The Australian PCEHR or My Health Record: The Journey Around a Large-Scale Nationwide Digital Health Solution

Abstract

This case study attempts to document key events and milestones in the development of Australia’s nationwide digital health solution the My Health Record (formerly known as the PCEHR). This is done by presenting an overview of the Australian healthcare system and in particular highlighting unique features about this system into which the My Health Record was implemented. This journey has only just begun, and in the next decades, it is expected that the My Health Record will change and evolve further; hence, the case study concludes with questions for the reader to consider rather than provide final statements. Ultimately, the success of such a solution can only be judged in the fullness of time; however, we note that this was a massive undertaking that has had far-reaching implications for healthcare delivery throughout Australia and impacts all stakeholders including patients, providers, payers, the regulator and healthcare organizations.

This case study has been written to capture the developments of a large-scale health technology journey to facilitate discussions, teaching, and learning only. It is not designed to identify good or bad management practices or make any comments about any of the organizations or individuals involved.

This case study is forthcoming as a chapter in a book publication by Springer, New York Eds Wickramasinghe, N and Bodendorf, F. 2019 Delivering superior health and wellness management with IoT and analytics and may only be used for educational purposes with the written permission of the authors.

Appendices

Appendix 1: Comparative Performance of the Australian Healthcare System

Compared to many other developed nations, the Australian healthcare system delivers above average outcomes (DoHA 2010), and the Australian population is ranked one of the best in terms of health status, with an average life expectancy at birth of 81.4 years, and there has been a significant decline in infant and youth mortality rates over the period of 1988 to 2007 (AIHW 2012).

Australia’s population is healthier than the OECD average, considering life expectancy and other general measures of health status (OECD 2013, 2017). Smoking consumption is also low, as is exposure to air pollution. But obesity rates are the fifth highest in the OECD (ibid). Further, despite universal health coverage, a relatively high share of the population reported skipping consultations due to cost (ibid). Quality of care indicators also show mixed results (ibid). The figure below shows how Australia compares across these and other core indicators from Health at a Glance (ibid).

This comparison is shown in a Table 2 (from OECD 2013, 2017).

Table 2 Australia - Relative performance compared to the OECD average

The following are key comparison statistics:

• Health status: life expectancy at birth was 82.5 years in 2015, the fifth highest in the OECD (the OECD average was 80.6). Mortality from ischaemic heart disease and the prevalence of dementia are also both lower than the OECD average.

• Risk factors: results are mixed. The proportion of Australian adults who smoke is 12.4%, amongst the lowest in the OECD. Air pollution is second lowest. Alcohol consumption is slightly above the OECD average. However, the adult overweight and obesity rate is 27.9%, the fifth highest in the OECD and well above the average of 19.4%.

• Access: all Australians are deemed to have access to healthcare. However, 16.2% of adults report that they skip medical consultations due to cost, well above the OECD average of 10.5%.

• Quality of care: Australia has the third lowest 30-day mortality rate following admission for heart attack in the OECD. Just over 70% of people diagnosed with colon cancer survive – the fourth highest rate in the OECD. However, hospital admission rates for asthma and COPD are high (371 per 100,000 people versus an OECD average of 236). Antibiotic prescribing is also higher than the OECD average (23.4 per 1000 people, compared with an OECD average of 20.6).

• Resources: health spending averages $4708 per person (adjusted for local costs), slightly higher than the OECD average of $4003. Australia has more nurses and doctors (11.5 and 3.5 per 1000 people) than the OECD average (9.0 and 3.4, respectively), but the number of hospital beds per capita is slightly lower than average.

Appendix 2 Structure of the Australian Health-Care System

Australia’s health landscape has four tiers (Fig. 5; DoHA & NEHTA 2011):

• The first and largest tier is ‘determinants of health and other demographic factors’. This includes education, employment, income, family and community, rural and remote and indigenous Australians.

• The second tier is ‘health promotion and disease prevention’. This includes immunization, food, physical activity, illicit drug use, tobacco control, alcohol consumption, mental health and cancer screening.

• The third tier is ‘primary health and community care’. This includes dental practice, pharmacy, allied health, general practice, primary health networks, community care and aged care.

• The fourth and smallest tier is ‘specialist, acute and residential care’. This includes specialist services (including out patient), diagnostic and pathology, local hospital networks, residential care and secondary and tertiary hospitals (public and private).

Fig. 5

The healthcare landscape in Australia. (Adapted from https://beta.health.gov.au/resources/publications/australias-health-landscape-infographic)

Factors that contribute to the health landscape (ibid):

• Impacts on individuals’ health and healthcare support

• Opportunities and challenges, including consumer and clinician expectation, ageing population, impact of technology and chronic disease

• Supporting regulations and infrastructure, including research and data analytics, information technology, quality and safety, infrastructure and workforce

• Health system funding of $2.3 trillion over the next 10 years. The funding in 2014–2015 was $182 billion including aged care. 11.9% was spent on aged care, 36.1% on hospitals, 32.7% on primary care and 19.3% on other recurrent costs. $58 billion came from individuals and the private sector, $43 billion from state and territory governments and $81 billion from the Australian government. The Australian government funding was for (from largest to smallest):

  • Medicare Benefits Schedule

  • Hospital funding

  • Aged care

  • Pharmaceutical Benefits Scheme

  • Private health insurance

  • Consolidated funds

  • Research

Public hospitals are managed and operated under the ownership of state and territory governments which provide free service at the point of delivery for all Australian citizens. State and territory governments are also responsible for the delivery of community health, aged care, mental health, patient transport and dental services for mostly free of cost to Australian consumers.

The Commonwealth government is responsible for healthcare policy development, healthcare service regulation and healthcare funding through Australian Health Care Agreements (AHCA) to state and territory governments as well as providing healthcare service rebates to patients through Medicare Australia, a universal health insurance system and Pharmaceutical Benefits Scheme, as well as regulating the private health insurance industry (Duckett and Willcox 2011; Willis et al. 2009).

Medicare provides universal access to subsidized care and pharmaceutical benefits. Medicare is partially funded by an income tax surcharge known as the Medicare levy (currently 1.5% of the taxable income or 2.5% for those who are high income earners and do not have private health insurance) and the balance is provided by government from general revenue (AIHW 2012). The Australian Institute of Health and Welfare has estimated that the total Australian health expenditure is $140.24 billion in 2011–2012 (AIHW 2013). This represents 9.5% of GDP. Another important component of Australian healthcare system financing is private health insurance (ibid). The Australian government encourages citizens to enrol for private insurance by giving them tax benefits for private health insurance premiums paid (ibid).

The flow of money around the healthcare system of Australia is a complex phenomenon and can be controlled by the institutional frameworks in place at both government and non-government levels. The government sector in this respect is comprised of federal, state and territory governments, and in some jurisdictions, local governments are involved (ibid). The non-government sector includes individuals, private health insurers, and other different non-government funding sources (ibid). The other non-government sources include worker’s compensation, compulsory third-party motor vehicle insurers, donations for health-related research and miscellaneous non-patient revenue sources for hospitals (ibid). The complexity of these funding arrangements and interaction between different levels of service providers and consumers in healthcare service delivery is explained here (ibid).

The funding model for healthcare services and delivery in Australia has perceived political polarization, with governments being critical in determining nationwide healthcare policy (Behan 2007). This leads to administrative duplications and lack of coordination at national level resulting in slow reactive and inefficient health policy (Wall 2002).

Appendix 3: System Architecture of the My Health Record

The My Health Record system (previously PCEHR) is situated in an e-Health ecosystem that has been designed to serve a number of communities:

• Consumers – including the individuals themselves, their family members and their carers. This also extends to working with organizations that promote public health and prevention programmes as well as those organizations that support self-managed care.

• Primary/community-based care – organizations and their staff, including, but not limited to, general practices, community pharmacies, allied and complementary healthcare providers, diagnostic imaging and pathology providers, specialists and aged care services.

• Acute/post-acute care – organizations and services, including, but not limited to, admissions, emergency care, outpatient care, surgical and medical care, rehab and subacute care units, hospital pharmacies and hospital diagnostic imaging and pathology providers. [Does this include Medibank Private, MBF, Medicare].

• Vendors – who provide products and services to support primary/community-based care, acute/post-acute care and consumers.

• e-Health services – operated either by public or private sector service providers that deliver online e-Health services, such as secure messaging, directories, prescription services, diagnostic services, registries and other secondary use services.

The e-Health community is also supported by a range of foundations (or national infrastructure) and standards for e-Health solutions (Fig. 6).

Fig. 6

The e-Health community architecture. (Adapted from NEHTA 2013, 2014)

Building on a series of stages of development, the PCEHR system provides a number of core services that allow authorized users to search for an individual’s PCEHR, clinical documents, view clinical documents and access reports.

A key feature of the PCEHR System is its ability to provide a series of views leveraging different clinical documents in an individual’s PCEHR. These views allow users of the system to easily see a consolidated overview of an individual’s allergies/adverse reactions, medicines, medical history, immunizations, directives and recent healthcare events from different information sources.

In the context of a national approach to e-Health, local systems at the point of care or in the home will be able to access a range of services, including:

• National infrastructure services, including, but not limited to, the Healthcare Identifier Service, National Authentication Service for Health, etc.

• Public- or private-operated online services, including, but not limited to, pathology services, radiology services, prescription exchange services, etc.

The interfaces for these services are based on national and international standards and other agreed specifications (Fig. 7).

Fig. 7

The target state architecture of the My Health Record. (Adapted from NEHTA 2013, 2014)