Practice managementPractice administration applications such as billing and scheduling are prevalent among most medical specialists (Exhibit 3). These applications provide immediate efficiency and cash flow benefits at a relatively low cost. Decisions to implement and use billing and scheduling applications in private practices are usually made in conjunction with practice managers, who are often the primary users.
Viewing information created by othersSpecialists frequently use self-contained eHealth applications (i.e. uses that do not require information exchange) for accessing information and content provided by others. For example, 72 percent of survey respondents used computers for accessing health-related information, and 70 percent used computers for completing educational courses. This strong response is not surprising given the relatively low barriers to using these applications and the need for specialists to complete Continuing Professional Development (CPD) courses, which is a requirement for registration in Australia. An increasing number of Medical Colleges are delivering CPD programs online and uptake has been strong due to the convenience and time savings. Similarly, specialists often find that the most efficient way to look up health-related information is through an online search. They also use computers to find and read journal articles in their areas of interest.
Some practitioners (39 percent) use computers to share information with their patients during a consultation. Online resources are particularly well-suited for some specialties (e.g. ophthalmology and surgery) because they provide a convenient and helpful way for specialists to explain procedures to their patients.
Beyond these basic eHealth applications, specialists are also using computers to view pathology results (62 percent) and imaging (53 percent). Specialists typically use a secure web-based interface to view test results, and some are able to download results directly into an electronic medical record system. Especially during the initial use period, specialists are concerned about missing a critical diagnosis and as a result, they often request and file hard copies of test results in duplicate. While specialists are generally pleased with the convenience of viewing results online, some have voiced complaints that they are only able to access results from certain laboratories or are limited to viewing imaging that they ordered themselves. Access limitations are specifically frustrating for specialists providing consultations to practitioners in remote areas because of the time delays that result.
Capturing informationSpecialists using computers to capture information typically cited internal efficiency gains as the primary driver, often because they access the same records over a long period of time. Although computerised health records are gaining popularity, relatively few specialists use an electronic record-keeping system as a single repository for all relevant patient information. Only 41 percent of survey respondents used a computerised health record-keeping system, and of these just 37 percent relied solely on computerised records (Exhibit 4). Most will use a computerised system for administrative purposes and storing patient notes, but maintain separate hard-copy storage for information received from other providers (e.g. test results, diagnostic imaging, and referral letters).
Many practices are in the process of transitioning to paperless operations, but are finding the process challenging for the following reasons:
- Duplication due to incompatibility. System incompatibility results in additional time required to complete certain operations. For example, some electronic medical record (EMR) systems are unable to integrate with billing/EFTPOS systems, so a paperless process requires duplicate data entry and additional time relative to the paper-based alternative
- Risk of technical failure, which can paralyse a practice if systems are forced to go offline or are unusable for a period of time
- Medicolegal concerns about losing information or missing critical test results due to a user error or oversight
- Workflow disruptions, because for some types of records and information, capturing notes in an online system does not fit well with the current process flow. For this information, the specialist often relies on faster and/or easier traditional approaches (e.g. handwritten notes)
- Inability to share information with other practitioners, either due to a lack of interoperability between computerised systems or the limitation that some practitioners can only receive information by fax or post
- Perception that patients still need hardcopies, that patients need print-outs of their pathology test requests so they can choose and locate a pathology lab, paper scripts so that they have flexibility in choosing a pharmacy, and physical records to share information with their families and GPs.
Sharing information electronicallyApplications requiring more sophisticated connectivity (e.g. test orders and sharing information with other practitioners) are not yet widely used. The perceived benefits from these applications are often outweighed by perceived risks to a practitioner’s ability to deliver care or to the practice’s efficiency. For example, some specialists cited concerns about confidentiality as reasons why they would not be willing to use computers to store and share patient records. Other practitioners mentioned that even though they had the ability to send information (e.g. discharge letters) electronically, it was significantly more time-consuming to use computers than to use a fax machine. In many cases, the benefits for information sharing accrue mostly to the overall health system and not to the individual specialist, limiting overall incentives for use.
Additional reasons specialists provided for not using eHealth solutions are listed below:
- Solution not available in current practice location. Some specialists, especially those based in hospitals, are constrained by the systems and software currently available in their operating environment. This was especially common among emergency medicine and intensive care specialists, who were often very interested in tools like interactive decision support or electronic medical records, but did not have access in their hospitals. Additionally, a lack of external connectivity frequently limits the ability to share information electronically outside of the practice or hospital setting
- Specific eHealth applications not perceived as relevant to specialist’s work. For example, some specialists do not hold consultations with patients and therefore would not use computers to take notes or otherwise engage with patients during a consultation
- eHealth application not used frequently enough to provide a significant benefit. Many specialists write prescriptions only on a limited basis and therefore have little interest in ePrescribing. For them, it is much easier to use a script pad than to implement and learn to use a computerised system
- Lack of awareness, especially for more sophisticated applications. Many specialists are still unaware of applications like computerised decision support, and among those who are aware, many do not understand how the applications could provide benefits. Some specialists (e.g. obstetricians) mentioned that to date, they had heard very little if any information on eHealth and how eHealth solutions might be used in their specialty
- Lack of demand from patients, GPs, or other practitioners. For example, some specialists are willing to share information electronically with their patients on request, but find that their patients rarely, if ever, ask for this service.
Interest in future eHealth useAmong eHealth applications that are not commonly used, specialists are especially interested in sharing information with other practitioners (57 percent of specialists surveyed don’t use but would like a computer), ordering tests and prescriptions, and decision support for test orders.
Specialists are least interested in using computers to share health records with patients (45 percent don’t want and don’t need a computer for this) and communicating with patients outside of consultations (46 percent don’t want and don’t need a computer for this). Specialists provided two primary reasons for their lack of interest in sharing records electronically. First, they stated that they have no need to change because the current process (providing patients with a printed copy of a discharge letter) meets their patients’ needs. Second, they were concerned that because they believe patients are not trained to interpret and understand medical information, patients may become unnecessarily worried over records or results that they are not interpreting correctly.
Specialists interviewed were also, for the most part, opposed to communicating with patients electronically outside of consultations. The primary concerns were legal risk, especially if a specialist did not respond quickly to an urgent note, and the increased time required to respond to patient emails (which would not be reimbursed).
Consistent with specialists’ relatively low level of interest in sharing records and communicating electronically with patients, they perceive that eHealth offers relatively fewer opportunities to improve patient relationships, satisfaction and engagement (discussed further in Section 6). In many cases, specialists’ patient interactions skew towards being transactional rather than long-term, and as a result, these specialists often focus on excellence in care delivery rather than sustaining relationships.