consistent and unified aged care system, as follows:
Current arrangements for joint funding of HACC services by CW and states will cease
from 30 June 2011 (B29; Appendix 3: Clause 8)
In simplified terms, CW will be responsible for HACC basic community care services
for people aged 65 or over, while states will be responsible for same services for
people aged under 65 years (Note: age is used as the threshold, not disability status)
(B32, 33)
The CW will assume funding responsibility for specialist disability services provided to
people aged 65 and over, while states will assume funding responsibility for community
packages and residential aged care for people under the age of 65 (B32, 33)
The age threshold for Indigenous Australians is 50 years, not 65 years; specific
arrangements relate to Indigenous Australians 50-64 years (Appendix 3, Clause 11)
Regulatory responsibilities (see Appendix 3, Clause 14, 15) are not fully aligned with
funding responsibilities; the CW retains regulatory responsibility for all community and
residential aged care; states retain responsibility for regulating specialist disability
services; both levels of government regulate ‘basic community care services’ (i.e.
HACC)
In regard to HACC services, the Agreement makes explicit that there is no
requirement for competitive tendering (Appendix 3, Clause 12); that services will
continue to be provided by mix of local government, NGO and states (App 3, Clause
18); and that providers will be able to service both clients with a disability and aged
clients
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COAG OUTCOMES: 2010 REFORM?
Major element
Mental health
National Access
Targets (NATS) and
National Access
Guarantees (NAGs)
Details
The Agreement is relatively silent on mental health issues with the following exceptions:
Primary mental health services targeting the more common mild to moderate mental
illnesses are to be transferred
There is to be a report back to COAG in 2011 about the potential for specialist mental
health services to be either transferred to the CW or for strong national reform (B34b)
The Commonwealth and states have agreed to create linkages and coordination
mechanisms between PHCOs and other state services such as those catering for people with
serious mental illness (B22)
Most of the commitments for additional mental health investment:
$78.3 million over 4 years for youth-friendly services (headspace)
$24.8 million over 4 years to expand Early Psychosis Prevention and Intervention Centre
(EPICC) model
$57.4 million over 4 years to care packages through the Access to Allied Psychological
Services arrangements for people with severe mental illness
$13 million over 2 years for extra mental health services
The $1.62 billion of capital investment in sub-acute care includes the provision of ‘step up,
step down’ sub-acute services for people with mental health needs
Neither NAGS nor NATS are explicitly mentioned in the actual NHHN Agreement.
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12 April 2017
COAG OUTCOMES: 2010 REFORM?
Major element
Details
The Agreement only mentions sub-acute in the context of it being one of the streams for
ABF.
All the sub-acute funding commitments include:
$1.62 billion to fully fund the capital and recurrent costs of an estimated 1,316 real, new,
sub-acute care beds by
It is also stated that there will be 1,200 “packages of sub-acute care over four years” and
that sub-acute includes “rehabilitation, palliative care, mental health and geriatric services
There is a further $200 million that states can use flexibly across EDs, elective surgery and
sub-acute
Sub-acute
Primary health care
organisations (PHCOs)
The establishment of PHCOs (Schedule B) will occur as follows:
PHCOs will be established as independent legal entities (B15), with the first to be
operational by mid 2011
Clause B26 outlines the specific responsibilities of PHCOs and Clause B2 includes the aims
The governance of PHCOs will include broad community and health professional
representation, as well as business and management expertise, with strong clinical
leadership (B17); there is also expected to be some commonality of governance membership
between PHCOs and LHNs (B18)
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COAG DIRECTION inc : 2010
$0.00 fore-Health: Business Case for
IEHR noted!
Approved by AMHC
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12 April 2017
PCEHR
2010 Budget Table
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12 April 2017
RELEASE OF ROADMAP TO REFORM
7/7/2010
The timeline for the further delivery of better health and hospital services released
by the Minister for Health and Ageing.
The implementation plan clearly shows what is already happening, and the delivery
dates for other initiatives. This work includes:
Health reforms already underway
Hospitals – extra funding to take the pressure off our stretched emergency
departments and to deliver more elective surgery procedures has already
started to flow.
Better safety and quality standards – legislation has been introduced into
Parliament.
E-health – passed the key legislation giving unique health identifiers to all
Australians.
Better GP facilities – GPs can now apply for up to $500,000 to improve patient
facilities.
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12 April 2017
RELEASE OF ROADMAP TO REFORM
7/7/2010
Later this year
Commencing this year, 1,316 sub-acute beds will be established to
provide approximately 24,900 additional services over four years for
people needing care for mental health issues, rehabilitation and
terminal illnesses.
Funding starts flowing to double the number of headspace mental health
facilities.
Starting this year, an additional 11,700 services will be provided over two
years by mental health care nurses
Additional telephone-based counselling for alcohol problems.
Innovative programs to tackle binge drinking begin.
Local Hospital Network and Medicare Local boundaries decided.
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12 April 2017
RELEASE OF ROADMAP TO REFORM
7/7/2010
January 2011 - Four Hour Emergency Department treatment target for high needs
patients starts.
July 2011
Any person, anywhere in Australia can pick up the phone to an after-hours GP
telephone service – any time of the day or night.
Establishment of the first Medicare Locals and Local Hospital Networks dedicated
to improving local health services.
Network of aged-care ‘one-stop shops’ commence.
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12 April 2017
What is E-Health?
E-Health is the use, in the health sector, of digital
data - transmitted, stored and retrieved
electronically
- in support of health care, both at
Definition
the local site and at a distance.
World Health Organisation’s definition of E-Health: www.who.int
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12 April 2017
Transitions
From Stacks of paper…..
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To secure, searchable
robust IT stacks….!
12 April 2017
Danish Situation in 1992
Each GP needed hundreds of different paper
based forms
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12 April 2017
Benefits of a National Approach
Cumulative Net Benefits of Alternative IEHR Strategies
Cumulative Net Benefit ($m)
28.000
Option 3: National IEHR
26.000
24.000
22.000
20.000
18.000
16.000
14.000
12.000
10.000
8.000
6.000
Option 2: Independent IEHRs
4.000
Option 1: Do Nothing
2.000
0
-2.000
2009- 2010- 2011- 2012- 2013- 2014- 2015- 2016- 2017- 201810
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National E-Health Transistion Authority
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E-Health: Enabler for Australia’s Health Reform. Booz & Company, 27/11/2008.
http://www.nhhrc.org.au/internet/nhhrc/publishing.nsf/Content/discussion-papers
12 April 2017
NHHRC & E-Health
NHHRC Recommendations:
13. To support people’s decision
making and management of their
own health we recommend that, by
2012, every Australian should be
able to have a personal electronic
health record that will at all times be
owned and controlled by
that person.
National E-Health Transistion Authority
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12 April 2017
NHHRC & E-Health
NHHRC Recommendations:
Implementing a national e-health system
120. (1)We recommend that the Commonwealth Government mandate that
the payment of public and private benefits for all health and aged
care services depend upon the ability to accept and provide data to
patients, their authorised carers, and their authorised health providers, in
a format that can be integrated into a personal electronic health record,
such that:
hospitals must be able to accept and send key data, such as referral
and discharge information (‘clinical information transfer’), by 1 July 2012;
pathology providers and diagnostic imaging providers must be able
to provide key data, such as reports of investigations and
supplementary information, by 1 July 2012;
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12 April 2017
NHHRC & E-Health
NHHRC Recommendations:
Implementing a national e-health system
120. (2)We recommend that…:
other health service providers – including general practitioners,
medical and non-medical specialists, pharmacists and other
health and aged care providers – must be able to transmit key
data, such as referral and discharge information (clinical
information transfer), prescribed and dispensed medications and
synopses of diagnoses by 1 January 2013; and
all other health care providers must be able to accept and send
data from other health care providers by 2013
National E-Health Transistion Authority
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12 April 2017
NHHRC & E-Health
NHHRC Recommendations:
Implementing a national e-health system
121. We recommend that the Commonwealth Government takes
responsibility for, and accelerate the development of a national
policy and open technical standards framework for ehealth, and that they secure national agreement to this
framework for e-health by 2011-12. These standards
should include key requirements such as
interoperability, compliance and security. The standards
should be developed with the participation and commitment of state
governments, the IT vendor industry, health professionals, and
consumers and should guide the long-term convergence of local systems
into an integrated but evolving national healthinformation system.
National E-Health Transistion Authority
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NHHRC: PEHR & shaping future
healthcare
12 April 2017
PEHR Explanation
For best health care and outcomes available records on PEHR,
should be:
 Comprehensive
 accurate and the concept of accurately recording
 up to date (requires data cleaning)
 PROVENANCE of entries is crucial
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NHHRC: PEHR & shaping future
healthcare
12 April 2017
PEHR Explanation
The veracity of the record as a trusted source must be
assured to allow it to be a source of data when making
clinical decisions.
The patient area for documentation by the individual, their
carer or other authorised representative / advocate is a
respected source and clearly annotated as such.
It is a vital part of the record providing information to guide care.
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An integrated approach
12 April 2017
Deloitte National EHealth Strategy
www.health.gov.au
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12 April 2017
Strategic Priority Development
To develop the Strategic Priority areas for NEHTA, an analytical framework has been used to
collate the data from various sources. The different recommendations, priorities, initiatives,
issues, concerns and principles were collected from multiple sources. These have been analysed
and grouped into four key strategic priorities for NEHTA.
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Recommendations
Principles
Priorities
Issues
Strategic Streams
Key Actions
Grouping
Workshops
Interviews
Other publications:
Australian Medical
Association, Australian
General Practice Network
Strategic Priorities
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Each Strategic Priority is then underpinned by a set of Strategic Initiatives, which articulate the
specific activity required in order to deliver on the outcomes of the four priority areas.
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Strategic Priorities and Initiatives
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Individual Electronic Health Record
12 April 2017
 Entire health profile in one view
 Supports self-managed and
preventative health
 Shared access for (authorised)
providers
 Clinical and workflow benefits
 Information source (de-identified) for
national health analysis and
evaluation
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12 April 2017
NHHRC & E-Health
NHHRC Recommendations:
Implementing a national e-health system
117. We recommend that the Commonwealth Government introduce:
unique personal identifiers for health care by 1 July 2010;
unique health professional identifiers (HPI-I), beginning with all nationally
registered health professionals, by 1 July 2010;
a system for verifying the authenticity of patients and professionals for this
purpose - a national authentication service and directory for health
(NASH) - by 1 July 2010; and
unique health professional organisation (facility and health service)
identifiers (HPI-O) by 1 July 2010.
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12 April 2017
The Foundations: Health Identifiers
• Ensures that the right information is
associated with the right person
• Operational July 2010
• Leverages Medicare
• The Healthcare Identifiers (HI) Service has
three primary core service components:
1. IHI : Individual Healthcare Identifier
2. HPI-I: Healthcare Provider IdentifierIndividual
3. HPI-O: Healthcare Provider Identifier –
Organisation
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Passed by Senate:1945/Reps: 2030 – 24/6/2010!
12 April 2017
E-Health:
The Foundations
The model healthcare community
The Model Health Community enables key stakeholders to:
1. See a demonstration of the HI Service that has been delivered
under Release 1
2. obtain a shared understanding of how the HI Service would, subject
to the required legislation being in place, be implemented and what
additional services will be delivered under Releases 2 and 3
3. provide feedback on the design and proposed approach to
implementation
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Page 29
12 April 2017
Key Requirements
The Absolute must haves….aka show stoppers..
1. A robust Privacy regime with powers and infrastructure
to police and prosecute breaches.
2. Secure and inter-operable systems
3. Nationally consistent standards
4. Compliance with Standards
5. Medico-legal requirements in-built from the ground up
6. A clinical safety and quality framework
7. On-going evaluation and constant review of systems
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What E-Health Can Deliver (1)
12 April 2017
Improved management of healthcare information through e-health offers
significant safety and quality benefits for all Australians.
SAFER HEALTHCARE
 Improving direct patient care as a consequence of timely access
to the transfer of better and more accurate clinical information
 Improvements to safety & quality from the capacity to share
clinical information and use of clinical decision support systems
 Continuity of Care
ACCESSIBLE HEALTHCARE
 Continuing to support choice in our health system
 Improving responsiveness in our health system to local needs
and demands
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What E-Health Can Deliver (2)
12 April 2017
Improved management of healthcare information through e-health offers
significant safety and quality benefits for all Australians.
EFFICIENT AND SUSTAINABLE HEALTHCARE
 Improved effectiveness in allocating health resources
 Improve management /planning of services (accurate / timely info)
 Contributing to increased accountability
 Monitoring health reform and performance of the health sector
 Cost savings: reduce duplication of treatment, tests and admissions
 Capacity for disease surveillance and disease management
especially with emerging diseases (HIV, Swine ‘flu’, Bird 'flu’, SARS)
 Improved outcomes in public health as more accurate health data
 Improving health research: access accurate and timely data
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What E-Health Can Deliver (3)
12 April 2017
Improved management of healthcare information through e-health offers
significant safety and quality benefits for all Australians.
HIGHER QUALITY HEALTHCARE
 Supporting team-based care: capacity to engage all health professionals in an
individual’s healthcare delivery through improved access to shared clinical
information
 Supporting improvements in chronic disease management
 Increasing the capacity for knowledge sharing nationally and internationally
EQUITABLE HEALTHCARE
 Promoting innovation and responsiveness to local needs and demands arising
from improved population health data, health monitoring and surveillance
 Consumer empowerment by increasing consumer access to tools that support
self health caring/health management, health awareness and literacy
 Ensuring transparency
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12 April 2017
E-Health:
The Foundations
Building blocks to e-health
Individual Electronic
Health Record
Clinical
Information
Individual
Information
Shared
Information
(Others)
E-Health Services
Shared Health
Profile
Event
Summaries
Self Managed
Care
Complex Care
Management
E-Health Solutions
ePathology
eDischarge
eReferral
eMedications
National Infrastructure
Components
Terminology
Secure
Messaging
Identifiers
Authentication
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12 April 2017
Messaging is easy and quick!
The messaging process will be carried
out automatically by the computer
systems used by each party.
From the viewpoint of clinical users of
these systems, the messaging
process will be:
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 Secure.
 Reliable.
 Invisible.
12 April 2017
GPAG Programme: Background
• A recognised need to improve e-communication, particularly with
Specialist rooms, Private Hospitals and Private Allied Health.
• Variety of clinical software products - each with its own patient record
• Historically no common easy to use way to transfer patient data efficiently
• Many still using Mail and Fax!
• Patient continuity of care is affected
• High need for a mechanism to connect providers
• The Division took a lead and selected a secure messaging system called
Referral-Net from Global Health
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www.gpageelong.com.au
12 April 2017
What is Referral-Net?
Secure Messaging software:
•Takes a document from a software package
•Scrambles and sends over the internet
•Receiver unscrambles and reads / files in the clinical record
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12 April 2017
Soothe the anxieties...
Labour
Day
2008:
Firepower
substation
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12 April 2017
Soothe the anxieties...
Labour
Day
2008:
Firepower
substation
My Practice!
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12 April 2017
Soothe the anxieties...(1)
Increasing connections & comfort
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Power cuts
The blue screen of death
Costs
Security of data
Blame game!
Swimming alone: provide the life guard
Provide robust /practical defensible Standards
Use the good offices which are respected to
increase confidence: by addressing
their concerns
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12 April 2017
Soothe the anxieties...(2)
Reality check
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Hole in the wall
E-mail / Internet information
E-Commerce
E-Banking
Losing the baggage
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Legacy of Windows
Upgrading and heartburn
Information loss
Data conversion
12 April 2017
Get going, keep going...
Future proofing
 NEHTA standards evolve too
 Achieving Standards gives surety
 Standards bring inter-operability
 Thinking of how future adaptations can be
incorporated but getting going Vs. waiting….and
waiting…and never actually taking up new
technologies
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12 April 2017
Themes...re-assure the Clinician!
IT is a tool
IT adds to clinical method
There is value in the Clinical record
The IP (intellectual property) has value
There are costs to the Provider including:
 Hardware, Software,
 Time to Explain to, Enroll and Answer patients
 Training: Implementing and Adapting to
Change
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12 April 2017
Themes...caution! Proceed with care
Bureaucracy & Control
Data Measure and benchmarks: Quality
Assurance Vs. Quality Control
Best available evidence
Best Practice Guidelines not Protocols
Enthuse Public & Health Care Workers
Preserve Clinical drivers & governance
Best evidence & practice will Change
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Secure Massaging in a nutshell
12 April 2017

Connectivity:
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
secure, reliable end-to-end communication between identified parties of a
specified message (eg a pathology report)
It entails all the processes required to ensure that communication
between healthcare organisations is:
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Identified – the sender and receiver are known
Authenticated – their identities are confirmed
Authorised – the communication is from a permitted party
Secured – it is encrypted & signed to prevent unauthorised reading/tampering
Located – it is directed to the address of the intended recipient’s service
Specific – the payload type and the action required is known
Reliable – the delivery is reliable, confirmed and unique
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12 April 2017
Thank You
Questions
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NHHRC: PEHR & shaping future healthcare
12 April 2017
PEHR Explanation: 1
Smart use of data is at the core of a
self-improving system
Key: nationally consistent standards
Data:
•Should drive Clinical decision-making
•Measure and improve health outcomes
•Measure and improve performance
•Transparent reporting
•Inform Planning
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NHHRC: PEHR & shaping future healthcare
12 April 2017
PEHR Explanation: 2
• All ‘users’ - consumers, health professionals,
managers, funders and governments have a part and will
benefit
• Access record: generate an audit trail to inform us
when and by who record viewed
•
•
•
•
Patient does not hold the infra-structure
They will not be using a USB key
They do control the access to the data
This does not change GP/local/hospital
records, use or ownership
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12 April 2017
E-Health: Shaping the future of healthcare
PEHR Explanation: 3
CORE COMPONENT: HEALTH SUMMARY RECORD: like
RACGP’s
Maintained at the Patient’s choice of ‘Health Care Home’: Generally by the
GP in the Practice setting (or other authorised source).
All Providers are part of the System which will provide data that is:
• Technologically current
• secure
• standards driven
• quality assured
Being able to link data:
Consistently
Confidence of users (Providers & Consumers)
Consent and Confidentiality
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NHHRC: PEHR & shaping future healthcare
12 April 2017
PEHR Explanation:4
System FOR the patient / citizen at the centre of the information tree
The PEHR is a driver of the change: bold and clear expectations
(from the health eco-system)
Our PEHR: We citizens drive:
What is on it
Who we permit to access it and write to it.
Control access to our own health information
(what information shared and with whom including which health practitioners –trusted source);
(add information: self carer alternative self-management (e.g. monitoring BP DM) (respected source)
Where and how health record stored, backed-up retrieved
Integrity of the data and provenance (who wrote the entry) is core
Can base decisions on this with PROVENANCE.
An entry can be added to or removed “in
toto” from share not altered
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NHHRC: PEHR & shaping future healthcare
12 April 2017
PEHR Explanation:5
Understand and inform that our care is better co-ordinated
• within practices
• between providers
Outcomes and satisfaction enhanced if information about care:
•
•
•
•
available at the point of care
up to date historical information
timely new interaction information
accurate
Enabled greater e-Health environment :
added functionality
indexed
allowing exchange of information from various data repositories.
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NHHRC: PEHR & shaping future healthcare
12 April 2017
PEHR Explanation:6
Patients controlling access to their own health information
may be confronting: can be liberating!
Patients chose to access different practitioners at points in
their life
may choose not to reveal all the details of their health and
health care.
This is regrettable and hampers their care and hinders the
efforts of those treating them.
National E-Health Transistion Authority
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NHHRC: PEHR & shaping future healthcare
12 April 2017
PEHR Explanation:7
A person-controlled electronic health record part of the
broader e-health environment
Health performance metrics measurement and data
enhance :
Health research and planning
Recognise, plan for and combat disease
Need ongoing development of e-Health records by health services
Must join up and integrate information across the care continuum.
General Practice consults: encounter remains on the
practice/primary care organisation’s system.
National E-Health Transistion Authority
www.nehta.gov.au
NHHRC: PEHR & shaping future healthcare
12 April 2017
PEHR Explanation:8
Add to the PEHR summary record (from the GPs, hospitals or other
trusted sources) at the push of a button (with patient request)
Patient requests information to be stored on their
PEHR
Copy resides on PEHR and in the Practice.
Accessed with patient permission by authenticated users
Enhance care co-ordination which is more complex
National E-Health Transistion Authority
www.nehta.gov.au
NHHRC: PEHR & shaping future healthcare
12 April 2017
PEHR Explanation:9
PEHR full and comprehensive summary of patient history e.g.
 Medications
 Allergies
 encounters with medical and other specialists
 pathology and radiology results and
 possible access to images can be through it being used as a
portal
but it may not be complete if patients so desire.
Health professionals are aware that even today all records
may not be complete.
National E-Health Transistion Authority
www.nehta.gov.au
NHHRC: PEHR & shaping future healthcare
12 April 2017
PEHR Explanation:10
For best health care and outcomes available records on PEHR, should be:
 Comprehensive
 accurate and the concept of accurately recording
 up to date (requires data cleaning)
 PROVENANCE of entries is crucial
The veracity of the record as a trusted source must be assured to allow it
to be a source of data when making clinical decisions.
The patient area for documentation by the individual, their carer or other
authorised representative / advocate is a respected source and clearly
annotated as such.
It is a vital part of the record providing information to guide care.
National E-Health Transistion Authority
www.nehta.gov.au