“The first 90 per cent of the code accounts for the first 90 per cent of the development time. The remaining 10 per cent of the code accounts for the other 90 per cent of the development time.”
- Tom Cargill, Bell Labs
The 90-90 rule of software development is well known in computer circles where cost and time overruns are so common as to be considered almost the norm. The rule parodies the Pareto principle in business and economics, which broadly reflects a non-linear relationship between inputs and outputs. For a general practitioner, by way of example, this might read, "20% of your patients generate 80% of your hassles."
The Commonwealth’s Personally Controlled Electronic Health Record (PCEHR) is a massive undertaking involving hundreds of millions of dollars, dozens of companies, tens of thousands of health professionals and millions of patients.
The PCEHR is new, complex and incorporates a variety of winners and losers – hopefully, patients will be in the former category. The scheme is still in its infancy and one of the greatest surprises is that it was not strangled at birth. Let’s hope it is a true survivor.
As general practitioners, we have both a moral and legal obligation to protect the privacy of our patients' information. This obligation is instilled into us during our training and on signing contracts with our employers and employees. If we see ourselves as the patients' agent in the medical system, as indeed we should, then our primary duty is to protect their interests.
Privacy and confidentiality come at cost, however.
We have the data but it is the patient who decides with whom we can share this personal information, the movement of which around the medical system creates friction. Friction is wasteful. It produces heat but rarely light.
Mark Zuckerberg, the creator of Facebook, recognised the value of frictionless sharing. While it has enabled hundreds of millions of internet users to connect in ways that enrich their business and personal lives, the undoubted benefits have come at the cost of some of their privacy.
Many people accept it, others bemoan it, some have come to regret it, and many more may yet do so – our children, for example!
One thing is certain, however: Facebook for Health will never be a goer.
The PCEHR is an attempt to address these two problems. Quality medical data can be uploaded by the patient's usual GP and the patient can then determine who else can see that data. This can be worthwhile even if the answer is nobody.
It is depressingly common to find that parts of your patient's health summary are wrong or incomplete despite being their doctor for years. Often the patient does not know what you have on your records or has not felt authorised to correct the errors or omissions.
The real value of the PCEHR will be felt when accurate information in the patient's Health Summary, Care Plans and Advanced Care Directives are available to other members of the health team. This controlled data sharing will minimise errors, save time and reduce costs, presuming that these other health professionals have an electronic system that can deal with the PCEHR.
So who are the winners? The patient hopefully, as well as specialists, allied health, pharmacy and emergency services. The Commonwealth is also hoping to benefit from the vast amounts of accurate medical information that will pour into the databases.
What about the losers? Probably the usual GPs whose medical records may be only marginally better even though they have to do all the work in creating a health record suitable for upload. They also have the ongoing work in maintaining the records. While GP can charge for time spent on the PCEHR during a consultation, in practice most of this work is done outside of the consultation.
So why would any GP get involved? While charity is good for the soul, it is not a great business model. GPs will be much more interested in the PCEHR and eHealth generally when it can save them time and money.
Two scenarios come to mind.
The PCEHR has brought some degree of standardisation to medical data. If information from the hospital, specialist, pharmacist or GP colleague came to the GP in a form that could automatically populate the records, they would be interested.
The pre-election announcement by the Minster for Health for funding to enable the upload of radiology and pathology results to the PCEHR raises an interesting possibility for GPs.
One could share the vast majority of "normal" pathology results with patient via the PCEHR. A pathology upload, just like any other upload, can be configured to send the patient an SMS.
It would not be suitable for abnormal results that need more immediate attention but could lighten the load on busy reception and nursing staff while saving the patient the inconvenience of a return visit or a long wait on the telephone line.
So what's in it for GPs? Not much so far, but get back to me when you get the medication and radpath sorted.