australian digital health agency - my ehealth …...my ehealth record (myehr), formerly known as the...

National E-Health Transition Authority

nehta My eHealth Record to National eHealth Record Transition Impact Evaluation Phase 1 evaluation report

10 July 2015

Approved for external information

National E-Health Transition Authority Ltd

Level 25, 56 Pitt Street

Sydney, NSW 2000

Australia

www.nehta.gov.au

Acknowledgements

Council of Australian Governments

The National E-Health Transition Authority is jointly funded by the Australian Government and all State and Territory Governments.

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http://www.nehta.gov.au/

My eHealth Record to National eHealth Record Transition Impact Evaluation Phase 1 evaluation report

10 July 2015 Approved for external information 3 of 54

Document information

Key information

Owner Head of Policy & Planning, NEHTA

Contact for enquiries Mitchell Burger or Andrew Ingersoll

t: 1300 901 001

e: [email protected] or [email protected]

Acknowledgement

The evaluation team recognises this work would not have been possible without the

contribution and collaboration of a wide range of people and organisations. Particular thanks to

the following:

Northern Territory Department of Health

Aboriginal Medical Services Alliance Northern Territory

Northern Territory Medicare Local

Aboriginal Health Council South Australia

Ms Sally Mainsbridge, formerly of NEHTA

Lastly, and importantly, thank you to the many healthcare providers who sacrificed their time

to provide input and insight into their use of the My eHealth Record service.

mailto:[email protected]

mailto:[email protected]

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4 of 54 Approved for external information 10 July 2015

Table of contents

Executive summary .................................................................................................... 5

1 Introduction ....................................................................................................... 9

1.1 Purpose and intended audience ....................................................................... 9

1.2 Background ................................................................................................... 9

1.3 Objectives of the Transition Impact Evaluation ................................................ 10

1.4 Overview of evaluation methodology .............................................................. 10

1.5 Structure of the report and generalisability ..................................................... 10

2 Value the MyEHR service provides .................................................................... 11

2.1 Increased access to consumers’ health information .......................................... 11

2.2 Reduced time spent sourcing health information .............................................. 14

2.2.1 Evidence of time saving out of hours .................................................. 15

2.3 MyEHR supports providers’ clinical decision making and safety .......................... 16

2.3.1 Evidence of improved clinical safety ................................................... 17

2.4 Improved continuity of care .......................................................................... 17

2.5 Increased confidence for both consumers and providers ................................... 20

2.6 Increased capacity to provide proactive population-based primary health care .... 21

3 Gradual evolution towards critical mass ........................................................... 23

3.1 Element 1: consumer registration .................................................................. 23

3.2 Element 2: actively participating healthcare providers across sectors ................. 24

3.3 Element 3: clinical content ............................................................................ 26

4 MyEHR service embedded into workflow .......................................................... 29

4.1 Approaches to using the MyEHR service .......................................................... 29

4.2 Variation in frequency of use ......................................................................... 30

5 Success factors ................................................................................................. 36

5.1 Fixed characteristics ..................................................................................... 36

5.2 Enablers ..................................................................................................... 38

6 Implications for the M2N transition .................................................................. 40

6.1 Advantages of transitioning to the PCEHR system ............................................ 40

6.2 Limitations of the MyEHR service ................................................................... 41

6.3 Issues requiring consideration through the transition ....................................... 42

7 Implications for the national PCEHR system ..................................................... 44

7.1 MyEHR as a benchmark ................................................................................ 44

7.2 Implications for PCEHR system enhancement, and change and adoption activities 47

7.2.1 Sustain consumer and provider registration activities ........................... 47

7.2.2 Stimulate content generation and utilisation across sectors ................... 48

7.2.3 Ensure policy and technical frameworks remain flexible and are clearly

communicated ................................................................................. 49

7.2.4 Clinical governance mechanisms needed to capture end-user input and

feedback ......................................................................................... 50

7.2.5 Optimise CIS use so high quality data is a by-product .......................... 50

7.3 Strong evidence validating potential value, but need further research into impact on

health outcomes .......................................................................................... 51

7.4 Opportunities for further research .................................................................. 52

Appendix A Evaluation methodology ..................................................................... 53



Executive summary

Introduction

My eHealth Record (MyEHR), formerly known as the Shared Electronic Health Record, is a way

of securely sharing an individual’s health information between their healthcare providers.

Similarly to the national eHealth record system (the Personally Controlled Electronic Health

Record, PCEHR), the MyEHR service was designed principally to overcome fragmentation of

clinical information by ensuring it could be quickly and easily accessed by participating

healthcare providers. The MyEHR service is operated by eHealthNT, NT Department of Health.

It has been operating since 2004 predominantly in the Northern Territory, but also in

surrounding Northern and Central Australia.

There is intent to transition the MyEHR service to the PCEHR System over time. NEHTA has

conducted an evaluation of the MyEHR service in order to inform this transition, and future

development and continued rollout of the PCEHR system. The objective of this evaluation was

to describe in detail how and why the MyEHR service is currently used.

This report documents the findings of the first phase of our evaluation of MyEHR service

adoption and usage data, covering the whole life of the service.

Value the MyEHR service provides

The evaluation provides very strong qualitative and quantitative evidence of the value that the

MyEHR service provides. The benefits attributable to the MyEHR service, which are

summarised in the figure below, provide evidence validating the value proposition of the

PCEHR system.

Benefits attributable to the MyEHR service

Importantly, providers across all professions who currently use the MyEHR service reported

receiving immediate benefits. For example, by acting as a bridge between unconnected clinical

information systems, the MyEHR service facilitates vast flows of clinical information between

different sectors. This flow of information between and within sectors is illustrated in the

following ‘riverplot’.

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Total document views by sending and viewing facility type

How the MyEHR service has realised this value

The MyEHR service was able to realise this value via a gradual evolution towards critical mass.

Three key prerequisite elements of critical mass are:

1. Population registration;

2. Actively participating providers across all sectors; and

3. Sufficient content to make accessing worthwhile.

The evaluation findings suggest there were no ‘silver bullets’ which triggered immediate and

sustained increases in sending, accessing, and viewing health information. This reinforces that

critical mass is not a discreet point in time. Rather, critical mass was achieved through

sustained effort, continual reinforcement, and iterative policy and system enhancements.

Consumer registration reached approximately 50% of NT Indigenous population during mid-

2010, approximately 5½ years post launch, using a successful community engagement model,

and dedicated registration efforts by both Northern Territory government and Aboriginal

Community Controlled Health Organisations. Achieving 50% registration overall appears to be

associated with the tipping point at which the MyEHR service reached critical mass, and usage

increased exponentially.

Provider registration efforts were also sustained over the long term; averaging between 150

and 200 registrations per month. MyEHR service registration and training is part of the

orientation process for new providers.

Finally, sufficient content to make accessing worthwhile, built up steadily over time, was

necessary to achieve value. An increase in document sending preceded the increase in viewing

at the mid-2010 tipping point. This underlines the importance of having content in the records

as a prerequisite for viewing.



A critical success factor has been the uploading of clinical documents via a ‘default to send’

policy setting, which ensures that documents are automatically generated as a by-product of

pre-existing clinical workflow. This minimises impact on providers.

Achieving critical mass has meant the MyEHR service has become embedded into routine

clinical and administrative workflow. The MyEHR service is currently used by a wide range of

providers in a variety of ways. Four distinct approaches were evident in how providers use the

MyEHR service – investigative, opportunistic, targeted, and supplementary. There is also an

interaction between the approach employed and the clinical scenario.

The MyEHR service is relied on most frequently at points of clinical handover. For example, the

MyEHR service is used by hospital pharmacists while undertaking an admission medication

reconciliation, during preoperative anaesthesia consultations, or return to primary care

following an emergency department or hospital admission.

There is large variability in the frequency with which providers use the MyEHR service.

Utilisation of the MyEHR service has been found to be highly concentrated on a subset of

registered consumers. 20% of consumers account for 67% of all sends, 84% of all record

accesses, and 94% of all views. Basic demographics provide only limited ability to identify and

describe the characteristics of the 20% of people whose records are used most frequently. This

suggests future research may be useful in understanding the characteristics of this high

utilisation cohort. Use of the MyEHR service by healthcare providers is also highly concentrated

– 20% of providers account for approximately 80% of all sends, accesses and views. This

further supports the finding that use of the shared by specific groups of providers at key points

of clinical handover is valuable.

The extent of integration and success of the MyEHR service has emerged from a complex set

of social, technical, environmental and political circumstances. Some of the factors that have

facilitated the success of the MyEHR service are fixed characteristics of the setting into which

the MyEHR was deployed – these cannot be directly influenced by an eHealth program. Others

are enablers, such as provider attitudes and behaviours, technical and functional capabilities of

the service, and policy and governance frameworks. These enablers are directly within the

control or able to be influenced by the implementation program. Some of the critical success

factors within the control of the program were ‘default to send’ settings, the MyEHR Clinical

Advisory Committee, and the intuitive design of the user interface.

Implications for the transition and PCEHR system

Understanding the program’s success factors and how the MyEHR service evolved provides an

opportunity to apply these lessons to the M2N transition. Transitioning to the PCEHR system

offers a number of advantages, including cross jurisdictional data exchange, consumer access

and control, and additional functionality, with atomised data. However, providers raised some

issues that require consideration, notably:

Anxiety about the transition, including (consumer) re-registration;

Concerns about effect on clinical workflow, e.g. arising from perceived policy differences

relating to identifying individuals and accessing records; and

Concerns about the PCEHR system not yet having equivalent breadth and depth of

content.

Importantly, these issues can be mitigated by current change management activities currently

planned and underway.

In addition to implications for the M2N transition process, an understanding of the gradual

evolution of the MyEHR service provides a yardstick against which to track progress of the

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PCEHR system, and allows us to assess if the PCEHR system is on track to achieve critical

mass and realise equivalent value.

The gradual evolution of the MyEHR service apparent in this analysis emphasises the

importance of sustaining effort aligned to a clearly defined long term strategy. Evaluation

findings suggest specific activities to accelerate achievement of critical mass and benefit

realisation, relating to:

Sustaining consumer and provider registration activities;

Stimulating content generation and utilisation across sectors;

Ensuring policy and technical frameworks remain flexible and are clearly

communicated;

Ensuring clinical governance mechanisms are in place to capture end-user input and

feedback; and

Optimising clinical information system use so high quality data is a by-product.

Importantly, this evaluation provides strong evidence validating the value proposition of the

national PCEHR system. With continued enhancement, benefits realisation management, and

initiatives to stimulate use, there is good cause to believe the PCEHR system will become core

eHealth infrastructure, and a valuable tool for clinicians.



1 Introduction

1.1 Purpose and intended audience

This document presents the findings from research conducted to evaluate the use

of the MyEHR service. The findings can assist in the transition process and

development and rollout of the PCEHR.

The findings make a valuable contribution to research in eHealth.

The audience for this report are:

The NT Transition Steering Committee, who have overseen the research;

The Commonwealth Department of Health, who commissioned the research;

The NT Department of Health, who operate the MyEHR;

Other MyEHR stakeholders including NT Medicare Local, AHCSA and

AMSANT;

Clinical leaders;

Health consumer advocates; and

Health service planners, policy makers and researchers.

1.2 Background

My eHealth Record (MyEHR), formerly known as the Shared Electronic Health

Record, is a way of securely sharing an individual’s health information between

their healthcare providers. Similarly to the national eHealth record system (the

Personally Controlled Electronic Health Record System, PCEHR), the MyEHR service

was designed principally to overcome fragmentation of clinical information by

ensuring it could be quickly and easily accessed by participating healthcare

providers.

The My eHealth Record service is operated by eHealthNT, NT Department of Health.

It was developed with financial assistance from the then Australian Government

Department of Health and Ageing, and has been operating predominantly in the

Northern Territory, but also in surrounding Northern and Central Australia since

2004. More information can be found at www.myehealthrecord.com.au

The Personally Controlled Electronic Health Record (PCEHR), or eHealth record

system, was launched in 2012. The Commonwealth Department of Health operates

the system, designed to allow consumers and their healthcare providers to

contribute and access their health information. The Department of Health and

NEHTA work to register consumers, and connect healthcare organisations to the

system, including hospitals, primary care providers, community health services,

pharmacies and aged care providers.

As part of this initiative, the MyEHR-to-National (‘M2N’) Transition Project is

transitioning the existing MyEHR Service over to the national eHealth record system

(PCEHR). At the request of the M2N Project Steering Committee, NEHTA is

conducting an evaluation of the impact of the transition in collaboration with NT

Department of Health and AMSANT, with assistance from NT Medicare Local and the

Aboriginal Health Council of South Australia (AHCSA).

http://www.myehealthrecord.com.au/

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1.3 Objectives of the Transition Impact Evaluation

Business objectives

The reasons for evaluating the impact of the transition are to:

Provide assurance that the transition has had a positive impact;

Produce information and evidence that can be directly utilised by NT Gov.-

operated and Aboriginal Community Controlled health services;

Inform next steps following transition;

Generate robust, evidence to strengthen the rationale for ongoing

investment in eHealth programs; and

Communicate success, where appropriate, in order to encourage continued

adoption and use of the national eHealth record system.

Project objective

The overall project objective is to evaluate whether or not the transition has been

successful in terms of outcomes, and produce an understanding of why or why not.

The evaluation (research) question is: has the transition to the National eHealth

Record System affected the utility and value being provided by the MyEHR service?

To answer this question it is necessary first to determine: what value does the

MyEHR service currently provide, and by what mechanisms is this value produced?

1.4 Overview of evaluation methodology

The methodology has comprised a qualitative phase involving semi-structured in-

depth interviews, and a quantitative phase involving analysis of MyEHR service

adoption and usage data. This provides an opportunity for a post-evaluation

comparison.

1.5 Structure of the report and generalisability

This report documents the findings of the first phase of the evaluation, including a

description of the benefits currently attributable to the MyEHR service.

The objective of the evaluation was to describe in detail how and why the MyEHR

service is currently used. The findings establish a baseline against which

subsequent measurements can be compared to evaluate the clinical impact of the

transition to the National eHealth Record System (PCEHR).

The report is structured into two key chapters: the themes and specific findings of

the evaluation; and the implications for both the MyEHR service transition and the

PCEHR system more broadly.

The methodology of this evaluation was designed and undertaken with the intent

that findings can be applied (generalised) to the national PCEHR system.



2 Value the MyEHR service provides

The baseline phase 1 of the evaluation provides very strong qualitative and

quantitative evidence of the value that the MyEHR service provides. Respondents

consistently expressed the view that the MyEHR service delivers value to both

providers and consumers. Providers across all professions, who use the MyEHR

service, reported receiving immediate benefits – summarised in Figure 1, and

described in more detail in the following sections.

Figure 1 – Benefits attributable to the MyEHR service

2.1 Increased access to consumers’ health information

Multiple clinical information system networks exist in Central and Northern

Australia, with varying degrees of interconnectivity. This creates silos of data, and

leads to fragmentation of health information. The MyEHR service bridges gaps

between unconnected systems, and in doing so overcomes data silos and

fragmentation.

Figure 2 – MyEHR service bridges gaps between unconnected clinical information systems

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Overwhelmingly, providers applauded the MyEHR service for providing access to

information they would otherwise struggle to obtain. This was reported across all

sectors and professions, and resulted in increased quantity of information being

available for decision making and provision of health care.

"Over the years it's improved dramatically... instead of ringing up and humbugging the

people in the office up there, you just go directly." Registered Nurse & Midwife

“They might present to ED overnight and come here with nothing, we can have a look

in MeHR1, if they're registered and see what's happened in that presentation.”

Aboriginal and Torres Strait Islander Health Practitioner

By bridging clinical information systems, the MyEHR service facilitates vast flows of

clinical information between different sectors. Figure 3 below is a ‘riverplot’ that

illustrates the vast flow of information from the primary sector into the acute sector

(green and blue to purple) that is facilitated by the MyEHR service.

Figure 3 – Total document views by sending and viewing facility type

It is apparent that the MyEHR service also acts as an information bridge between

unconnected facilities within the same sector – for instance there is a large flow

from acute facilities to other acute facilities (purple to purple), and between

unconnected NGO Health centres (green to green).

Figure 4 over the page shows that in recent years, this volume of information

exchange between and within sectors has increased exponentially. It is evident that

NT Government-operated acute facilities view more than they send, and that

primary sector facilities (both NT Government and non-government) contribute

more than they view (though they have still view a great deal via the MyEHR

service).

1 The MyEHR Service is referred to locally as the ‘MEHR’.



Figure 4 – Document views by sending and viewing facility type, per year

Analysis also reveals that the majority of information exchange occurs within

geographic regions, e.g. between primary and acute facilities within the same

region (Figure 5). However there are substantial flows of information across regions

into referral centres (Alice Springs and Darwin) from surrounding regions, and back

from these referral centres to surrounding regions.

Figure 5 – Total document views by sending and viewing facility region

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Because the majority of information exchange occurs within geographic regions,

this suggests consumers seek healthcare from facilities predominantly within the

same region. This is in contrast to the generally held assumption about the mobility

of the population being a principle driver of MyEHR utility.

Immediate access into disease and immunisation registers, via the MyEHR service,

has also proven valuable. During 2014, the MyEHR service facilitated an average of

over 1,000 views of the NT childhood immunisation and NT rheumatic heart disease

(RHD) registers per month (Figure 6). On average, 1 in 100 MyEHR record accesses

involves viewing the linked NT immunisation register. In addition, 1 in 100 accesses

involves viewing the NT rheumatic heart disease register.

Figure 6 – Views of the NT childhood immunisation & RHD registers per month

Access to childhood immunisation and RHD registers via MyEHR service is valuable

– qualitative evidence suggests this prevents repeat immunisation and allows for

proactive follow-up, particularly in the case of RHD.

“I was ever so excited when I learned this system was available because there is quite

a big gap in terms of communication that I have access to but that is the register that

is just fantastic.” Nurse Manager

2.2 Reduced time spent sourcing health information

Accessing the MyEHR service reduces the amount of time and effort required to

source a consumers’ health information.

In the absence of the MyEHR service, providers are often required to manually

source health information from external organisations and providers. This can

involve the faxing of a ‘consent to release information’ form signed by the

consumer, receipt of fax, sourcing relevant information for sharing, and then

receiving a returned fax. Avoiding this process is a key driver for providers of all

professions to use the MyEHR service (Table 1). Both the original requestor and the

individual retrieving the information save time.

0

500

1,000

1,500

2,000

2,500

3,000

3,500

1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11

2009 2010 2011 2012 2013 2014

Vie

ws

per

mo

nth

NT childhood immunisation register NT rheumatic heart disease (RHD) register

6 per. Mov. Avg. (NT childhood immunisation register) 6 per. Mov. Avg. (NT rheumatic heart disease (RHD) register)



Table 1: MyEHR saves time for providers

Aboriginal and Torres

Strait Islander Health

Practitioners

“We're trying to keep reminding doctors and staff to have a look if they've got

the green icon, check there, because they might already have that

information sitting there instead of ringing up and chasing letters and things

like that.” Aboriginal and Torres Strait Islander Health Practitioner

General Practitioners "A lot of time is spent just chasing up administrative things of details about

medications, appointments, and discharge summaries. You definitely had to

make use of it and if information was there, then it definitely did save you a

lot of time.” GP

"I've been obsessive with MeHR since it first came in because of everything I

can see. It saves you so much trouble, so much time." GP

“Without the MeHR I'd be completely lost. I'd be making heaps of phone calls,

I'd be ringing all over the place to find out what their current medicines are,

what all their diagnoses other than renal failure are, et cetera, et cetera.” GP

Registered Nurses and

Midwives

“It's a lot less time consuming because you're not ringing up another clinic

down the road to find out what they presented for or Alice Springs Hospital or

Congress.” Registered Nurse

"So what was happening before MeHR or HealthConnect was that we'd spend

a lot of time on the phone trying to find information out, because the

population's quite mobile.” Registered Nurse & Midwife

Pharmacists "So having patients on the electronic record, it helps in time. I'm not having

to call up a clinic nurse and say does this patient usually come to you? Have

they been to you recently? Do you have a list? Can you read it out to me or

fax it through?” Pharmacist

“It just became one of your first points of call for investigating, as I said,

rather than calling up the clinics or the GPs, you would go there first and

then go onto - it very quickly became routine practice.” Pharmacist

Specialist doctors “Previously we would have had to ring up the clinic and ask them to either

fax through some information or whatever but now you can just link straight

through to the e-health record that might be on another information

system.” Specialist doctor

2.2.1 Evidence of time saving out of hours

The MyEHR service has been particularly helpful during non-clinic hours when

providers need to access health information knowing other health services are not

open or readily available. This saves interrupting primary healthcare providers in

remote health centres.

“Particularly on weekends a lot of the community pharmacies that actually supply all

the medications to the remote clinics might not be open… So that's where it can be

really useful to jump on there and have a look as well.” Pharmacist

“We could have upwards of three, four, five thousand people here for a long weekend

and we get a lot of patients coming from - people coming in from other communities

and MeHR gets flogged.” Registered Nurse & Midwife

The pattern of document viewing by time-of-day (Figure 7) supports the qualitative

observation that the MyEHR service is saving clinicians’ time on the weekend, and

avoiding the need to interrupt clinicians at remote health centres. For example,

after controlling for the proportion of hours out of the week that are business

hours, a quarter of all viewing by doctors in acute facilities occurs outside normal

business hours (data not shown). The MyEHR is also enabling non-traditional health

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facilities such as police watch houses to gain access to vital health information at

the right time.

Figure 7 – Document views by time of day, weekend versus weekday

2.3 MyEHR supports providers’ clinical decision making and safety

Information accessible via the MyEHR service supports providers’ clinical decision

making by providing a more comprehensive clinical overview than a consumer

and/or existing local clinical information systems can offer. With access to a more

comprehensive clinical overview, providers are able to make clinical decisions based

on more recent and relevant information (Table 2).

Table 2: MyEHR supports clinical decision making



Practitioners

“I look up the date and when they were last there or whatever and then I

would judge whether that's the latest or whatever they've come in for or

when was your last fracture, look at that, see what the doctor said from the

hospital.” Aboriginal and Torres Strait Islander Health Practitioner

General Practitioners “I think we can approach the whole complex problem a bit better because

we're better informed basically. I think that's what I kind of - I find I've got

the big picture, I've got a better picture.” GP


Midwives

“Because there's such widespread chronic disease and complex care of

people, you need to do your homework to treat these people, because if you

treat them wrong, the consequences could be quite bad.” Nurse Manager

"Without the MeHR you couldn't have made the same decision" Registered

Nurse & Midwife

Pharmacists “I'll look up for the medication list, I'll look up the notes, the progress notes

because that gives the description of why stuff has happened and often we'll

also look up any results, any recent lab results or observations that are put

in there as well, like blood pressures and sugars and HBA1C.” Pharmacist

0%

2%

4%

6%

8%

10%

12%

14%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Per

cetn

age

of

tota

l vie

ws

Hour of the day

Weekday

Weekend



Specialist doctors “You can look back and see what he's had done so you don't repeat tests,

see what's missing.” Specialist doctor

“I use it in assessment of patients to get a picture of people who might not

be able to give me their own medical history, of the things that are going to

be important to me in the decision making.” Specialist doctor

2.3.1 Evidence of improved clinical safety

Additionally, access to the MyEHR service has reportedly resulted in improved

clinical safety. Information contained within the MyEHR service has instigated

amendments to planned treatment. For example, the alteration of medication

regimes due to allergies. With the MyEHR service acting as a safety mechanism,

potential adverse events have been avoided.

“We actually looked up on the MeHR and that's where we've seen it, this patient is

actually allergic to penicillin. So the patient didn't get the needle and went onto a

different medication.” Registered Nurse & Midwife

2.4 Improved continuity of care

Points of clinical handover emerged as a critical time for providers to access the

MyEHR service. By bridging communication gaps at points of handover and

facilitating timely access to clinical information providers may not otherwise be able

to readily access, the MyEHR service is able to improve continuity of care.

Table 3: MyEHR improves continuity of care


Strait Islander

Health Practitioners

"There was this Indigenous lady moved into the community new, because of

her family that living here, her daughter and she's got dementia and she had

stroke. She came in from [community omitted] so she had nothing; no record.

So I went into e-health and that's where I found everything." Aboriginal and

Torres Strait Islander Health Practitioner

General Practitioners “A woman who’s just had a baby and her post natal discharge is complicated

or a patient who’s had an ischemic event and is in hospital and has been

discharged but we haven’t seen the letter or an important surgical outpatient

relating to a breast lump. They’re just a few scenarios that I know I’ve gone

looking for to find out the information that hadn’t been received electronically

and any other way.” GP

Registered Nurses

and Midwives

"You know that you referred them to the specialist and they've come back and

said hey doc, I saw the cardiologist two weeks ago, he wants me on a new

tablet and the specialist letter hasn't come back yet. Then you have a look -

Christ it's in there, hallelujah and there it is. All the information is there of

what you need." Registered Nurse

"I can look after them better. When they're at school at least I know what I

need to follow up or what treatment they need to get." School Nurse

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Strait Islander

Health Practitioners

"There was this Indigenous lady moved into the community new, because of

her family that living here, her daughter and she's got dementia and she had

stroke. She came in from [community omitted] so she had nothing; no record.

So I went into e-health and that's where I found everything." Aboriginal and


Pharmacists “She'd actually brought in medications from the nursing home where she's

staying but the date on that was from August, like it was packed in August.

The list of medications from where she gets dialysis was slightly different and

more recent…I could get on the shared electronic record and look at where

she goes to her GP and they also had the most current list. So what was in

her Webster pack was an old Webster pack, she shouldn't have been using,

but what was documented elsewhere was what she should be taking. When

she was coming to hospital the doctor has obviously gone great, she's

brought a Webster pack and charted everything up according to that, but I

had to go actually no, that's not right, she shouldn't be using that pack.”

Pharmacist

Improvement in continuity of care is most beneficial for consumers with complex

care needs, who receive care across multiple sectors, from multiple providers. For

instance, almost a third of all MyEHR records have been accessed by two or more

different providers in the last 12 months (Nov 2013 to Nov 2014) (Figure 8).

Figure 8 – No. different providers who have accessed a consumer's record, last 12 months

Similarly, over 20% of records have been accessed at two or more facilities in the

last 12 months (Figure 9).

Figure 9 – No. different facilities where a consumer's record has been accessed, last 12

51.3%

17.4%20.6%

5.7% 4.1%0.8%

0%

20%

40%

60%

80%

100%

0 1 2–5 6–9 10–19 20 +

Per

cen

tage

of

all r

eco

rds

No. different providers who have accessed a record



months

For these consumers who received care at multiple locations, the MyEHR service

enables clinical information to be accessed at a person’s non-usual place of care,

thereby overcoming the limitations of point-to-point communication, and enabling

better care for these patients.

To illustrate, overall, 87% of all documents viewed within the MyEHR service are

viewed at facilities that are not the person’s ‘home health centre’ (HHC), which is

their nominated usual place of care. Figure 10 shows that 97% of documents

viewed by facilities located in Outback South Australia are viewed in facilities that

are not the record holders’ HHC.

Figure 10 – Percentage of documents viewed at a facility that is/is not the consumer’s home health centre (HHC), by viewing facility region2

Furthermore, Figure 11 shows that since 2008, emergency department discharge

summaries have been viewed almost 40,000 times at non-government health

2 Home health centre is the location identified by the consumer as a preferred / main healthcare facility, i.e. their usual place of care.

57.4%

20.3%

11.7%6.0%

2.8% 1.9%

0%

20%

40%

60%

80%

100%

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No. different facilities where a record has been accessed

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Outback SA

Anangu Pitjantjatjara Yankunytjatjara

Queensland

Western Australia

East Arnhem

Katherine

Darwin

Alice Springs

Barkly

Percentage of documents viewed

Reg

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ere

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Viewed at a facilty that is NOT the record holder's HHC Viewed at a record holder's HHC

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centres that are not the consumer’s home health centre, and therefore likely would

not have received the information via point-to-point communication.

Figure 11 – Total documents sent by NT acute facilities and subsequently viewed at an NGO

health centre that is not the consumer’s HHC, by document type

Point-to-point communication requires manual addressing by the sender to ensure

delivery to the correct provider or organisation. This is compromised where

consumers have multiple providers, attend facilities in different regions, or see

providers who work in multiple locations. In effect, the MyEHR service acts as a

‘safety net’ when point-to-point is inadequate; enabling care by a cross-sector,

multidisciplinary team, irrespective of where the consumer presents for care.

“Quite a high percentage of them will actually have ‘no GP nominated’, which means if

there's no GP nominated or remote health centre nominated, it's not actually getting

sent anywhere electronically, so essentially the discharge summary has been done and

just sitting in the computer, but not actually sent anywhere.” Pharmacist

“Someone sent from Alice Springs to Darwin for repair of a fractured mandible who

didn't have their document, they'd lost their documentation but I could get the

emergency department discharge summary from down there and work out what the

heck was going on.” Registered Nurse

"But [the MeHR service] is a bit of a safety net thing." Medical Director

2.5 Increased confidence for both consumers and

providers

Providers expressed the view that improved access to health information has

increased their confidence in their ability to provide the most appropriate care.

Additionally, providers commented that consumers now expect health workers to

access their health information via the MyEHR service and provide care accordingly.

This has reportedly instilled a sense of confidence in consumers that they are

receiving the most appropriate care.

Providers also reported that by registering for the MyEHR service, consumers have

a sense of empowerment knowing their health information is accessible regardless

of where they present. Consumers are no longer required to communicate their

comprehensive health information to each and every provider they encounter.

0

5

10

15

20

25

30

35

40

45

2008 2009 2010 2011 2012 2013 2014

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ED Discharge Summary

Inpatient Hospital Document

Other Hospital Document

Outpatient Hospital Document



Table 4: MyEHR instils consumer and provider confidence

Aboriginal and

Torres Strait

Islander Health

Practitioner

“I go in there, information like when discharged from hospital. Like when

they've been in there, what they had, the procedures or whatever they have

done. You can always refer back to that and what medications.” Aboriginal and


General Practitioners "They're here with me now and they expect me to do something so I'll do the

best I can under the circumstances, and now a lot of the time you can be a

great deal more confident about what you're doing." GP

"I've found it fantastic and it's just helped solve so many medical kinds of

dilemmas. I had a recent case a few weeks ago where a guy started to vomit

up blood and he vomited a lot of blood. It was like why would this guy be

vomiting blood? Then I looked on his e-health and I found he'd been given high

doses of Aspirin at a clinic - for very valid reasons." GP

Registered Nurses

and Midwives

“I think for the patients, us being able to access previous consults makes them

feel as though we are actually starting to understand what they're talking

about.” Registered Nurse

“They expect you to use it.” Registered Nurse & Midwife

Specialist doctor “They want to come to the hospital and expect you to know their

medications.” Specialist doctor

In addition to increased confidence, some providers also reported that the MyEHR

service alleviated anxiety about providing appropriate care in geographically

isolated areas. Providers are often required to make clinical decisions on the basis

of limited information, and this can mean escalating a consumer from community

care to hospital care to be on the safe side. Having a comprehensive clinical

overview available via the MyEHR service alleviates the need to escalate care

unnecessarily. In some instances this has had the effect of avoiding costly hospital

transfers and evacuations, as providers feel they can provide adequate care in the

community.

"But the anxiety of trying to care for people when you know there's something going

on and you don't know what, you just look at a nurse's face when someone turns up

and she knows they're sick and she gets on there [the MEHR] - oh, thank God for

that!" GP

“I can see when they've last been seen, I can see if they've been seen for the same

problem or not, might have been seen last week, started on antibiotics somewhere

else. I can see all their other diagnoses. I can see their current medicines. I can read

the latest specialist letter from the nephrologist, I can read the last discharge

summary, I can look at their x-rays, I can look at their recent pathology and I know

that it's not 100 per cent true but it's pretty good and it makes me feel a great deal

more confident in being able to prescribe for that patient.” GP

2.6 Increased capacity to provide proactive population-

based primary health care

The MyEHR service has fostered providers’ ability to deliver proactive, population-

based primary health care, and thereby improve population health outcomes, such

as control of chronic disease.

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Two MyEHR use cases illustrate this benefit: preparation for clinics, and tracking

the whereabouts of consumers so that providers may follow-up consumer recalls.

Both of these use cases are enabled by providers being able to proactively access

information in the MyEHR service under an ongoing consent model, without the

consumer being present.

“It's amazing the wealth of information which is in that record, just looking at their

progress notes and getting a background of the patient; because it's nice when you

first meet them to have a bit of an idea of their background.” Registered Nurse

As a tracking tool, providers are able to obtain benefit from opening an MyEHR

record, identifying recent locations where the consumer received care, isolating a

geographic area where a consumer may be located, and then contacting the health

services in that area to relay pertinent consumer information. In this case, there is

benefit in opening the record without having to open a clinical document, and as

such the landing page has been a critical source of information for providers.

“There was a 22 year old girl… She has rheumatic heart disease, so she needs a BLA

every three weeks and she hasn't had one for a couple of months and I was just

tracking where she was.” Specialist doctor

“You can talk to family and you can look on the MeHR. Then you can say actually

they've been away and they've had it done elsewhere and we can change our recall

now because actually they've had that check-up done over there.” GP



3 Gradual evolution towards critical

mass

Sections 3, 4 and 5, describe how the MyEHR service has been able to realise the

benefits described in section 2.

It is evident from the evaluation that the MyEHR service evolved gradually towards

critical mass (tipping point) over its ten years. Critical mass is “the minimum

amount (of something) required starting or maintaining a venture.”3 The three

prerequisite elements of critical mass include – consumer registration, actively

participating organisations and providers, and clinical information. These elements

took time to establish whereby there were no ‘silver bullets’. Once the three

elements were in place, usage increases exponentially, and the level of usage is

sustained.

3.1 Element 1: consumer registration

There has been a steady increase in registrations over time, with three main

pushes: at launch in 2004, during 2007-08 (rollout beyond the Katherine region

using a strong community engagement model), and during 2012, coinciding with

the ‘Advancing SeHR to PCEHR’ (ASP) project4 (Figure 12). Registration drives

conducted by the Northern Territory government and Aboriginal Community-

Controlled Health Organisations (ACCHOs) have been able to build a significant

base of registered consumers.

Figure 12 – Total consumers registered over time

Research into the Summary Care Record in the United Kingdom has shown that

clinicians are unlikely to look for eHealth records if there is not widespread

utilisation of the system, because they are unlikely to find records.5 Registration

3 Cognitive Science Laboratory, Princeton University. WordNet. 2005. Available from: http://wordnet.princeton.edu/. 4 A precursor to the MeHR to National (M2N) transition project. 5 Greenhalgh, T. Stramer, K. Bratan, T. Byrne, E. Russell, J. Potts, H.W.W. (2010) ‘Adoption and Non-Adoption of a Shared Electronic Summary Record in England: A Mixed-Method Case Study.’ British Medical Journal. 340: p3111.

0

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reached approximately 50% of NT Indigenous population6 during mid-2010, 5½

years post launch (see Figure 33, p45), though in a number of communities

registration rates are as high as 95%. Achieving 50% registration overall appears

to be associated with the tipping point at which the MyEHR service reached critical

mass, and usage increased markedly.

"Because our push was back in 2004 I think, 2006 sort of and that's where we got

most of the people all signed up. In 2006 we had most of them signed up, I think. So

now it's only new babies usually that we're signing up or visitors that have come in

from elsewhere that we've signed up." Registered Nurse & Midwife

Release of the eRegistration functionality in both PCIS and Communicare clinical

information systems, which are used in primary health centres, saw the capability

for ongoing registration to occur at the point of care by administrative staff,

registered nurse, midwives and/or GPs.

“In the beginning because only 20 per cent of the community was signed up, it just

wasn't worth it...You had in the end probably 80 per cent plus of the rural community,

remote community, signed up, which is a great success.” GP

“Here there was a big push so probably 80 per cent of the community was registered

and we've kept that going. So we must be 95 per cent of registration, because it's

important for us to be able to do our job properly.” Registered Nurse & Midwife

"Every client, if they're not on it, I'll put them on it.” Registered Nurse

The resulting high level of utilisation of consumers’ MyEHR records is evident in

Figure 13. In the last 12 months, three quarters of all records have had a document

uploaded, half have been accessed, and over a third have had a document viewed.

Figure 13 – Percentage of consumer’s records that have been utilised in the last 3/12 months, by type of interaction7

3.2 Element 2: actively participating healthcare providers across sectors

Similarly to consumer registration, there has been a steady increase in the number

of registered providers (Figure 14). Provider registration efforts were sustained

6 MeHR service registration was focussed on Indigenous communities, therefore using the Indigenous population of the NT as the denominator is warranted. 7 Last 12 months defined as Nov 2013 to Nov 2014, and last 3 months as Sep to Nov 2014.

0%

20%

40%

60%

80%

100%

≥ 1 sends ≥ 1 accesses ≥ 1 views ≥ 1 sends ≥ 1 accesses ≥ 1 views

Last 3 months Last 12 months

Per

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over the long term; averaging between 150 and 200 registrations per month.

MyEHR registration is part of the orientation and training process for new providers,

and registration activities for new providers are distributed across sectors, so the

burden does not fall entirely on the central operational team.

Figure 14 – Total registered providers

Provider registration is an example of a ‘network effect’, where the more

participants there are, the more potential value the system will have, and therefore

the more attractive it will be for others to join. Critical mass of provider adoption

occurred across multiple health care sectors, including urban, rural and remote

primary care, NT public hospitals, some acute and community based specialists,

speciality clinics, and some allied health services. The majority of registered

providers are assigned to (work in) NT acute facilities (Figure 15). This indicates

that the MyEHR service has been embraced within the acute sector.

Figure 15 – Number of registered providers by profession, assigned facility type

Registration across all sectors has meant a breakdown of sector silos, and ensured

that providers believe ‘there’s someone on the other end’ to view the information

they upload. Figure 16 shows the breadth of providers utilising the MyEHR service,

0

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0 2,000 4,000 6,000 8,000 10,000

Acute - Interstate

Other - NGO and Interstate

Other - NTG

Health centre - NTG

Health centre - NGO and Interstate

Acute - NT

Number of registered providers

Nurse Doctor Aboriginal Health Worker Allied Health Professional

Health Facility Admin Officer Dentist / dental nurse Pharmacist Other

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with hospital pharmacists, doctors and social workers tending to have accessed the

most records in the last 12 months.

Figure 16 – Average number of unique records accessed, by profession8

3.3 Element 3: clinical content

The third element of critical mass is clinical content. A breadth of clinical content,

built up steadily over time, is necessary to achieve value. Figure 17 shows how

growth in document viewing was preceded for a number of years by document

sending. It was not until 2008 to 2009 that the volume of document viewing

quadrupled, and then doubled again from 2010 to 2011.

Figure 17 – MyEHR service usage per month

Qualitative evidence supports this finding:

“In the initial first four, five years or so there just wasn't that critical amount of data

there.” GP

8 For providers who have accessed at least one record in the last 12 months.

Pharmacist

Doctor

Social WorkerHealth Facility Admin

OfficerNurse

Aboriginal Health Worker

Allied Health Professional

Occupational Therapist

Dental Nurse

Nurse (Student)

Physiotherapist

Doctor (Student)

Dentist

Audiologist

0 50 100 150 200 250 300 350

Average unique records accessed in last 3 mths Average unique records accessed in last 12 mths

0

50

100

150

200

250

1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

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s Sends Record accesses Document views



“The amount of information as it built up, built the clinicians' confidence in using it.”

Department Director

“In the beginning it was really slow because there wasn't anything to go and look at

and there wasn't that much information on that many people.”

Registered Nurse

Event summaries, health profiles, and pathology reports are automatically

generated with each episode of care, and therefore have the highest sending rates

(Figure 18). Other documents require deliberate authoring by a provider, and

therefore have lower sending volumes.

Figure 18 – Document sends per month by document type

Collectively, it is nurses who send the most clinical content to the MyEHR service,

followed by doctors and Aboriginal Health Practitioners / Workers. Relatively

though, individual doctors send the most documents on average (Figure 19).

Figure 19 – Average document sends per provider per year, by profession

Sustained sending over time has meant the majority of records have content. At

the end of 2014, 86% of consumers had at least one document in their MyEHR

record. 10% of records contained more than 330 documents, and 0.5% contained

0

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Event Summary

Health Profile




Pathology Report

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Doctor

Health Facility Admin Officer

Nurse

Other

Pharmacist

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1,000 or more. Over 50% of records contained an ED discharge summary, and

almost 40% contained an inpatient hospital document (i.e. non-ED discharge

summary) (Figure 20).

Figure 20 – Percentage of records with 1 or more documents, by type

Over time, not only did the amount of content build up, but the rate of document

viewing compared to the rate of sending also increased. Figure 21 shows that in

2014, for every inpatient hospital document (discharge summary) sent, 1.3 were

viewed. This ratio was only 0.2 in 2008. Accounting for how many are uploaded, a

higher proportion of deliberately authored documents are viewed. This is indicative

of the relative utility of these document types.

Figure 21 – Naive ratio of views to sends per year, by document type

80.6%

80.5%

68.8%

51.8%

38.1%

25.5%

19.4%

5.4%

0% 20% 40% 60% 80% 100%

Health Profile

Event Summary

Pathology Report





Antenatal

Percentage of records with one or more documents of each type

0.0

0.5

1.0

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2008 2009 2010 2011 2012 2013 2014

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Antenatal


Event Summary

Health Profile




Pathology Report



4 MyEHR service embedded into

workflow

Achieving critical mass has meant the MyEHR service has become embedded into

clinical and administrative workflow as ‘business as usual’. The MyEHR service is

currently used by a wide range of providers in a variety of ways (section 4.1),

however there is large variability in the frequency with which providers use the

MyEHR service (section 4.2).

4.1 Approaches to using the MyEHR service

This evaluation has revealed that ‘how’ a provider makes use of the MyEHR service

is dependent on the type of information they are sourcing and what they intend to

do with the information once it is obtained. Importantly, the design and integration

of the MyEHR service has meant that accessing information fits into clinical and

administrative workflow regardless of profession or health care setting. Use of the

MyEHR service has become integrated into routine clinical practice.

Table 5 describes four distinct approaches in how providers use the MyEHR service.

Depending on the approach, providers varied the manner in which they interacted

with the MyEHR service to access the requisite information. More information on

modes of use is available in the comprehensive qualitative report.

Table 5: Approaches to using the MyEHR service

Investigative Who is this patient? What is

their history? What medications

are they on? Why are they

here? Have they had their

medications? Where has this

patient gone?

“I use it in assessment of patients to get a picture of

people who might not be able to give me their own

medical history, of the things that are going to be

important to me.” Specialist doctor

Opportunistic A trigger, prompt or

observation during a

consultation which causes the

provider to search through the

MyEHR service for further

information.

“We'll get patients back from being discharged and

they might mention that they've been on antibiotics.

They may need to be on a second dose of antibiotics.

So it's about having that follow through, easy access

to the discharge summary about what the clinic

actually has to do.” Registered Nurse

Targeted Providers have a specific piece

of information in mind they

want to find that is missing

from their local system.

“We just look in the past history, if they come in, I'm

coming in for my BP check, so we just look back in

their record and check what their last BP was.”

Aboriginal and Torres Strait Islander Health

Practitioner

Supplementary Extracting MyEHR service

information to populate,

complete or supplement local

records.

“If someone comes to the clinic and said I had my

penicillin somewhere, I usually go and check which

clinic they had it at so I can update my chart.”

Aboriginal and Torres Strait Islander Health

Practitioner

There is also an interaction between the approach employed and the clinical

scenario. Specifically, the approaches employed depend on whether the provider is

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preparing for a clinic or other occasion of service, interacting with a consumer, or

doing follow-up (Figure 22). Significant use of the MyEHR service occurs when

patients are not present. Flexibility in policy settings has allowed these use cases to

emerge.

Figure 22 – Methods of accessing the MyEHR in relation to consumer interactions

4.2 Variation in frequency of use

The following table describes the variation in frequency of use of the MyEHR

service.

Table 6: Variations in use frequency across professions



Practitioners

“We press it all the time.” Aboriginal and Torres Strait Islander Health

Practitioner

“…Probably once a week. When we've got a new patient coming in or if

we don't find any results, then we get into e-health and find it.”


“In a month I might rely on it three times.” Aboriginal and Torres Strait

Islander Health Practitioner

General Practitioners “I think I've used it for every patient I've seen there.” GP

“I'd probably use it for about half of the patients that I'm either seeing or

looking at records for.” GP

“To be honest, I don't use it very often. I have sometimes used it when I

worked in a different clinic when I actually went in and searched to find

out what recent investigations people have had.” GP


Midwives

“My use of MeHR is just every patient that's at Royal Darwin. I check to

see if they are registered and if they are that gives me a huge wealth of

information than what it does if they are not there.” Registered Nurse

“Probably daily, or probably every couple of days, yeah, if someone's

come in with no paperwork.” Registered Nurse & Midwife





Practitioners

“We press it all the time.” Aboriginal and Torres Strait Islander Health

Practitioner

“…Probably once a week. When we've got a new patient coming in or if

we don't find any results, then we get into e-health and find it.”


“In a month I might rely on it three times.” Aboriginal and Torres Strait

Islander Health Practitioner

Pharmacists “I had some new patients in the ward yesterday that I was looking up

and I will have some today, I just haven't got to looking them up yet.”

Pharmacist

“Probably more than once a day, yes if the patient has it, I'll look at it as

a source of information.” Pharmacist

Specialist doctors “I'd use it every day easily.” Specialist doctor

“If I'm doing a clinic, maybe once a fortnight or once every three weeks

and I might use it three or four times, and occasionally otherwise, but

mostly in the pre-admission clinic.” Specialist doctor

“Most of them are living in that community, so their records are all

contained within the PCIS system. It's probably at the moment only

once a month.” Specialist doctor

The frequency with which a provider uses the MyEHR service depends mainly on:

The need to overcome fragmentation caused by non-connected clinical

information systems, (this creates a ‘hierarchy’ in sources of information);

Provider type (profession) / clinical scenario; and

Individual preference / inclination.

In relation to point one, the need to use the MyEHR service predominantly arises

when providers are accessing consumer information from outside their local clinical

information system network. As noted in section 2.1, the MyEHR service is able to

bridge gaps between unconnected clinical information systems. A hierarchy in

information sources was evident (Figure 23).

Figure 23 – Hierarchy in sources of health information

In the absence of information from a consumer or a provider’s local CIS (or local

paper documentation), a provider may access the MyEHR service.

“You can get a history immediately [via the MeHR service] rather than starting again.”

Registered Nurse

“Rather than ring the clinic and humbug them, if you look on the shared records it

should be all there.” Clinic Manager

If further information is still required, the provider will then attempt to contact

other providers or organisations via a phone call, emails or fax. Therefore, the less

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interconnectivity, the more valuable the MyEHR service becomes as a source of

information, and the more frequently the service is accessed. For example, the

relatively fewer views in NT government-operated health centres evident in Figure

3 (p12) is likely attributable to the fact that all NT government-operated health

centres are connected to the same Primary Clinical Information System (PCIS)

network. In contrast, in some settings the MyEHR service may be the only readily

available electronic source of information, e.g. after-hours access, providers

utilising the MyEHR view-only web portal.

“I did use it but nowhere, nowhere to the extent of what I use it here… With Croker

Island where I worked, it was typically there and the West Arnhem region, they're all

on PCIS, so there was no need. My highest need and trust me; the most value of this

system has been at this [Communicare] community.” GP

“For Indigenous people moving around and realising that there's not uniformity of IT

system, it helps enormously.” Specialist doctor

In relation to point two above, frequency of use varies with clinical scenario, and is

most frequently used at points of clinical handover (Figure 24).

Figure 24 – Frequency of access by scenario

For example, a primary care provider in a community with a stable population does

not experience a clinical handover as often as an anaesthetist in which nearly every

interaction is a clinical handover. Additionally, a ward nurse often provides care at a

time beyond the handover point, and thus the MyEHR service is not relied upon as

a part of their standard workflow.

Primary providers often cited the hospital discharge summary or specialist letter as

a valuable source of information when receiving a consumer back into the

community, or a current health profile for a consumer who has visited another

health centre while travelling. Alternatively, hospital-based providers found

medication and medical history information particularly helpful in providing

appropriate care upon hospital admission. For example, hospital pharmacists view

the most documents on average (Figure 25), and they are predominantly viewing

health profiles for medications information (Figure 26).



Figure 25 – Average document views per year per provider, by profession9

Figure 26 – Percentage of views by document type, per viewing provider profession

Qualitative research indicates that hospital pharmacists in particular have

embedded use of the MyEHR into their workflow.

“From a pharmacy point of view, the green kangaroo is one of our sources of

information when we're completing a medication history.” Pharmacist

Utilisation of the MyEHR service has been found to be highly concentrated on a

subset of registered consumers. 20% of consumers account for: 67% (1-33%) of

all sends, 84% of all record accesses, and 94% of all views (Figure 27).

9 Providers with at least one view in any given year; analysis excludes some high viewing generic provider logins.

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40%

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50%

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20%

27%

21%

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15%

9%

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13%

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13%

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32%

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13%

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4%

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8%

9%

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8%

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Other

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Doctor


Pharmacist

Percentage of documents viewed per profession

Health Profile Event Summary Pathology Report ED Discharge Summary

Inpatient Hospital Document Other Hospital Document Outpatient Hospital Document Antenatal

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Figure 27 – Concentration of MyEHR service usage amongst consumers

This raises the question: Who are the 20% of people whose records are used

frequently? Regression and decision tree analysis was used to assess whether

consumers with relatively high levels of utilisation are systematically different from

other consumers in terms of age, sex, record contents, and number of home health

centres. This analysis suggests that sex, age, record contents and number of HHCs

explain only a little of the variation in measures of utilisation. For example, there is

a marked age trend in sending; older people have a sending rate 3-4 times higher

(Figure 28).

Figure 28 – Average no. documents sent to a consumer’s record, by sex and age, last 12 months10

37% of consumers have had one or more documents viewed in the last 12 months.

The median number of document views per record is reasonably stable with age

(Figure 29), though there is high variability and a large number of outliers.

Figure 29 – No. documents from a consumer’s record viewed in the last 12 months, by sex,

10 For consumers with ≥1 document sent to their record during the period. Last 12 months: Nov 2013 to Nov 2014.

6%

16%

33%

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25%

50%

75%

100%

0% 20% 40% 60% 80% 100%

Cu

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se

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12

mo

nth

s

Cumulative percentage of registered people

Sends Record accesses Document views

0

20

40

60

80

100

0-4 05-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

Ave

rage

nu

mb

er o

f d

ocu

men

ts s

ent

per

re

cord

in la

st 1

2 m

on

ths

Current age category (years)

F M



age (for consumers who had at least one document viewed in the last 12 months)

Utilisation of the MyEHR service by healthcare providers is also highly concentrated.

Figure 30 shows that 20% of providers account for approximately 80% of all sends,

accesses and views.

Figure 30 – Concentration in usage of the MyEHR service by providers11

This 80:20 rule is repeatedly evident in measures of MyEHR utilisation, indicating

use of the MyEHR service is highly concentrated. Further quantitative research

could explore the characteristics of the providers and consumers who are using the

MyEHR most extensively.

11 Analysis excludes two high-viewing generic provider logins, and also excludes senders that could not be distinctly identified in the data. Last 12 months defined as Nov 2013 to Nov 2014. Note also that a number of providers are likely to be inactive because they no longer work in the Northern Territory.

0%

20%

40%

60%

80%

100%

0% 20% 40% 60% 80% 100%

Cu

mu

lati

ve %

of

sen

ds/

view

s/ac

cess

es in

last

1

2 m

on

ths

Cumulative % of providers who have sent/viewed >0 documents, or accessed >0 records during last 12 months, ordered from lowest to highest count of sends/views/accesses

Document sends Document views Record accesses

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5 Success factors

The extent of integration and success of the MyEHR service has emerged from a

complex set of social, technical, environmental and political circumstances. Some of

the factors that have facilitated the success of the MyEHR service are fixed

characteristics of the setting into which the MyEHR was deployed – these cannot be

directly influenced by an eHealth program. Others are enablers, such as provider

attitudes and behaviours, technical and functional capabilities of the service, and

policy and governance frameworks, which are directly within the control or able to

be influenced by the implementation program (Figure 31).

Figure 31 – Classification of factors that facilitated success of the MyEHR service

An understanding of the different types of success factors, and the extent to which

they can be directly influenced, provides an opportunity to apply these lessons to

the M2N transition project. In addition, this understanding helps to identify the

prerequisite conditions necessary for the PCEHR system to reach critical mass, and

also to identify factors that can be directly influenced in order to accelerate benefit

realisation nationally.

5.1 Fixed characteristics

The following table provides an overview of the fixed characteristics of the setting

into which the MyEHR service was deployed which were conducive to the success of

the service. A more detailed explanation is provided in the comprehensive phase 1a

qualitative report. Note that while it is not possible to actively replicate these

circumstances elsewhere, it is possible to identify ‘fertile ground’ where these

circumstances already exist.

Table 7: Fixed characteristics that were conducive to MyEHR success

Characteristic

How the characteristic was conducive to the success

of the MyEHR service

Co

nsu

mers

English as an

additional language

Increased access to health information via the MyEHR

service reduces the onus on consumers to recall and retell

their medical history in a non-preferred language;

increases confidence and empowers consumers

Sensitivity to

Indigenous concepts

of identity required

The MyEHR service has search and alias features which

facilitates providers’ ability to accurately identify individuals



Characteristic

How the characteristic was conducive to the success

of the MyEHR service

Gender propriety The MyEHR service allows providers to access gender-

specific health information without having to confront and

query the consumer

Mobile population;

multiple care

providers

Care is often sought from multiple providers, creating data

silos and fragmentation of health information. For instance,

over 20% of consumers attend two or more ‘home health

centres’ (Figure 32) – this is the location identified by the

person as a preferred / usual place of care.12

Figure 32 – Number of Home Health Centres per consumer

Accessing the MyEHR service overcomes the fragmentation

of health information.

Pressure to provide

timely care

The MyEHR service increases the ability to provide timely

care, which is culturally valuable:

“If you've got three to five patients waiting, you know

you've got to see those patients in 15 or 20 minutes before

they walk out.” Registered Nurse

Pro

vid

ers

Majority of healthcare

providers have a

salary remuneration

model

Allows time for proactive population based care versus an

episodic funding mode; enables providers to dive deep into

consumer health information to identify issues and address

emerging problems prior to an acute episode, thereby

enabling proactive approach to primary care

Provider mindset The mindset of providers was often characterised by a

sense of responsibility, vigilance, a duty of care, and even

obsessiveness. This mindset translates into a willingness to

‘go that one step further’ to provide proactive population

based primary care, which manifests as a provider

searching through a consumer’s MyEHR record, identifying

a clinical need (e.g. missed dialysis or BLA needle for

rheumatic heart disease), and then proactively tracking

them to arrange for them to receive the appropriate care.

Primary care involves

a wide scope of

patient acuity

The complexity of service delivery requires high level

teamwork, particularly effective communication, and

coordination for people who are acutely unwell

Staffing models and

high turnover

The MyEHR allows new, rotational, and transient providers

timely access to consumer health information in a way

which supports an informed provider-consumer relationship

and more quickly enables building of trust and rapport

12 According to the NHPA report Frequent GP attenders and their use of health services in 2012–13, even a person who goes only occasionally to the GP (4-5 times per year) sees on average 2.4 different GPs and 1.4 different medical specialists. This indicates rates of utilisation amongst the MeHR cohort are comparable to the general population.

2.2%

76.6%

13.0%4.2% 3.9%

0%

25%

50%

75%

100%

0 1 2 3 to 5 6 or more

Per

cen

tage

of

all r

eco

rds

Number of home health centres (HHCs) a consumer has nominated

http://www.myhealthycommunities.gov.au/Content/publications/downloads/NHPA_HC_Frequent_GP_attenders_Report_March_2015.pdf

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5.2 Enablers

The following table gives an overview of the enablers that were directly within the

control, or under the influence, of the implementation program and system

operators, over the course of the evolution of the MyEHR service. They are

classified into policy and governance frameworks, technical and functional

capabilities of the service, and provider attitudes and behaviours.

Table 8: Enablers that were within the control of the implementation program

Enabler

How the enabler has facilitated the success of the

MyEHR service

Po

licy a

nd

go

vern

an

ce

Collaboration and

continuity

Individual stakeholders involved in the development and

ongoing management/operation of the service have largely

been maintained, or had long tenures

Clinical Advisory

Committee

Clinically driven usability enhancements have been

influential in promoting adoption and use of the MyEHR

service, by fostering a sense of participation and trust, and

encouraging peer advocacy. Enhancements include:

Single sign-on

eRegistration within CIS

Pathology: aggregated view, ‘previous’ / ‘next’ buttons

Inclusion of current health profiles from multiple clinics

Portal links to immunisations registers

Changes to the look and feel during the transition from

SEHR to MyEHR service

Peer-to-peer

encouragement

Peer-to-peer encouragement was crucial in the early years

of the MyEHR service to ensure providers used the service

as a source of information and embedding its use into the

culture of the workplace and routine practice

Ongoing consent for

access

The ‘ongoing consent’ policy model has allowed for

increased capabilities for providers to access the MyEHR

service and in turn proactively coordinate care

Recognisable branding Because of the strong community engagement done in a

respectful and culturally sensitive way, the kanga

represents a trusted brand, and has become a recognisable

brand amongst providers and consumers

“When people come in I explain what the green kangaroo is

- because everybody seems to understand about the green

kangaroo, they've seen it before.” Aboriginal and Torres

Strait Islander Health Practitioner

Registration drives

with community

engagement model

Activities were targeted with the aim of registering as many

consumers as possible to the MyEHR service. The allocation

of individuals to this role allowed the building of a critical

mass of registered consumers

Key performance

indicators promote

enhanced data quality

The introduction of Northern Territory Aboriginal Health

Key Performance Indicators promoted improvement in

clinical information system data quality, where a by-

product of a high standard of documentation is a high

standard of content in the MyEHR service



Enabler

How the enabler has facilitated the success of the

MyEHR service

Fu

ncti

on

al

an

d t

ech

nic

al Default to send The ‘default to send’ setting of MyEHR service has meant it

is easy for providers to contribute information to the

service without adversely affecting their clinical workflow.

Furthermore, documents that are automatically generated

with each episode of care (event summaries, health

profiles, and pathology reports) are sent most frequently;

whereas other documents that require deliberate authoring

by a provider have lower sending volumes (see Figure 18,

p27). Uploading documents that are automatically

generated as a by-product of pre-existing clinical workflow

is not reliant on clinical users changing their behaviour and

has minimal or no impact on workflow.

Intuitive design Due to the consistent layout and design of the MyEHR

service across different clinical information systems,

minimal training is required for providers to receive benefit

from engaging with the service

Progress note,

consultation note and

free text contribution

Progress notes, in the form of event summaries, provide

deeper contextual information and a rationale for consumer

treatment regimes

Ability to sort

documents

Documents are available in a number of views, with search

functions by facility and author allowing the provider a

choice in how to search for and view information

Capability to extract

information

Allows providers to copy and paste content into a Word

document which can be saved in a local system and thus

supplementing and enriching a provider’s local system

Ability to access the

MyEHR service via

web portal

Web portal accessibility has enabled providers not using

conformant software to view consumer health information

from across sectors and interstate, which has resulted in a

larger number of providers capable of benefiting from the

MyEHR service than have conformant software

Care plan templates

facilitate data quality

Templates and care plans afford providers structure and

consistency in their documentation, which has facilitated

data quality, and therefore high quality data in the MyEHR

Existing recalls

facilitate proactive

care model

By accessing the MyEHR service, a provider can see the

recent interactions with the health system in the document

list, phone the most recent organisation, and then pass on

the necessary follow up instruction

Att

itu

din

al

an

d b

eh

avio

ural Benefit of engaging

with MyEHR service is

immediate

MyEHR service has become information dense over a

number of years, therefore the benefits of using the MyEHR

service are immediate for providers and consumers. This

fosters a virtuous cycle of continued engagement

Consumer willingness

to register

Community engagement, trust and buy-in was obtained

from the onset through clear, targeted and culturally

sensitive communications, which contributed to a

perception that the MyEHR was valuable and necessary

Staff skilled at

identifying consumers

Identifying patients requires skill, patience and detective

work, which MyEHR system enhancements have aided

Minimal privacy

concerns

Due to the community consent model approach, as well as

targeted education sessions for providers; consumers

reportedly have little concerns about having their health

information available in the MyEHR service

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6 Implications for the M2N

transition

As noted above, there is an opportunity with this evaluation to apply lessons from

our understanding of the different types of facilitating factors of successful shared

record systems, and the extent to which they can be influenced directly by design,

policy and concerted change management.

The following sections set out the key learnings and implications from this research.

6.1 Advantages of transitioning to the PCEHR system

Specific advantages of transitioning to the PCEHR system have been identified

(Table 9). Both providers and consumers will benefit from enhanced functionality

when registration and participation is achieved at equivalent rates. Clear, targeted

communication of these advantages is essential to support the transition process.

The risk of not doing this is a loss of the hard-won trust and confidence consumers

and providers have in the MyEHR system.

Table 9: Advantages of transition to the PCEHR

Funding sustainability The focus on one national eHealth record system will reduce the

need for ongoing funding to maintain of the MyEHR service

Cross jurisdictional data

exchange

National connectivity will increase the ease of sharing clinical

information across jurisdictions

"It will be good with the national because we do get a few coming

from South Australia; a lot of people moving between South Australia

and NT." Registered Nurse

"Getting the correct discharge information from Adelaide has been

fraught with a lot of danger. They would probably complain about us

not giving them the information of patients we're sending down if truth

be known. So that's really crucial, that cross border stuff is just going

to be gold for us." Nurse Manager

Individual Healthcare

identifier (IHI)

National identifier eliminating manual entry of identifiers

Consumer access and

control

Consumers will be able to access and personally control their

health information (not currently available to MYEHR consumers),

and can be more involved in their healthcare

"Aboriginal people tend to be very happy but it would be so much

better if they could actually electronically control their e-health record

and go yeah, have it or not. I can see that that's a huge advantage,

that personal control and stuff." Physiotherapist

Additional functionality,

with atomised data

The PCEHR has additional functionality, including: advance care

directive custodian information, prescribe and dispense

notifications, eReferrals, Child eHealth record data, consumer

entered notes, MBS and PBS data, and organ donor register

Additional sector

connectivity

Aged care, community pharmacy, private hospitals and NT based

GPs will be able to access and use the PCEHR



6.2 Limitations of the MyEHR service

Respondents generally praised the MyEHR service for its value and benefits, though

some did report concerns. The identification and mitigation of these concerns is

valuable as part of the ongoing process to not only improve the current MyEHR

service, but also as preparation for the transition to the PCEHR system, and

operation of the PCHER itself.

Examples of these limitations include:

Need to improve the look and feel of the interface,

Differences in how the MyEHR service functions between different clinical

information systems,

Absence of hospital pathology records,

Inability of providers not utilising conformant systems to contribute to the

MyEHR service,

Primary care continues to bear the onus of consumer registration efforts,

Slow internet speeds and reliability, and

Training and awareness is variable within provider groups and

organisations.

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6.3 Issues requiring consideration through the transition

The following table describes issues that have been raised through the evaluation that require consideration by the transition

project. Potential mitigation strategies have also been suggested.

Table 10: Issues requiring consideration through the transition

Issue Description and evidence of issue Potential mitigations

Provider anxiety about

the transition

A number of providers reported being anxious about the

impact of the transition.

"There's a lot of anxiety because - not just because they're used

to the MeHR, but because it's so simple and it the information it

contains is so much easier." Clinical Coordinator

"Are you going to take anything out of our system? Are we getting

everything that is in our system that will be replicated in the

PCEHR?" Registered Nurse & Midwife

A clear communication strategy. Existing and future

material should be informed by the findings in this

evaluation and aligned to policy relating to the

transition.

Concerns about re-

registration for PCEHR

system

A major concern amongst providers and administrative staff

was the need to re-register consumers in the PCEHR system,

after they had spent so much time on MyEHR registration.

"I have to say this, it was quite disheartening, we did an awful lot

of work in terms of getting patients signed up, getting clinicians

motivated and engaged and then when it didn’t go to the MeHR, it

was going to the PCEHR and you're going to have to start that

process all over again, it was just like really – there's so much rich

information for these guys, clients need clinicians to know what's

going on." Clinic Manager

The current legislative framework for the PCEHR

requires voluntary registration by each consumer.

MyEHR registration cannot translate to PCEHR

registration without agreement from each consumer.

Change and adoption should consider investing

energy into the coordination of national eHealth

record system registration drives, including dedicated

eHealth officers to re-register consumers

PCEHR system does not

yet have equivalent

content breadth and

depth

The MyEHR service has had many more years to build breadth

and depth of health information. The benefits attributable to

the MyEHR service are the result of information density.

Given the current information in the PCEHR system is less

clinically-rich, there is a risk the PCEHR system is not capable

of initially providing the same utility and value currently

afforded by the MyEHR service.

Targeted, communication is essential for providers to

understand how data in local clinical systems is

uploaded to the PCEHR. This will need to include

information about the use of the Event Summary and

Shared Health Summary.

Monitor the rate of uploading of clinical content, i.e.

frequency of documents for consumers that have

been re-registered in the PCEHR, so as to ensure all

modes of use (see section 4.1, p29) are still possible.



Issue Description and evidence of issue Potential mitigations

Policy differences may

affect clinical workflow

and how providers

interact with the PCEHR

system

There is a risk consumers registered and receiving benefits

from the MyEHR service may not have adequate identifying

information to be successfully registered for the national

eHealth record system. The MyEHR service monitors

attempted access by unregistered providers and notifies health

care organisations of failed accessed.

“If we have a query over identity, so I can go into the MeHR and

check the record from the home clinic that the patient might be

from, so date of birth, because it has in the details section, it

might have their next of kin and their Medicare number as well, so

I can cross reference with the home community.” Registered

Nurse

Change and adoption communications need to

provide a detailed understanding of the policy

differences in how the national eHealth record

system operates and how it can be accessed and

used in comparison to the MyEHR service.

Internet bandwidth

limitations in remote

locations

It is not known to what extent the transition to the PCEHR

system will affect local systems’ ability to connect to the

information they need. There is a potential risk that providers

may blame the PCEHR system for a slowing of local systems

when accessing shared consumer information (this was

reported as an issue with the rollout of the MyEHR service). A

common example cited is where a PDF attachment can be

embedded in a clinical document and uploaded to the PCEHR.

Existing internet connection speeds and bandwidth limitations

are an existing issue.

Ensure PCEHR system functions are suitable for low-

bandwidth clinical settings

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7 Implications for the national

PCEHR system

This evaluation provides strong evidence validating the value of a shared record

system. There are a number of lessons relevant to the national PCEHR system that

can be drawn from the success achieved by the MyEHR service, and the

circumstances and enablers that contributed to this value being realised.

The following sections present data to support various aspects of development and

operation of the PCEHR into the future.

7.1 MyEHR as a benchmark

The evolution of the MyEHR service provides a yardstick against which to gauge

progress of the PCEHR system, and allows us to assess if the PCEHR system is on

track to achieve critical mass and realise equivalent value as the MyEHR service. As

described in section 3, the gradual evolution of the MyEHR service towards critical

mass took a number of years – there were no silver bullets that triggered

immediate, sustained increase in sending, accessing and viewing of health

information. This reinforces that critical mass is not a discreet point in time – the

fabled ‘ka-pow!’ moment.

Three prerequisites of critical mass are needed:

1) Population registration;

2) Actively participating providers; and

3) Sufficient content (clinical information) to make accessing worthwhile.

In the case of the MyEHR service, achieving a critical mass of consumer information

and provider participation took time, continual effort, reinforcement and iterative

policy and system enhancements.

50% registration appears to be associated with the tipping point at which

the MyEHR service reached critical mass, and usage increased markedly.

There was a steady increase in provider registrations from the outset, and

continuing throughout the life of the system.

The increase in sending preceded the increase in viewing at the mid-2010

tipping point. This implies the importance of having content in the records.

To assess relative progress of the PCEHR system towards reaching a tipping point,

the following analysis uses normalised measures of utilisation to compare MyEHR

service to PCEHR system uptake.



In the figure below it is evident that 2½ years following launch, registration rates

for the PCEHR system and MyEHR service were similar; however, the trends are

diverging. As noted in section 3, MyEHR service registration reached approximately

50% of NT Indigenous population mid-2010, 5½ years post launch. Based on

projected registration trends, and assuming the current registration approach is

maintained, the PCEHR system will not reach 50% population registration for

another 12 years (2027).13

Figure 33 – Estimated percentage of the population registered, by system14

In Figure 34 the normalised sending rate of the MyEHR service begins to increase at

about the same time the system reached 50% population registration. Sustained

volume of sending is a prerequisite for critical mass.

Turning to the PCEHR system, if NPDR (prescribe and dispense) records are

included, the PCEHR document uploading rate is actually higher than the MyEHR

service at a comparable stage of maturity.

13 Noting that in some regions, and for some age categories, the percentage of the population with a PCEHR record is actually higher than 10%. 14 MeHR service registration was focussed on Indigenous communities, therefore using the Indigenous population of the NT as the denominator is warranted. Total NT population is given for comparative purposes. Note: MeHR registration data for first 12 months not available.

0%

10%

20%

30%

40%

50%

60%

70%

0 12 24 36 48 60 72 84 96

Esti

mat

ed p

erce

nta

ge o

f th

e p

op

ula

tio

n

(AB

S ER

P)

regi

ster

ed

Months since system launch

MyEHR (NT total popn) PCEHR (Australian popn)

MyEHR (NT Indigenous popn) Linear projection (PCEHR)

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Figure 34 – Document uploads per month per 1,000 records, by system

However, at a comparable time, the normalised rate of PCEHR accessing is

substantially less than the MyEHR service (Figure 35). In addition, during

September to November 2014, 11.5% of MyEHR records were accessed by two or

more different providers. In comparison, the proportion of PCEHR records that were

accessed by two or more providers during the same period was 0.003% (3 out of

every million records) (acknowledging that the PCEHR is not yet at a comparable

stage of maturity).

Figure 35 – Record accesses per month per 1,000 records, by system

And finally, on current trend, normalised PCEHR viewing rates are comparatively

lower (Figure 36).

Point in time where MyEHR registrations

reached approximately 50% of Indigenous NT

population

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

0 12 24 36 48 60 72 84 96 108 120

Sen

ds

/ u

plo

ads

per

mo

nth

per

1,0

00

reg

iste

red

p

eop

le


MyEHR Sends PCEHR clinical document uploads PCEHR clinical document uploads (incl. NPDR)

Point in time where MyEHR registrations reached approximately 50% of Indigenous NT population

0

500

1,000

1,500

2,000

0 12 24 36 48 60 72 84 96 108 120

Acc

esse

s p

er m

on

th p

er 1

,00

0 r

egis

tere

d

peo

ple


MyEHR Accesses PCEHR Accesses



Figure 36 – Document views per month per 1,000 records, by system15

In summary, the evidence suggests that on current trends, the PCEHR has

comparable or better rates of registration and content generation, but lower rates

of utilisation compared the MyEHR service at an equivalent point in its maturity.

Reiterating, this evaluation provides strong evidence validating the value

proposition of a shared record system (see section 7.3), which can be unlocked by

a sustained change and adoption effort. Specific implications regarding ways to

accelerate achievement of critical mass are given in the following section.

7.2 Implications for PCEHR system enhancement, and

change and adoption activities

The MyEHR service also provides a blueprint for program activities that can be

applied to the PCEHR system. The challenge for the PCEHR system is how to best

replicate the complex circumstances (section 5.1) that led to the success of the

MyEHR service, in a scalable and sustainable way. This section provides specific

implications for PCEHR system enhancement, and change and adoption.

7.2.1 Sustain consumer and provider registration activities

The findings from this evaluation strengthen the case for actively encouraging high

levels of consumer participation. Notwithstanding a recommendation to introduce

an opt-out consumer participation regime for PCEHR16, a sustained effort to register

people is required whilst keeping a 50% population target in mind. Given the

concentration of use of the MyEHR service is amongst a 20% subset of consumers,

it would be appropriate to continue to target consumer segments with high care

needs.

Continual effort to register organisations, sustained over the long term, is also

required. This was a key reason the MyEHR service was able to achieve critical

mass (see section 3.2, p24). This includes increasing participation across all

15 Data on MeHR viewing for first three years not available. 16 Royle, R., Hambleton, S., and Walduck, A. (2013). Review of the Personally Controlled Electronic Health Record. December 2013. http://health.gov.au/internet/main/publishing.nsf/Content/PCEHR-Review

Point in time where MyEHR registrations

reached approximately 50% of Indigenous NT

population

0

100

200

300

400

500

600

0 12 24 36 48 60 72 84 96 108 120

Vie

ws

per

mo

nth

per

1,0

00

reg

iste

red

peo

ple


MyEHR Document Views PCEHR Document Views

http://health.gov.au/internet/main/publishing.nsf/Content/PCEHR-Review

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sectors, including non-traditional health facilities such as school medical clinics,

prisons, watch houses, and workplace health clinics.17

This evaluation demonstrates that utilisation of a shared record system by

providers is likely to be concentrated on particular roles and specific clinical

scenarios, particularly points of handover. Therefore change and adoption activities

should focus on viewing clinical content and prioritise the providers specifically

involved at points of clinical handover, such as:

pre-admission clinics,

day procedure and elective surgery admissions,

after hours clinics,

accident & emergency,

hospital pharmacists,

return to primary care after hospitalisation, and

outpatient specialist clinics.

In addition, the majority of information exchange in the MYEHR system occurs

within regions (see Figure 5, p13). This suggests a region-based ‘eHealth

communities’ approach to change and adoption would be appropriate for broader

adoption of shared records. PCEHR system change and adoption initiatives should

focus on regions and/or specific population segments to build pockets of critical

mass.

It should be recognised however that adoption will not automatically translate into

use. A high level of consumer registration is not a silver bullet in of itself, because it

only addresses the first prerequisite of critical mass. Sustained efforts to encourage

and support provider registration will also be required.

7.2.2 Stimulate content generation and utilisation across

sectors

The third prerequisite of critical mass is clinical content. Automated generation of

documents with a ‘default to send’ policy setting has been critical to generate

sufficient content in the MyEHR service. Policy and technical mechanisms to expand

the rate of uploading to PCEHR system should be considered for vendor systems

connecting to PCEHR, including automated generation of documents with default to

send settings. For instance, uploading hospital emergency department discharge

summaries and outpatient department specialist letters to the PCEHR system as a

by-product of existing workflows should be prioritised, given these documents have

relatively high marginal utility (see Figure 21, p28). The automatic uploading of

antenatal and chronic care plans should also be prioritised.

In order to support continuity of care it is important that content be contributed

from all sectors and by all professions (e.g. nurses contribute the majority of

information to the MyEHR system). This underscores the importance of pathology

and diagnostic imaging reports being uploaded automatically.

There has been a rapid increase in upload to the PCEHR system of hospital

discharge summaries, and prescribe and dispense notifications as an automated by-

product of existing workflow. In contrast, upload rates of documents that require

deliberate authoring – shared health summaries, event summaries, and specialist

17 The provider portal could be utilised for viewing by sectors that would not necessarily need to contribute data, e.g. school medical clinics, and watch houses. This may necessitate re-working the provider portal model to more closely mimic the successful MeHR view-only URL model of operation.



letters – have remained static (Figure 37). This highlights the potential of

automated uploading to quickly build a volume of content.

Figure 37 – Clinical documents uploaded to the national PCEHR system per week

In the absence of processes that automatically upload as part of existing workflows,

it was evident from this evaluation, and from the Clinical Usability Programme

Impact Assessment undertaken by NEHTA18, that remuneration is a determinant of

providers’ willingness to deliberately author documents. Specifically, compared to

providers with a salary remuneration model, episodic funding restricts the ability

and/or willingness of primary care providers to upload documents that require

deliberate authoring, such as shared health summaries and events summaries,

within the tight timeframes of a consultation.

The evidence from this evaluation suggests shared record content generation

should be reframed as a by-product of effective clinical information system use, not

an additional task requiring incentivisation. Change and adoption activities should

target providers whose remuneration model is sensitive to the time taken to

incorporate upload into their workflow. For example, encourage registered nurses

and midwives, registered nurse practitioners, and Aboriginal and Torres Strait

Islander Health Practitioners to deliberately author shared health summaries and

event summaries.

Lastly in relation to content, 10% of MyEHR records contain 330+ documents, and

0.5% contain 1,000+ documents. This volume of content suggests that in the long

term, consideration should be given for options within the PCEHR system to handle

records with a large number of documents (i.e. a large amount of information). This

could involve a shifting away from a discreet ‘document viewing’ paradigm, and

more towards intelligent aggregation and use of atomic data (i.e. information)

contained in the uploaded CDA documents.

7.2.3 Ensure policy and technical frameworks remain flexible and are clearly communicated

The MyEHR service is now used in ways that were not originally anticipated, e.g.

care coordination, communication, tracking patient location, preparation for clinics,

18 NEHTA (2014). Clinical Usability Programme – Clinical Impact Assessment, 5 June 2014.

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and proactive population health. The MyEHR service is much more than a

supplementary data source.

The MyEHR policy frameworks governing use and consent were deliberately

designed to be flexible enough to support new (and difficult to foresee) uses.

Importantly, the policy (and technical) settings evolved over the life of the system

to respond to emerging use cases, barriers and trends. For example, when it was

apparent that populating the record with clinical content was critical to drive use,

the consent model was changed from the initial setting requiring consent to upload

in each instance, to an ongoing consent and default to send setting. This was

supported by technical changes to support automated generation of clinical

documents.

This is relevant to the PCEHR system because as the richness of information in the

PCEHR system grows and the system evolves, providers will utilise its capabilities in

unforeseen ways. The experience of the MyEHR service suggests that PCEHR

system policy and technical frameworks must remain flexible enough to facilitate

unforeseen uses, be responsive to emerging barriers and trends, and also be

communicated clearly to users. For example, in relation to consent, current PCEHR

system policy settings permit clinicians to access records for the purposes of

providing healthcare. There was uncertainty evident in the in-depth interviews

about whether this extended to situations where the patient was not present.

Therefore it must continue to be communicated clearly that policy does not restrict

the capacity of a provider to provide proactive care and upload information in the

absence of the patient.19 In addition, policy adjustments combined with technical

changes may be necessary to stimulate content generation.

7.2.4 Clinical governance mechanisms needed to capture end-user input and feedback

The MyEHR service Clinical Advisory Committee, which was established during the

initial 2004 HealthConnect Trial, ensured that the usability enhancement priorities

of end users were considered and acted upon when suitable. As noted in section

5.2, this quarterly forum was a critical success factor for achieving end user buy-in,

optimising MyEHR service usability, and fostering a sense of participation and

ownership, which thereby encouraged adoption and peer advocacy.

Clinical governance of the PCEHR system comes in a number of forms. The valuable

role of the MyEHR service Clinical Advisory Committee suggests that robust clinical

governance mechanisms that continually capture end-user input – throughout the

full lifecycle from requirements setting through to end-user feedback – will be

important to foster a sense of participation and ownership.

7.2.5 Optimise CIS use so high quality data is a by-product

The experience of providers using the MyEHR service demonstrates that using a

clinical information system improves their capacity to provide high quality care. Our

experience with the MyEHR and the CUP Impact Assessment show that where

providers use the full range of (relevant) functionality within their clinical

information systems, high quality, structured data is a by-product. High quality

19 Furthermore, in the absence of clear standards or guidance from peak bodies, clinicians have raised medico-legal concerns. These were echoed by respondents in this evaluation. The PCEHR Review stated that any transition to opt-out should take effect following the establishment of clear standards for compliance by all clinical users of the electronic health record (Recommendation 13).



data in turn enables improved monitoring of trends, chronic disease control,

surveillance, and decision support. In the case of the MYEHR service, high quality

data has enabled clinicians to generate useful clinical information automatically for

sharing, with minimal impact on their workflow.

In order for uploaded documents to have greater clinical utility, high quality data is

required in local clinical information systems. Utility of automated uploaded

documents to the PCEHR system would require high quality, structured data.

However, creating documents for sharing is, by itself, arguably not a sufficient

motivator to improve data quality. Therefore, the focus of change and adoption

activities for providers should not be on data quality as an end, but rather it should

be on encouraging optimal use of their clinical information system as an integral

part of delivering high quality care. Optimal use of clinical information systems will

generate improved data quality as a by-product, and thereby provide the benefits

conferred by high quality data. This will also enable shared health summaries and

other documents to be generated automatically and uploaded by default, with

minimal additional provider effort required.

7.3 Strong evidence validating potential value, but need further research into impact on health outcomes

The benefits realised by the MyEHR service validate the value proposition of a

shared electronic health record system. The vast flows of information between and

within sectors enabled by the MyEHR service are strong validation of the capacity of

a shared electronic health record system to facilitate exchange of clinical

information, thereby overcoming fragmentation.

This evaluation has also validated the capacity of a shared record system to

overcome limitations of point-to-point messaging by creating a ‘safety net’.20 This

enables care by a broad, multidisciplinary team, irrespective of where a consumer

presents. Rates of accessing the rheumatic heart disease register and childhood

immunisation registers via the MyEHR, in combination with the qualitative evidence

indicate increased immunisation compliance and a prevention of repeat

immunisations both enabled by proactive follow-up.

This evidence validates the potential benefit attributable to the PCEHR system

containing childhood immunisation (ACIR) data, and suggests connecting PCEHR to

additional disease registers would be valuable. Overall, this evidence supports the

case for the role of a shared record in healthcare delivery.

The benefits attributable to the MyEHR service are consistent with the benefits

anticipated in the National eHealth Strategy21 and the original PCEHR system

economic impact assessment.22 The patterns of information exchange validate

assumptions used in benefits modelling that the primary care sector is the main

generator of value, and acute sector the main recipient; though there is a

considerable flow of information from acute facilities to primary health centres.

Importantly, this evaluation provides evidence to support the initial benefit

proposition of the national PCEHR system. With continued enhancement, benefits

20 Note that point-to-point messaging still has a critical role, which is transfer of responsibility / duty of care. Point-to-share is arguably a more efficient and reliable means of sharing information to making it available to other providers. 21 Australian Health Ministers’ Conference (2008). National eHealth Strategy Summary December 2008. http://www.health.gov.au/internet/main/publishing.nsf/Content/National+Ehealth+Strategy 22 Deloitte. (2010). Economic Impact Assessment of a National Individual Electronic Health Record System. Draft Report for the Department of Health and Ageing: Deloitte.

http://www.health.gov.au/internet/main/publishing.nsf/Content/National+Ehealth+Strategy

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realisation management, and initiatives to stimulate use, there is good cause to

believe it will become core infrastructure, embedded as part of routine clinical and

administrative practice.

Moreover, evidence from the evaluation strongly suggests that the exchange of

information facilitated by the MyEHR service is having a positive effect on health

outcomes and health service efficiency.

However, there is a gap in our understanding of the extent to which use of the

MyEHR service has specifically translated into improved health and efficiency

outcomes. Utilisation of the MyEHR service is concentrated on a subset of

consumers, however it is not known who these consumers are (i.e. why they have

such high utilisation), or to what extent they have specifically benefited.

This quantitative analysis has not been able to assess the impact of use of the

MyEHR service on health outcomes and service efficiency. Further research would

be required to compare people who have a shared electronic health record that is

used extensively and those who do not - in terms of health service utilisation,

health risk factors, non-communicable disease morbidity, indicators of non-

communicable disease control, immunisation compliance, and mortality.

7.4 Opportunities for further research

This research provides a unique data set of the use and value of a shared health

record system. It provides a baseline upon which further analysis may be based.

Specifically, further quantitative research could explore the characteristics of the

providers and consumers who are using the MyEHR most extensively.

Comparative evaluation of the consumer and provider value of the system post-

transition may also be of value.



Appendix A Evaluation methodology

A.1 Overview of methodology

This research was undertaken prior to transition of the MyEHR to the national

eHealth record system. It comprised qualitative and quantitative components.

The qualitative component involved in-depth semi-structured interviews with a

sample of 94 individuals, including a range of clinicians and administrative staff

(see appendix A.3 below).

The quantitative component was a comprehensive analysis of MyEHR service

adoption and usage data, building on the analysis that was completed by NEHTA in

October 2012. A range of system, operational and transaction data was extracted

from the MyEHR service in accordance with policy and privacy provisions.

A.2 Scope limitations

The following tasks were out of scope of the evaluation:

Evaluating the extent to which the project has affected the sustainability of

shared record system operation, maintenance and enhancement (e.g.

sources of funding to operate the system);

Potential impact of transition on policy settings and privacy;

Potential impact on access to operational data for system management and

other secondary purposes;

Measuring the ROI of the transition project and validation of the transition

project business case;

Financial evaluation of ROI of the MyEHR Service;

Consumerl satisfaction with the transition; and

Involvement of participants not involved in the use, design, operation, or

management of the MyEHR service.

A.3 The qualitative sample

Collaborating organisations nominated a range of clinicians and administrative staff

currently using the MyEHR service, and also NT Government staff (and staff from

other organisations where appropriate) involved in the design, operation, and

management regarding the MyEHR service. Nominated people participated in face-

to-face, semi-structured in-depth interviews at the participant’s normal place of

work or over the phone where necessary. Consideration for group interviews was

site specific with reliance on participants to express the preference, and only

preferable as a method of collection to ensure participation. These interviews were

conducted by two researchers from the NEHTA Benefits and Evaluation Team.

The methodology for interviewees was amended once data collection had begun.

Some participant nominations from participating organisations were unavailable due

to leave or inability to contact. Additionally, researchers were presented with

opportunities to speak with additional persons not previously nominated by

participating organisations. This enhanced the robustness of the sample size and

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amount of contributors to the phase of the project. A breakdown of contributing

individuals by profession is given in the figure below.

Figure 38 – Evaluation Qualitative Sample (n=94)

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Registered Nurse/Midwife - Primary

Registerd Nurse/Midwife - Acute

Rural/Remote Doctor - Primary

ATSI Health Practitioner - Primary

Clinical Coordinator - Primary

Nurse Manager - Acute

eHealth Officer

Department Director/Manager

Specalist Doctor - Acute

Clinic Manager - Primary

Pharmacist - Acute

Administrative Staff - Primary

Physiotherapist - Primary