National Health Reform

Primary Health Care Reform in Australia - Report to Support Australia’s First National Primary Health Care Strategy

Element 6: Better management of health information, underpinned by efficient and effective use of eHealth

Objective: Consumers and providers benefit from greater sharing and improved access to health information, clinical knowledge resources and emerging technologies to better support patient-centred care.

eHealth is a fundamental building block for improvements in patient experience and outcomes in primary health care.

For all consumers, better management of their health information is integral to the safety and quality of their health care.²⁵⁸ Making relevant health information available electronically when and where it is needed is seen as essential to support change in primary health care services leading to improvements in the quality of care.^{259 260 261} The availability of clinical information electronically also has the potential to add to workforce productivity and provide economic efficiencies across the primary health care sector.^{262 263} Fundamental is the availability of personal health information such as medications, pathology results and discharge information which will contribute to significant improvements in consumer health outcomes.

Top of pageAlthough discussed specifically in this Element, the value of electronic enablement in primary health care is acknowledged across this Report.

Currently in primary health care, an individual’s health record is either paper-based or held in multiple, isolated clinical information systems. Consumers need to remember what has happened to them and when, what tests and treatment they have received and what medication they are on. Not only is this frustrating, it means there is often incomplete information available for their chosen carers, adding to the risks of adverse events for consumers and the costs of their health care. This also creates significant challenges for primary health care providers by increasing the time required to obtain patient information and hampering the efficient communication between providers involved in an individual’s care.

The development and use of nationally compatible eHealth systems, including Individual Electronic Health Records (IEHRs), will support multi-disciplinary primary health care collaboration and enable efficient exchange of information between the primary health care, community and specialist health care settings. It would also allow information to be available when a patient needs care, including after hours, or if seen by someone who is not their regular carer. This would be a significant improvement on the current situation for consumers and clinicians.

For consumers an IEHR means that, over time, their information would be able to travel with them, be seen by them and be available to their chosen health and family carers when and where they need it. This is of particular benefit in primary health care where the vast majority of Australians receive most of their care and especially to people with complex and chronic health conditions whose health is likely to be managed by a variety of health care providers.

Consumers expect access to online health knowledge and self-management tools to assist them to actively participate in their health care and to inform discussions with their providers. Clinicians want additional opportunities for knowledge support and professional education through e-applications. Consumers and clinicians want remotely accessible services such as e-consultation and video case-conferencing. This would be especially valuable in assisting consumers and primary health care clinicians in rural and regional Australia who often have limited access to services. Primary health care business management and reporting can also be improved through electronic infrastructure, giving providers more time for clinical care and/or work/life balance.

While consumers and clinicians appear supportive of eHealth, they would like to have these systems available to them as soon as possible. The key issues to ensure the efficient and effective use of eHealth to support patient-centred primary health care are:

• promoting eHealth across the breadth of the primary health care sector;
• establishing a robust shared electronic health records system to support information availability; and
• supporting consumers to be active in their health care management.

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Where are we now?

Promoting eHealth across the breadth of the primary health care sector

eHealth in primary care requires health care providers to have reliable information and communications technology (ICT) tools, know how to use them and see value in them. Additionally, they need to be able to exchange information within and across organisations.

Availability and usage of ICT varies considerably across the primary health care sector. Although 96% of general practices are computerised²⁶⁴ in part reflecting the Australian Government’s considerable investment through the PIP, the use of computers for clinical purposes still lags a little behind their use for business purposes. While there are some limited examples of general practices using ICT to analyse data to monitor and plan service delivery, this has raised the issue of data quality and the need for agreed standards.

Although general practice has been assisted to use ICT with training and support programs conducted through the Divisions of General Practice, the ICT capability of other key areas in the primary health care sector is relatively immature.

Community pharmacies are almost completely computerised and connected, with capabilities supporting nearly all of their business and clinical operations. Aged care services are reasonably well connected with basic business capability but very few clinical services.²⁶⁵ Most allied health service providers have little computing or communication capability.

The story of mixed capability also holds for those areas of the health system with which primary health care regularly interacts. Pathology and radiology services are well advanced and some non-GP specialists use computers to record clinical information but their ability to safely exchange clinical information is limited. Hospitals, both public and private, have a high degree of variability in their ICT capability. Initial work on advancing the ICT capability of the community care sector has resulted in some improvement but it is still limited.

But even with good computerisation at practice levels, information about any individual patient is likely to be held in each provider’s separate system and not available to all of that individual’s carers. This means clinicians are often working blind to important care information, relying on the patient’s ability to remember what happened to them when. Both are frustrating and have the potential to reduce patient safety and increase costs of care.

Chronically ill patients are most likely to suffer the consequences of poor care coordination and transition between care settings.²⁶⁶ This is because they are required to have multiple contacts with the health care system and often see a range of specialists and primary health care professionals to manage their more complex needs in the course of an acute episode of care.²⁶⁷ Significant care coordination problems (with high potential for errors and adverse events) are also experienced when patients transition across health sectors or stages of care provision (eg from inpatient to ambulatory care; from acute to long-term care, including residents of aged care services).²⁶⁸

A 2005 Commonwealth Fund survey reported:

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Table 9: Care coordination in Australia²⁶⁹

Problem reported in the last two years	%
Test results or records not available at time of appointment	12
Duplicate tests: doctor ordered test that had already been done	11
Percentage who experienced either coordination problem	19

Source: Commonwealth Fund survey, 2005

Building the capability for clinical information exchange between primary health care providers has been driven through locally initiated eHealth solutions and government funded programs. There are some successful regional systems with electronic transfer of referrals, pathology results and hospital discharge summaries, however these are not based on national standards and are not easily scalable to a national level.

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Establishing a robust shared electronic health records system

Currently in Australia there are approximately 80,000 Australians with some form of shared electronic health record. These people are located around Katherine, western Sydney, the Hunter region and north Brisbane. These specific implementations, resulting from the HealthConnect initiative, have provided important lessons in preparing for a national electronic health record system. The Royal Flying Doctor Service (RFDS) has recently rolled out an electronic medical records system which is available twenty four hours a day, seven days a week.

The National E-Health Transition Authority (NEHTA) foundation work funded by the Council of Australian Governments (COAG) is developing the common language and standards critical to enabling reliable health information exchange across the system. The NEHTA clinical packages’ work programs are focussed on medication management, transfer of images and pathology results, referrals to and discharge and transfer in and out of hospitals, rehabilitation and aged care settings.

Uptake of secure, business-grade broadband is a key foundation for secure clinical information exchange. As a result of the Broadband for Health Program, general practice take up reached 63% while community pharmacy take up reached 96%. The new Practice Incentive Program (PIP) eHealth incentive aims to help improve the security of patient health records by encouraging general practices to adopt a secure electronic messaging capability. There is also work underway by the software industry to develop data interchange standards for general practice.

A national health information regulatory framework is being developed to address the key issue of consistent health information privacy law. This is being addressed through work by all governments in response to the Australian Law Reform Commission’s review of privacy law.

Released in December 2008, the National E-Health Strategy provides an appropriate basis to guide the development of eHealth and proposes the incremental adoption of IEHRs.

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Supporting consumers to be active in their health care management

Currently consumers are largely responsible for coordinating the sharing of their health information but in most cases have poor or limited access to health information retained by their care provider. As Australians increasingly access online information and services through mobile and e-technologies, they expect that the health sector will operate as does other sectors, affording them similar access and efficiencies.

Commonwealth and state/territory-based resources such as HealthInsite and Better Health Channel, and the COAG investment in the National Health Call Centre Network healthdirect Australia website, provide trusted and reliable sources of online information. The emergence of personal health record systems are increasing consumers’ expectations in relation to recording and storing of personal health data and access to information held in other systems.

All Australians have access to health call centres through either the National Health Call Centre Network or jurisdiction-based services. These services provide nurse-based telephone triage services.

There are also some isolated examples of telehealth services which are assisting consumers to access services remotely. These are of value to both consumers and clinicians but are disparate and usually isolated from other clinical information systems. Clinicians are also seeing the value in these technologies for time efficient e-consultation and counselling, professional e-learning and case-conferencing. While there are technical system issues to be addressed, clinicians express frustrations at the current funding barriers they face in progressing this way of providing primary health care.

Consumers have little or no access to information held about them in their health carers’ records. And, while consumers may keep their own records of home monitoring and access online health knowledge resources, there is little opportunity for them to share this with their providers. Their ability to self-manage their conditions, especially those with chronic complex conditions or in areas where workforce is not available locally, is limited by their lack of access to person-centred eHealth tools and electronic health information exchange systems.

There is little or no automatic data extraction currently available in the primary health care setting. Most data collation for reporting and evaluation is still done as a separate administrative function.

There are some examples of embedding guidelines and evidence resources into clinical applications but this is not robust and is currently application-dependent. The General Practice Sidebar initiative in South Australia is showing some value across the primary health care team as it applies nationally agreed standards and is clinical application-independent.

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What the submissions said

Of the 265 submissions received on the Discussion Paper, nearly half provided specific comment on this Element. Consumers and clinicians appear both supportive of eHealth and demanding in their expectations that it be available to them as soon as possible.

Consumers are supportive of e-health initiatives that will improve health outcomes, improve access to services, develop stronger partnerships and reduce disadvantage.²⁷⁰ Better management of health Information underpinned by effective use of E Health would be the greatest thing since the stethoscope for better health management.²⁷¹ A robust e-health infrastructure would support better care coordination and provide more timely access to available technologies that can deliver better patient outcomes. …True patient centred care requires a comprehensive approach to the development [of] a robust e-health system that supports all aspects of patient care.²⁷² …the use of eHealth is fundamental to primary health care. Health care professionals require access to information in a timely manner and consumers of care need to know that these professionals have access to this information…²⁷³ The whole area of eHealth is an area which in Australia has been very slow to develop …. It is imperative that the current hurdles impeding progress are addressed so that greater advancement in this crucial area is achieved.²⁷⁴There was a strong message across submissions that all involved in primary health care, not just GPs, need access to and support with electronic enablement. Consumers want to be involved and their care providers increasingly support this. Organisations want eHealth infrastructure and systems used to support staff competency, consumer safety, new service models and systems monitoring. Submissions were supportive of promoting eHealth use and training across primary health care. The key matters raised in relation to electronic enablement were the:

• need to address variability in infrastructure and workforce capability;
• importance of medication management, knowledge support and recalls, as part of eHealth in primary health care;
• need to ensure support for evaluation, research and monitoring of the primary health care system; and
• need to facilitate new care models which take advantage of ‘e’ (eg tele-medicine and e-consultations) and provide access by different modalities (eg mobile phones and personal digital assistants).

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The following are a selection of the submissions which identified the need to support adoption of eHealth across all primary health care professionals and clinical settings.
Crucial to the full scale introduction of eHealth systems into primary health care is attention to building computer literacy capacity amongst [all] health care professionals.²⁷⁵ AHPA [Allied Health Professionals of Australia] strongly believes that an integrated and universally accessible electronic record system is imperative to team-based multidisciplinary patient centred care. This would allow for sharing of agreed information with other team members in real time, improving patient care and outcomes.²⁷⁶ Divisions [of General Practice] are well placed to support other private health care providers, such as allied health professionals and specialists, as these professions become increasingly computerised.²⁷⁷ Many submissions identified the importance of key clinical applications as part of eHealth in primary health care but also raised the need for software standards.

Effective patient management systems must include recall and reminder systems, preventative and screening practices and clinical decision support tools. Quality data that is clean, accurate and complete can be used for benchmarking, peer review, clinical outcomes assessment and to offer more tailored packages of care.²⁷⁸ ACT Health would support a universal eHealth record in place for all people registered with Medicare. Health care organisations and health care professionals should be required to comply with national standards to implement the system in a timely way. ²⁷⁹NPS [National Prescribing Service] has conducted research on the quality of drug interaction support in clinical software and found considerable variability. The lack of national guidelines or standards for pharmaceutical decision support tools is a major contributor to the inconsistencies and limitations in Australian clinical software.²⁸⁰ A national knowledge base for clinicians is needed. The availability of knowledge resources by clinicians is variable in terms of access and the quality of the resources. While most states provide access to knowledge resources in public hospitals there is no national equivalent for community-based health practitioners. A national library of accredited knowledge resources is needed for access and use by all…²⁸¹Top of page
Submissions noted the need to address evaluation, research and monitoring to support the sustainability, efficiency and effectiveness of primary health care.

Intelligent use of data generated by e-health systems will also enable better research on the effectiveness of health care interventions for individual patients, at a practice or community level and at a whole of population level...²⁸² Systems need to be designed which can incorporate monitoring and data collection functions for the range of professional groups using the system to allow for expanded clinical and quality audits and to contribute to research in the area of primary care.²⁸³ There is a need for additional] discussion of better use of health information, particularly in terms of policy/program analyses, or statistical uses, of the data for monitoring, reporting and evaluation purposes, and with which to form health policy and undertake service planning. Such data are also essential to enable assessment of whether primary health care is financially sustainable, efficient and cost effective (Element 10). ²⁸⁴Top of page
Many submissions noted the opportunity for education support and new service delivery methods in primary health care through electronic enablement.

Rural Australia in particular stands to benefit from e-health in a number of ways… [including] through its potential contribution to professional development, peer support and decision tools that assist all health professionals in their work.²⁸⁵ Professionals and consumers require education regarding the potential role of technology in the provision of health care and an understanding that quality care may be available through means other than just face to face contact. At the same time however, it is imperative that due consideration be given …. to the ethical and logistical challenges that will inevitably arise through the use of telehealth and e-technology.²⁸⁶ We believe that e-health has many potential applications in the remote context, including videoconferencing, remote patient monitoring and use of the internet to facilitate access to information, thereby increasing health literacy.²⁸⁷ Submissions strongly supported the introduction of a shared electronic health records system. There was a strong thread in submissions that not only should consumers have access to their records, the record itself should be designed to be person-centred. Submissions were generally clear that establishing a national IEHR for Australia should be a high priority for governments. The key matters raised were:

• a high level of acceptance for a national electronic records system;
• the imperative to make it happen;
• to provide access for consumers not just clinicians; and
• support for progressive rollout – delivering value along the way.

The sharing of information on the individual electronic health record between health professionals is an essential contributor to the benefits that will flow from an IEHR. The sharing of that information with the consumer is as critical to deriving the enormous benefits as sharing between health professionals. Access to the shared record and the data it contains is a strong matter of principle for health care consumers. The details of how and what and how data can be varied are all details for negotiation further down the track – the critical element is the consumer access to the data. ²⁸⁸ACCHSs [Aboriginal Community Controlled Health Services] have been early adopters of the use of electronic health records. The main ongoing problem is that of information-sharing across health systems.²⁸⁹For general practice nurses who play a key role in initial assessment, chronic disease management and coordination of patient care, access to an electronic health record is essential. For patients to have access and ownership of that record is very congruent with the partnership approach to care in nursing and we strongly support such an enabling resource for patients. ²⁹⁰Privacy must be a central feature of an IT strategy as required by law. Consumers, communities and general practices need to have trust in the system before it can be successfully and widely embraced. ²⁹¹The Pharmacy Guild supports… the need to implement eHealth systems to support the secure use and transfer of health information. … Community pharmacy is ready to embrace wider use of eHealth to enhance community pharmacy between health professionals.²⁹² While supportive of IEHRs that provides information] to an authorised healthcare provider to whom the individual gives permission, …. the Network does not consider there is sufficient protection in any IEHR, whether this is opt in plus the ability to withhold information, to obviate the need for the sensitivity label. Many of us would want to have an IEHR for all the benefits this would provide, but need to be very assured that any information about our mental illness would be quarantined if that was determined by us.²⁹³ Submissions made it obvious that consumers expect to be involved and active in their health care management, and should have access to tools to enable self-care and assist them to navigate the health system maze effectively. They want their providers well informed and care options to be well researched and cost-effective. Providers not only want to improve the information flows about their patients with each other across multi-disciplinary teams to improve the health outcomes for consumers, they also want to be able to communicate more effectively with their patients, and many put forward electronic service delivery as a way of helping this happen.
The effectiveness of e-health will be greatly influenced by consumers’ ability to understand and make decisions on the information available. This will be dependant to a large extent on improved health literacy and education of health consumers; improved information flows, including explanations, between consumers and practitioners; and the readiness, willingness and ability of health care agencies and health care professionals to listen to and consult with health consumers.²⁹⁴
A valuable benefit that should flow from eHealth is the strengthening of the information base available to consumers, that can inform the consumer and their carers, and empower them in discussions with health professionals.

Understanding that [an IEHR is a] major initiative [which] will take some time to come into effect, consumers would like the following e-health initiatives to be pursued now: electronic medication lists; electronic save my life data; electronic discharge summaries, and information to help consumers navigate Australia’s health system… CHF [Consumers Health Forum] has developed ‘Consumers and E-health project principles’ that reflect consumer needs and expectations in this area.²⁹⁵ The development of a web based information system similar to that used in the United Kingdom (NHS Direct) that provides authoritative health information and advice on navigating the health system would enhance the individuals’ knowledge of, and ability to, interact with the health system. This facilitates personal responsibility, and with a limited impact on health system capacity.²⁹⁶Web-based information allows health care professionals to direct clients to particular sites for information, either through use of computers set up in the primary health care facilities or to refer to at home.²⁹⁷ Consumers need access to appropriate resources to support their journey through the health system, including shared electronic health records and appropriate knowledge and resources to support decision-making.²⁹⁸ eHealth… permits health care organisations to… provide patients with access to their own health information to assist them to understand their medical treatment…[and] provide patients with access to the same health record as their participating healthcare providers, thus supporting collaborative care...²⁹⁹
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What is the way forward?

The National E-Health Strategy, endorsed by Health Ministers in December 2008, provides a framework to take this work forward. It emphasises the need for engaging all stakeholders to support the uptake and continuance of eHealth solutions that improve consumer access, health outcome quality, and primary health care workforce productivity and economic efficiency. While there are important key foundations and infrastructure being developed through NEHTA on identifiers, terminology and standards, building on these foundations to support the better use of health information in primary health care requires a number of streams of work to be advanced. These include:

• Getting key eHealth infrastructure in place across primary health care. Specifically there needs to be attention given to increasing the use of electronic enabled clinical tools and solutions while acknowledging the ongoing participation costs for primary health care providers.
• Building the capacity of the primary health care workforce to use electronic health information as part of their clinical practice. This needs to be provided through health training and ongoing professional development programs to address basic computing and general health information skills. Health care organisations will need to provide application-specific training relevant to the systems in use in the workplace.
• Developing and delivering clinical applications that are of high value and priority for primary health care clinicians and supporting emerging models of primary health care service delivery, eg through telehealth.
• Providing safe and secure information exchange in primary health care and connection across sectors to support referrals to and transfer in and out of hospitals, rehabilitation and aged care settings. While the work of the NEHTA on foundational infrastructure is important, adoption of standardised secure messaging and authentication services by provider organisations is the key. Areas requiring further work in the primary health care sector include allied health, community care and aged care services. Outside primary health care, the messaging capability of non-GP specialists and hospitals also requires further work to strengthen communication across sectors.
• Enabling primary health care monitoring, planning, research and evaluation through use of electronic systems to collect and aggregate health data. This will need to be supported through improvements in data quality and also in establishing robust privacy protections.
• Ensuring privacy of personal information while allowing the health care benefits that can be gained through better sharing of health information.

Acknowledging that any national electronic health records system will take time to implement, primary health care will benefit from incremental steps which provide opportunities for the exchange of information both among themselves and with the acute sector. The introduction of scalable and nationally interoperable eHealth solutions including ePrescribing, eReferrals, eCare Plans and electronic test ordering and results capacity will be important to primary health care providers and their patients. This will help prepare the way for a national IEHR by embedding clinical terminologies, providing secure messaging capability and supporting clinicians to use electronic work practices. It will also need to be supported by the implementation of national identifiers, robust security and authentication models, and appropriate regulatory requirements.

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As primary health care is a key point of access to health care for Australians, it is important to ensure primary health care providers are supported and ready to embrace an IEHR system. To achieve this, work will need to continue on laying the foundations for its adoption by primary health care providers.

While it is envisaged that consumers will have access to their records, consumers will also need support to understand, amongst other things, what a national electronic records system will offer them, how they can access it and how they can authorise their carers to participate. The primary health care setting is likely to play an active role in this education and support process for most Australians.

The National Health Call Centre Network provides opportunities to support consumers in being more active in their health care management. For example, the healthdirect Australia website could be used as a national web platform to provide access to a range of creative e-tools constructed to encourage consumers to self-assess their health, plan and join self-managed health improvement programs including life coaching, self monitoring or personal response monitoring. This would be similar to the progression of National Health Service (NHS) Direct in the UK which has evolved from the original health call centre concept into a full consumer-centric health delivery service, providing an interactive website, health information channel on digital television, printable self-help guides and an online enquiry service.

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258 Australian Commission on Safety and Quality in Health Care, 2009. The Proposed National Safety and Quality Framework, available from: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/com-pubs_NSQF (accessed June 2009).

259 Garling P, 2008. Final Report of the Special Commission of Inquiry Acute Care Services in NSW Public Hospitals, ISBN 978-1-921301-83-4, available from: http://www.lawlink.nsw.gov.au/acsinquiry (accessed November 2008).,

260 Deloitte, 2008. National E-Health Strategy Summary, report produced for the National E-Health and Information Principal Committee, available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/National+Ehealth+Strategy (accessed June 2009). ,

261 Booz & Co, 2008. E-Health: Enabler for Australia’s Health Reform Prepared for the National Health and Hospitals Reform Commission, available from: http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/home-1 (accessed May 2009).

262 The Allen Consulting Group, 2008. Economic Impacts of a national Individual Electronic Health Records System, Report to the National E-Health Transition Authority.,

263 Access Economics, 2009. The economic benefits of intelligent technologies. Report by Access Economics Pty. Ltd. for IBM, available from: http://www.accesseconomics.com.au/ (accessed May 2009).

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264 Australian Institute of Health and Welfare, 2008. Review and evaluation of Australian information about primary health care: a focus on general practice. Cat. no. HWI 103. AIHW, Canberra, p.97.

265 Australian Government Department of Health and Ageing, 2006. IT Readiness Survey of the Aged Care Sector, Summary of Findings. Prepared on behalf of the Department of Health and Ageing by CHIK Services Pty Ltd.

266 Hofmarcher M, Oxley H, Rusticelli E, 2007. Improved Health System Performance through Better Care Coordination, OECD Health Working Paper No. 30.

267 ibid.

268 ibid.

269 The Commonwealth Fund, 2006. The Commonwealth Fund 2005 International Health Policy Survey of Sicker Adults in Six Countries, available from: http://www.commonwealthfund.org/Content/Surveys/2005/2005-Commonwealth-Fund-International-Health-Policy-Survey-of-Sicker-Adults.aspx (access June 2009).

270 Submission from Consumers’ Health Forum of Australia (Sub #169)

271 Submission from Ipswich and Moreton Bay Division of General Practice (Sub #84)

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272 Submission from Australian Medical Association (Sub #51)

273 Submission from Australian Nursing Federation (Sub #200)

274 Submission from Royal District Nursing Service (Sub #134)

275 Submission from the Australian Nursing Federation (Sub #200)

276 Submission from Allied Health Professions of Australia (Sub #232)

277 Submission from Australian General Practice Network (Sub #141)

278 ibid.

279 Submission from ACT Health (Sub #180)

280 Submission from National Prescribing Service (Sub #103)

281 ibid.

282 ibid.

283 Submission from Allied Health Professions Australia (Sub #232)

284 Submission from Australian Institute of Health and Welfare (Sub #223)

285 Submission from National Rural Health Alliance (Sub #81)

286 Submission from Speech Pathology Australia (Sub #130)

287 Submission from Royal Flying Doctors Service of Australia, National Office (Sub #97)

288 Submission from Health Care Consumers’ of the ACT (Sub #64)

289 Submission from Aboriginal Health Council of South Australia (Sub #50)

290 Submission from Australian Practice Nurses Association (Sub #203)

291 Submission from The Royal Australian College of General Practitioners (Sub #173)

292 Submission from The Pharmacy Guild of Australia (Sub #178)

293 Submission from Private Mental Health Consumer Carer Network (Australia) (Sub #153)

294 Submission from Health Care Consumers Association of the ACT (Sub #64)

295 Submission from Consumers Health Forum of Australia (Sub #169)

296 Submission from The Royal Australasian College of Physicians (Sub #253)

297 Submission from Australian Nursing Federation (Sub #200)

298 Submission from National Prescribing Service (Sub #103)

299 Submission from NSW Government (Sub #187)

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