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An integrated electronic health record and information system for Australia?

Christopher D Mount, Christopher W Kelman, Leonard R Smith and Robert M Douglas

An integrated health record and information system, although costly and difficult to implement, would provide benefits for clinicians and patients through better clinical care, and for the healthcare system through better data for policy development and resource allocation.

MJA 2000; 172: 25-27
 

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Introduction - Health records - The Integrated Health Record and Information System - Benefits - Implementation - Conclusion - Acknowledgements - References - Authors' details
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Introduction It is almost 100 years since the introduction of the "unit record" at St Mary's Hospital in 19071 marked the beginning of the modern medical record. The centenary would be an appropriate target date for the full implementation in Australia of a national Integrated Health Record and Information System (IHRIS) which goes beyond existing institution-based, sector-based or system-based records to cover all contacts with the healthcare system. In 1997, the House of Representatives report Health on Line recommended the development and deployment of such a system.2,3 The idea of an integrated national approach has been endorsed by the UK National Health Service information policy. It includes plans to create a lifelong electronic health record by 2005.4 The New Zealand Health Department is well advanced in the implementation of an integrated health record system,5 and a number of healthcare funding bodies in the United States have introduced comprehensive electronic health records and information systems.6-8

Here, we present the case for a national system, as recommended by the House of Representatives report. Our views have been strongly influenced by a series of multidisciplinary forums which we convened to explore the proposal.9,10

Health records

The health record has undergone many changes and is still evolving.11,12 The more significant current developments are the linking of all of each person's health information to create a single integrated health record, and the increase in the range of both the users and the uses of personal health information. These changes are being realised through the development of the computerised health record.13,14

Traditionally, health records have focused on the needs of clinicians. Other users (such as planners, administrators, researchers and policymakers) have had to develop alternative systems to meet their needs, even though much of the information they require resides in the clinical record.

The Integrated Health Record and Information System

Central to the system recommended by the House of Representatives Committee is the integrated health record (IHR): a compilation of an individual's health information, which is currently scattered throughout the healthcare system. This does not mean gathering the information together at one location; rather, it means a virtual integrated record based on the use of pointers to the location of the individual components, which are brought together as necessary.

The IHRIS would contain summary reports from every health-related event. The event report would be stored locally and indexed centrally. Linking all or some of an individual's event reports would allow the creation of a completely or partially integrated health record.

It might be possible to satisfy clinical needs by creating an IHR for all individuals which could be stored on a portable storage device or even kept as a secure Web page, especially if supported by comprehensive provider communications. The Health Key Trial in Melbourne, by the Southern Health Care Network, is an example of such an approach.15 However, this approach would still require separate systems to meet the needs of other users.

The key feature of the IHRIS is that it is intended to satisfy the needs of clinicians and those of other users. The Figure shows the activities that would be supported by the IHRIS, while Box 1 outlines the principles and assumptions that underlie the model.

Benefits

We believe that the benefits of an Australian IHRIS would justify the costs and difficulties in developing it.

 

Benefits for clinicians and citizens

Few patients today deal with only one healthcare provider. This is particularly true for those who have complex health problems, for those who move frequently for work purposes, and for travellers generally. In the absence of continuity of care, continuity of information is essential to optimise healthcare. The benefits expected for individuals include:

  • improved clinical decision making;16

  • reduced duplication of diagnostic testing, imaging and history taking;

  • better medication management;17 and

  • increased adoption of screening programs and preventive health measures.18

As a consequence of these projected benefits, the quality of individual care can be expected to improve substantially, as illustrated by two hypothetical case histories (Boxes 2 and 3).

 

Benefits for the healthcare system

The ability to perform epidemiological and other medical and health services research based on national data would deliver a number of benefits. These include:

  • better-informed policy development;

  • improved resource allocation and management;

  • outcomes and cost-benefit analysis of interventions;

  • identification of causes and risk factors of disease;

  • more efficient collection of demographic data for management and epidemiological purposes;

  • monitoring of disease outbreaks and adverse reactions;

  • establishment of registers for diseases, devices and treatments; and

  • postmarketing surveillance of drugs, devices and procedures.

Implementation

Introducing a national IHRIS will not be simple and will take time. The following are some of the factors that would be critical to the success of such an undertaking.

 

A shared vision, strategic framework and standards

For a national approach to be effective there will need to be a shared vision to enable the development of a national strategic framework. Ensuring compatibility requires the development and implementation of agreed national standards for the capture, classification, storage, communication and security of information.

 

The scale of the project

The size of a national health information system is likely to exceed that of any existing information system in the country. In addition, a large number of groups will be involved. It will be important to learn from the experiences of other industries and other countries.

The size of the task suggests that development should be carried out incrementally. There are at least five axes of development possible:

  • geographical area (eg, start in one region or State and expand over time);

  • proportion of the population covered (eg, involve specific groups and adopt an opt-in approach);

  • variety of health providers supplying and using information (eg, include specific classes of providers initially);

  • the proportion of each type of health provider involved (eg, adopt an opt-in approach); and

  • record content (eg, start with a problem list, add in medication data etc.).

Any staged implementation strategy must be achievable and must provide sufficient benefits at each stage to justify continuation.

 

Privacy and security

There are significant privacy and security requirements which need to be satisfied. The needs of both consumers and providers must be addressed. This is essential, challenging, and achievable. Information privacy in health involves optimising individual rights and public good. We agree with the Consumers' Health Forum view that this should not be seen as an "either/or" conflict, rather that these are "parallel objectives", and that cooperation between consumers and organisations wanting to use people's personal health information would be productive.19 Realising these objectives will require debate, policy development, and the use of appropriate security methods and technology.20

 

Provider computerisation

A threshold requirement of the system is the adoption of computer-based clinical records, especially in general practice. Currently, only 7% of general practitioners have electronic clinical record systems.21 The Practice Incentives Program22 is improving this situation.

Conclusion

The opportunity now exists to adopt a comprehensive approach to our health information management needs. It will require the involvement and commitment of all the relevant stakeholder groups in health, and will be a lengthy and challenging task. It is a task to which we believe our governments should now make a firm policy commitment.

Postscript

On 4 November 1999, the National Health Information Management Advisory Council released Health online: a health information action plan for Australia <www.health.gov.au/healthonline>. The framework outlined in Health online and the IHRIS model presented here are based on entirely congruent principles.

Acknowledgement

We are indebted to the participants in the Health on Line Discussion Forums, who have contributed significantly to our views.

References

  1. Kurland LT, Molgaard CA. The patient record in epidemiology. Sci Am 1981; 245(4): 46-55.
  2. House of Representatives Standing Committee on Family and Community Affairs. Health on Line. Report into health information management and telemedicine. Canberra: Commonwealth of Australia, 1997. Available at <http://www.aph.gov.au/house/committee/fca/tmreport.pdf>.
  3. Mount C, Kelman C, Douglas RM, et al. Submission to the House of Representatives Standing Committee on Family and Community Affairs Inquiry into Health Information Management and Telemedicine. Submissions authorised for publication. Canberra: House of Representatives, 1997. Report No. 5.
  4. Wyatt J, Keen J. The NHS's new information strategy. BMJ 1998; 317(7163).
  5. Johnston JA. Implementing the health information strategy for New Zealand. Medinfo 1995; 2: 1608-1611.
  6. Chin HL, Krall M. Implementation of a comprehensive computer-based patient record system in Kaiser Permanente's Northwest Region. MD Comput 1997; 14: 41-45.
  7. McDonald CJ, Tierney WM, Overhage JM, et al. The Regenstrief Medical Record System: 20 years of experience in hospitals, clinics, and neighborhood health centers. MD Comput 1992; 9: 206-217.
  8. Murphy J. Creating seamless care delivery using integrated EPR's. Informatics in Healthcare -- Australia 1998; 7: 140-147.
  9. Mount C. Summary proceedings of the "Health on Line" discussion forum. NCEPH Discussion Paper. Canberra: National Centre for Epidemiology and Population Health, 1998. Report No. 14.
  10. Mount C. Proceedings of the second "Health on Line" discussion forum. NCEPH Discussion Paper. Canberra: National Centre for Epidemiology and Population Health, 1998. Report No. 15.
  11. Reiser SJ. The clinical record in medicine. Part 1: Learning from cases. Ann Intern Med 1991; 114: 902-907.
  12. Reiser SJ. The clinical record in medicine. Part 2: Reforming content and purpose. Ann Intern Med 1991; 114: 980-985.
  13. Dick RS, Steen EB. The computer-based patient record: an essential technology for health care. Washington, DC: National Academy Press, 1991.
  14. Detmer D, Steen EB, Dick RS, editors. The computer-based patient record: an essential technology for health care. 2nd ed. Washington: National Academy Press, 1997.
  15. McNamara M. GPs trial patient smart cards. Aust Doctor 1998; 11 December.
  16. Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA 1998; 280: 1339-1346.
  17. Evans RS, Pestotnik SL, Classen DC, et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 1998; 338: 232-238.
  18. Sullivan F, Mitchell E. Has general practitioner computing made a difference to patient care? A systematic review of published reports. BMJ 1995; 311: 848-852.
  19. Consumers' Health Forum. Consumers' Health Information for Research Purposes -- Final Report. Canberra: Consumers' Health Forum, 1998.
  20. Summons P, Regan B. Secure mechanisms for an electronic patient medical record. In: Thelander N, Bennet J, Ward M, editors. HIC '98. Brisbane: Health Informatics Society of Australia, 1998.
  21. Neilsen AC. A study into levels of, and attitudes towards information technology in general practice. Volume 1. Canberra: Department of Health and Family Services, 1998.
  22. Commonwealth Department of Health and Family Services. Budget 1998-99 Fact Sheet 4. General Practice -- Foundation for Partnership. <http://www.health.gov.au/pubs/budget98/fact/hfact4.htm>. Accessed 11 November 1999.

Authors' details

National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT.
Christopher D Mount, BEng(Hons), PhD Student;
Christopher W Kelman, MB BS, PhD Student;
Leonard R Smith, PhD, Visiting Fellow;
Robert M Douglas, MB BS, MD, Director.

Reprints will not be available from the authors.
Correspondence: Mr C D Mount, National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT 0200.
christopher.mountATanu.edu.au

©MJA 2000
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The activities supported by an Integrated Health Record and Information Service (IHRIS)

Figure

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1: The principles and assumptions underlying the model

Principles

The health information system:

  • should serve the health needs of both the individual and the nation.
  • should enable the monitoring of trends, and facilitate health administration and management.
  • should improve the efficiency of health service delivery, both personal care and public health services.
  • should build from a primary care and population health base.
  • should meet privacy and confidentiality requirements.
  • should be developed intentionally rather than accidentally, in a coordinated rather than fragmented manner.
Assumptions

  • Communication between healthcare providers will be by electronic means.
  • All healthcare providers will use electronic clinical record systems.
  • Healthcare providers will continue to maintain detailed and confidential case notes for their own purposes.

These principles were endorsed by the House of Representatives Standing Committee on Family and Community Affairs.2
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2: General practice

While away on work, Mr X, a truck driver, sees a GP. He complains of severe headaches and requests strong pain relief. He presents to the doctor as an unkempt man from out of town requesting a drug of addiction. After obtaining Mr X's approval to access his records, the GP calls up a medication report detailing all medications currently prescribed and dispensed to Mr X. The report shows no S8 drugs being dispensed.

A prompt pops up on the screen to advise the GP that the national adverse events register has recently detected an interaction between two of the drugs Mr X has been prescribed. The report advises that the drug combination was rare, but postmarketing surveillance based on the national IHRIS had found a high incidence of hypertension and severe headaches. The GP discusses the issue with Mr X and prescribes an alternative medication.

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3: Hospital

A person who had been found unconscious lying in the gutter and smelling of alcohol is brought in to the emergency department. A provisional diagnosis of ethanol intoxication is discarded when the doctor uses a contingency access protocol to view the patient's health records. The records show that the patient has a history of depressive illness.

The patient's medication report shows that a prescription for a tricyclic antidepressant was filled that afternoon. Upon seeing the information, the doctor promptly admits the patient to the intensive care unit, with a referral for psychiatric consultation the next morning.

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