The digital health land that time (and govt) forgot

11 minute read

Somebody left the specialists off the country’s healthcare digital transformation party invitation list. At least, for now At this month’s senate hearings into the My Health Record (MHR) one of the star witnesses for the defence (the defence of the MHR that is), was the Australian Digital Health Agency’s (ADHA) chief operating office Ms Bettina […]

Somebody left the specialists off the country’s healthcare digital transformation party invitation list. At least, for now

At this month’s senate hearings into the My Health Record (MHR) one of the star witnesses for the defence (the defence of the MHR that is), was the Australian Digital Health Agency’s (ADHA) chief operating office Ms Bettina McMahon.

Ms McMahon is a very strong second act to the ADHA’s charismatic and articulate CEO Tim Kelsey, previously an accomplished war correspondent, highly successful entrepreneur in healthcare, and a senior figure in the British government’s rollout of transformational digital health strategies through the NHS a few years back.

Neither Ms Kelsey nor Ms McMahon get rattled much. And they’ve had a lot of reasons to be rattled lately.

Even though the MHR opt-out rollout had faltered enough  on privacy and a few other key issues to be referred by the Greens for a senate enquiry, and many in the public were aiming their submissions aggressively and squarely at what they felt was some fairly major screw-ups in rolling out this major piece of future health system infrastructure, both Mr Kelsey and Ms McMahon maintained an air of calm. And, importantly, they usually had a reasonable and logical sounding explanation for nearly everything that was thrown at them. 

It was rare that one of their senatorial inquisitors, even the Labor ones, who seemed a lot more interested and clued up on the issues surrounding the project than their Coalition counterparts, could trip up either Mr Kelsey or Ms McMahon.

But deep into the hearings on September 17 someone asked Ms McMahon a question that  seemed to catch her off guard.

After ADHA representatives had confidently and even proudly dispatched some impressive statistics around growing engagement on the rollout of the MHR, including that nearly 7000 GP practices and 4000 pharmacies, had already registered to use the MHR system, meaning a significant majority of our GP and pharmacist workforce now had access to this rapidly evolving database of the future, one senator followed up with the question: “How many specialists can access the system?”

Ms McMahon was initially perplexed. It was if she’d never been asked that before. She thought for a bit and then had to dive into a pile of files and whisper to a minder to get some answers. Eventually, in her inimitable style, she delivered.

The answer was 287.


It seemed like it couldn’t be right given all those impressive other figures for major  professional health provider groups.

Although Ms McMahon didn’t know the figure by rote, like she did so many others, she must of known it was extraordinarily low compared to all the other important healthcare professional groupings.

Of the nearly 14,000 healthcare organisations that qualify for a HIP-O number and are hence cleared to access the MHR, of which GPs make up just about half, only 287 private specialist practices have registered for the MHR.  Remember, registering does not mean a practice, or its doctors, actually use the MHR.

A few months back it was estimated that outside of GPs who were uploading patient summaries as a part of the PIP, something like only 6% of the GP workforce was regularly engaging in the MHR.

Apply that ratio to the 287 number and you get a very clear sense  that our approximately 30,000 dtong private-practising specialist workforce is largely disengaged with the MHR project.

This story started life as a suggestion by a Rheumatology Republic board member who , having fleetingly seen something on a bus stop poster  on the way to work recently that worried them a little, thought that specialists might be in need of a bit of a dummies guide to the MHR.

They pointed out that they didn’t know much about the MHR,  but they thought maybe they now should be, given all the recent bad media, and the implied importance of the project. They wondered if quite a few specialists might not also be in their position.

To do such an article you would need to assume that specialists knew at least the most basic things about the MHR, the objectives of the ADHA,  a bit of its history and its potentially pivotal role in reinventing key aspects of efficiency and safety in Australian healthcare delivery.

Given the long and very expensive gestation of the MHR  and the ADHA – both have cost about $2 billion so far – and given the importance of specialists as a professional healthcare group, you’d assume the majority of specialists might be up to speed.

But you should never assume, should you.

Most specialists don’t even remember getting a letter from the ADHA  in mid May this year outlining the impending opt-out launch.

The letter they were sent via email was mostly high-level imaginary future good news material. All good stuff, and interesting.  But not in the orbit of most specialists focussed on their daily clinical schedule and their businesses. And the letter contained nothing at all about where specialists would fit into the scheme of things.

I asked some of our board members on a straw poll – all highly influential and connected KOLs in their field – where they were on the MHR.

This was a typical answer:

“ I think I heard about it on the news, but I’m not really sure. I don’t use it. My patients don’t mention it. I have a patient management system but I have never noticed it (the MHR) and don’t know if it’s in there. I don’t have a MHR, and I have opted my whole family out. Personally, I would like to pick up the phone and talk to the right person to get the right information to care for my patients, rather than relying on potentially outdated online information of questionable provenance.”

This sort of “sample of one” anecdote, understandably, drives the ADHA apparatchiks a bit crazy. But if you add these anecdotes to the registered numbers on record, and you look at where in the ADHA’s strategy specialists seem to be countenanced (not really anywhere) you begin to suspect the situation is as bad as that anecdotal quote suggests.

Specialists are ill-informed about, indifferent too and not engaged with the MHR. And that’s not good. The MHR is an important, integrated, system-wide project. Not having specialists on board seems to be more than a “sequencing of strategy” issue.

Worse, at present, as a group specialists look set to continue on this path for some time without understanding just how important digital system integration  with something like the MHR might be with their clinical and working lives.

Do we risk specialists being isolated on an island of non-digital integration with the rest of the healthcare system? An island that time, and the government, hasn’t exactly forgotten, but certainly has pencilled in the diary for a later time.

There quite a few more specialists, and specialists in training, than GPs, and despite stories of hoards of croaky 72-year-olds dictating their notes to be transcribed by their equally aged PAs, many are modern and digitally savvy. Digitally frustrated, even.

According to James Scollay, the CEO of major specialist patient management vendor Genie Solutions, specialists are unclear on how or when they should be engaging with MHR and their major concern with the initiative, at this stage, is that they won’t be caught out by their patients with something on the MHR they need to have done, or that their patients expect they’ll be able to easily access it.

Genie, which services more than 50% of the 85-90% of privately practising specialists in the country, has MHR access capability within it. It is the only specialist patient management system that does. Which means that a not insignificant number of specialists could access the MHR if they were engaged enough to go through the registration process. On our numbers, that is maybe 16,000 or so of the 30,000 or so privately practising specialists.

Mr Scollay, who says he is working closely with the ADHA “to help advocate specialist requirements “ and is “committed to making sure our products give specialists the best possible interaction with MHR” believes the MHR will be very important to the future of specialist practice.

“MHR needs to provide a complete view of a patient’s healthcare and specialists are a vital part in the mix as they are usually involved in the most complex and important elements of healthcare but don’t necessarily have an ongoing relationship with patients”, he told Rheumatology Republic. “Therefore, having good access to the data related to their treatment is vital to their ongoing wellbeing.”

But the 287 number is as clear an indication as anything that the specialist community has been, at the very least, parked by the ADHA in terms of engagement in the project so far.

You might still be wondering why?

Well it wasn’t a flip of coin as to who got first dibs, GPs or specialists.  GPs are in front because of a perceived low level of computerisation by specialists, and, to some degree health system digital literacy.

GPs have been showered with attention and money by the ADHA in the recent relaunch of the MHR as an opt-out system.

PHNs have been funded into the millions to educate and train their GP flocks, and the RACGP has been engaged deeply at various levels in recruiting GPs into the plans of the ADHA.

The ADHA and the government feel that the best initial “bang for buck” is going to come from GPs, pharmacies and hospitals, all of which have very high levels of computer use and literacy.

Someone described this decision to me as ‘sequencing, not prioritising”, which might even make sense. Do GPs first, as they do have higher patient management system usage and connectivity, and they are the intersection between most primary and tertiary care. Then deal with specialists.

So there is a degree of logic in what the ADHA has decided. It’s just that it feels an awfully big hole to back-fill at a later date.

How less computerised than GPs are specialists, and perhaps more importantly, why and how does the government change that quickly?

The figures are not well understood.

It is estimated that somewhere around 85-90% of private practices use a PMS, but some don’t use them for clinical workflow, and therefore they aren’t really used by the specialists themselves but by back-office staff. So it is very hard to determine how many of that 90% of private specialists actually engage daily the digital world via their work computer.

But even discounting heavily for the effect of back-office use only, it feels like specialists in private practice are  still reasonably well computerised.

We think about 30,000 specialists are private practising, and the rest are public. Public practising specialists all have access to sophisticated hospital based systems, but it is difficult to gauge just how much they engage with them and how much they engage with the MHR as a result.

Hospital systems vary by hospital, by state and are eclectic at best.

We know that private and public hospital MHR registration is high and growing fast. But we don’t know clearly how much doctors actually access and use the MHR within those registered institutions. But there is a big push from the ADHA into hospitals, mainly because they want to break the traditional disconnect between primary and tertiary health.

The thing is, if you add up all this potential specialist access, it doesn’t feel like specialists are the dinosaurs in the digital health land that time forgot, which feels a little bit like how the ADHA is treating them.

Mr Scollay says most specialists he talks to are very computer savvy and quite frustrated by the limitations they face in their technology.

Around 1994, the federal government put a stake in the ground on GPs and computers, determining that for various reasons of efficiency in the system, they’d prefer GPs to be using computers to prescribe and record all their patient data.

They introduced a scheme through the long standing practice incentive program and  offered every GP in the country enough in one-off money to set themselves up with a computer and an electronic scriptwriter.

Within three years something like 85 to 90% of all GPs had a computer and were using electronic scriptwriting and record keeping.

That was a seminal few years for Australian healthcare because to this day, Australia has one of the most computerised GP sectors in the world.

We wonder whether the ADHA should rethink the “land time forgot” paradigm for specialists, and use some of that $350 million it gets each year to run its new centralised database, to encourage the specialist community to gear up over the next few years in a manner that will allow them to integrate digitally with the rest of the healthcare system.

That should bring  unheard of efficiencies, standards of safely and connectivity to the healthcare community.

For your tailored starting guide to the MHR (all we think you need to know in less than 1000 words and few picturess), please turn to our feature on page 20.

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