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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The National E-Health Transition Authority Ltd (NEHTA) makes the information and other material (‘Information’) in this document available in good faith but without any representation or warranty as to its accuracy or completeness. NEHTA cannot accept any responsibility for the consequences of any use of the Information. As the Information is of a general nature only, it is up to any person using or relying on the Information to ensure that it is accurate, complete and suitable for the circumstances of its use.
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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.
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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
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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.
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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.
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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).
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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.
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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’.
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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)
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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
Aboriginal and Torres
Strait Islander Health
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
Registered Nurses and
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
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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
Aboriginal and Torres
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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Aboriginal and Torres
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
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
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No. different providers who have accessed a record
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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%
0 1 2 3 4 5 +
Per
cen
tage
of
all r
eco
rds
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
ion
wh
ere
the
view
ing
faci
lity
is lo
cate
d
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
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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
Torres Strait Islander Health Practitioner
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
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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
10
20
30
40
50
60
70
11 2 5 8 11 2 5 8 11 2 5 8 11 2 5 8 11 2 5 8 11 2 5 8 11 2 5 8 11 2 5 8 11 2 5 8 11
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
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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
cen
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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
2
4
6
8
10
12
14
16
11 2 5 8 11 2 5 8 11 2 5 8 11 2 5 8 11 2 5 8 11 2 5 8 11 2 5 8 11
2007 2008 2009 2010 2011 2012 2013 2014 2015
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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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“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
10
20
30
40
50
60
70
80
1 6 11 4 9 2 7 12 5 10 3 8 1 6 11 4 9 2 7 12 5 10 3 8
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
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Antenatal
ED Discharge Summary
Event Summary
Health Profile
Inpatient Hospital Document
Other Hospital Document
Outpatient Hospital Document
Pathology Report
0
100
200
300
400
500
600
2013 2014
Ave
rage
do
cum
ent
sen
ds
per
pro
vid
er p
er
year
Aboriginal Health Worker
Allied Health Professional
Dentist / dental nurse
Doctor
Health Facility Admin Officer
Nurse
Other
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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
ED Discharge Summary
Inpatient Hospital Document
Other Hospital Document
Outpatient Hospital Document
Antenatal
Percentage of records with one or more documents of each type
0.0
0.5
1.0
1.5
2008 2009 2010 2011 2012 2013 2014
Nai
ve r
atio
of
view
s p
er y
ear
div
ided
by
sen
ds
per
yea
r
Antenatal
ED Discharge Summary
Event Summary
Health Profile
Inpatient Hospital Document
Other Hospital Document
Outpatient Hospital Document
Pathology Report
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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
Aboriginal and Torres
Strait Islander Health
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.”
Aboriginal and Torres Strait Islander Health Practitioner
“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
Registered Nurses and
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
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Aboriginal and Torres
Strait Islander Health
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.”
Aboriginal and Torres Strait Islander Health Practitioner
“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).
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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.
0
25
50
75
100
125
150
175
200
2007 2008 2009 2010 2011 2012 2013 2014
Ave
rage
nu
mb
er o
f d
ocu
men
t vi
ews
per
p
rovi
der
* p
er y
ear
Aboriginal Health Worker
Allied Health Professional
Dentist / dental nurse
Doctor
Health Facility Admin Officer
Nurse
Other
Pharmacist
17%
33%
35%
35%
40%
38%
50%
79%
21%
23%
20%
27%
21%
19%
15%
9%
13%
17%
13%
11%
13%
17%
22%
2%
32%
13%
18%
13%
11%
11%
7%
4%
14%
8%
9%
6%
8%
8%
4%
3%
0% 20% 40% 60% 80% 100%
Other
Nurse
Aboriginal Health Worker
Health Facility Admin Officer
Allied Health Professional
Doctor
Dentist / dental nurse
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%
0%
25%
50%
75%
100%
0% 20% 40% 60% 80% 100%
Cu
mu
lati
ve %
of
tota
l vie
ws
/ ac
cess
es /
se
nd
s in
last
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
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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
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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
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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
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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
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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.
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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.
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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
Months since system launch
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
Months since system launch
MyEHR Accesses PCEHR Accesses
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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
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00
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iste
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ple
Months since system launch
MyEHR Document Views PCEHR Document Views
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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.
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10 July 2015 Approved for external information 49 of 54
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.
0
10
20
30
40
1-J
an-1
3
1-A
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ct-1
3
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4
1-A
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1-J
ul-
14
1-O
ct-1
4
1-J
an-1
5
1-A
pr-
15
Tho
usa
nd
s
Automated/Integrated Upload
Discharge Summary
Prescription Record
Dispense Record
0
10
20
30
40
1-J
an-1
3
1-A
pr-
13
1-J
ul-
13
1-O
ct-1
3
1-J
an-1
4
1-A
pr-
14
1-J
ul-
14
1-O
ct-1
4
1-J
an-1
5
1-A
pr-
15
Tho
usa
nd
s
Deliberate Authoring
Shared Health Summary
Event Summary
Specialist Letter
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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).
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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.
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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.
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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)
18
15
12
11
7
6
6
5
4
4
3
2
1
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