This week, I made an appointment to be treated at a large skin clinic which is very much at the "business end" of medical practice. The appointment book was computerised but the receptionist still wrote out a reminder card. The Medicare rebate could be claimed electronically from the surgery but only if I had available my bank account and BSB details; otherwise a cheque would be sent in the time-honoured way.
Although a growing minority of doctors now takes notes electronically, for the convenience of their practices, an integrated electronic health record that draws on the work of many different health professionals is still a long way off. That's because it's not in anyone's immediate interests to put in the effort. To doctors and other treating professionals, it often seems like a cost to them so that others can benefit. To senior health policy-makers, it is never as urgent a priority as providing better and more accessible clinical services or responding to the latest crisis.
My first scripted speech as health minister, in November 2003, set a five year deadline for an integrated electronic health record and for paperless Medicare claiming. Almost my last scripted speech nearly four years later, lamented that this target would be missed. That speech, which is electronically attached to this article, while admitting failure, also talked about the progress that had been made. I'd be interested in any informed observations about whether I was over-optimistic about imminent progress.
The inability of ministers, public servants, managers, IT experts and health professionals as yet to move the health sector into the modern world, at least in this one critical respect, constitutes an important systemic failure. The fact that no other country appears to have done much better is no excuse. It's important to reflect on the scope of this failure and to ponder what has contributed to it. In particular: why are doctors and other health professionals still reluctant to use IT for their clinical notes or for patient convenience; why won't health professionals and institutions more readily make their information available to patients or to other professionals; and why hasn't officialdom been able to change this in a decade of trying?
Doctors and other health professionals want to improve their professional standing, increase the size of their practices and boost their financial returns. Their primary professional concern is in treating their patients rather than in running their offices. Doctors are very interested in technology that will make them better doctors but much less interested in technology that will be more convenient for their patients unless, understandably enough, there's also something in it for them. This is not criticism of doctors, just recognition that they are human. Unless they couldn't possibly want more work or couldn't possibly question the standing of another professional, they are unlikely instinctively to support measures that dispense with the need for a further consultation or a new test. Like everyone, they often resent new technology, at least until they've mastered it, especially if it seems to be primarily there to help someone else.
Most GPs (albeit often reluctantly) have accepted the need to keep up-to-date their professional standards (through ongoing membership of the College of General Practice). This only happened once the government had decreed a lower Medicare rebate for non-vocationally-recognised doctors. GP surgeries are now mostly a far cry from the traditional room at the front of a house because practices need accreditation in order to qualify for government benefits such as the Practice Incentive Payment. I suspect that the quickest way to ensure that most doctors' clinical notes are IT compatible would be to make it part of vocational registration. This would be a matter for the relevant College which might be swayed by the reduction in medical error that legible case notes would achieve. I further suspect that the only way to speed the introduction of card-swipe claiming is to pay doctors for the resultant Medicare savings. This rarely appeals to officials with a tendency to regard doctors as over-paid already. Obviously, groups like the AMA would need a lot of persuading over any measure that had elements of compulsion.
On governments' part there have been two big obstacles to e-health progress. The first is the governmental tendency to prefer universal systems built to bureaucrats' specifications. The Eclipse system for private health insurance information and billing is a good example of how government-produced IT systems, unlike (say) the systems on which EFTPOS is based, never quite seem to work. The second is decision-makers' inevitable preoccupation with something more pressing or more immediately appreciated. Compared to listing a new drug, funding a new procedure or responding to another scandal, e-health is, at most, important but hardly urgent. Often, the people dealing with e-health are below decision-makers' pay grade while the real decision-makers aren't really engaged with e-health or familiar with the health benefits that IT can lead to.
Some health funds are developing online record systems for their members. The doctor participation required for information to be accurate and up-to-date might be hard to obtain. Because it already has Medicare and PBS data that could be made available to patients in intelligible form and provided by them to treating professionals, the federal government probably remains best-placed to sponsor the platform for an integrated electronic health record. If the work required to make this information available and accessible is a high priority for the new government, it's kept unusually quiet about it.
In my view, government should be prepared to pay for an e-claiming system that will reduce costs for Medicare; the professional colleges and the AMA should be involved in discussions about modern record-keeping; and the government should invest in giving each Australian an electronic health file that can be the repository for tests, scans, and information about medications, procedures and potentially life-threatening conditions. Almost by definition, newly elected governments are more competent than their defeated predecessors. Even so, achieving what everyone says is a good idea but isn't necessarily ready to work for will be a huge challenge for the new minister.
Tony Abbott is the federal member for Warringah, and shadow minister for families, community services, indigenous affairs and the voluntary sector.
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