E-health: The Saviour of the frail and the elderly – or not?


As both a dedicated Family Physician (aka General Practitioner) and a self-taught computer Nerd I would love to believe that the future would have us use technology to improve the care of our patients and especially those who are disabled, frail and/or elderly.

If one could believe the medial releases one would like to think and say that this is the aim of our Government when they implement various e-Health programs such as the PCEHR – unfortunately this appears to be far from the truth as their agenda and methods indicate either sheer incompetence or perhaps even a more sinister hidden plan.

The Elderly

Elderly patients have multiple challenging issues and each town, district and city have systems that assists them in receiving these services. This ranges from getting Aged Care Assessments (without which they cannot enter a Nursing home) to getting home help with eating, showering and so on.

These systems worked reasonably well in most places and fantastically in others – especially in smaller rural communities where the patients were often relatives and friends of the care givers,

As of 1 July 2015, without any warning to GPs this all changed – one by one we discovered that we could no longer contact our local health services to arrange these services – instead we had to log on to the myagedcare website from where we had to either enter all the patient, and our own, details in on a supposedly secure website (which anyone with the slightest computer knowledge could tell you was not the case) or register with the Department to get an Aged care specific PKI USB Dongle to do the same process in a more secure way (more about this process later). This all off course assuming the website is up and running which it often is not

10/08/15 – Addendum: The secure log-on this site does not require a USB Dongle – it requires the installation of software and a digital certificate similar to those required for a business to lodge their BAS online.

The issue with this system is that there is one certificate issued per user – this is then linked to a specific workstation. Our Clinic is not big enough for each doctor to have a specific room and computer – we swap around depending on who is working which makes this device/doctor specific certificate un-useable.  

Oh – and it does not work with Chrome

Other service providers such as Residential Aged Care facilities (aka Nursing Homes) were also restricted by this and were expected to use the Dongles only.

Our Practice became aware of this process about three weeks ago. We had referred an elderly patient for an Aged Care Assessment using the normal Community Health intake fax line that we have used for this purpose for nearly a decade. Having not heard anything back after a few days we called and were told that they could no longer accept the referrals. At least they had some common sense and had sent the paperwork on to the myagedcare people (somewhere interstate).

We managed to make alternative arrangements for this patient so when we finally received a call back two weeks later we could tell them to stop bothering us in the middle of consultations and go away. Thankfully we were also able to get the local ACT Community Health Team to start accepting the ACAT assessments again in the interim.

Elsewhere in Australia people were unfortunately not so lucky – the following are harrowing stories of GP colleagues collected on internet forums in the last few days:

A rural GP recounts:

“The old fella with vascular dementia, propped up at home by his spouse of 70 years, and for whom I was trying to organise placement was ‘bounced’ – a call centre operative rang him, asked some questions then told him where nearest Nursing Home was and suggested he ring them to see if he could have a visit. Of course he didn’t – he felt he could manage perfectly (dementia, natch)

My middle-aged lady with a wound needing community nurse dressings – the call centre operative has told her that her RSD address (roadside delivery -a common rural address) was rejected by the computer and that her property (a sprawling homestead on 500 hectares) doesn’t exist. So no dressings for HER…her wound remains untended or she must travel 59km to clinic where my practice will pay for dressings and make a financial loss for providing the service!

The allied health staff and community nurses are demoralised – they now receive referrals from MyAgedCare via a computer system on which they have had no training whatsoever – and referral details are scant “Mrs X. OT.” – no further details. They cannot complain, as risk losing their job..”

A City based GP reports:

“I’ve not had the ‘pleasure’ yet personally, but my poor nurse was having a struggle with the new system with a patient who post CVA wasn’t able to use phone or Internet. I find it similar to the mental health contact centre we have. Making patients who are already pretty reluctant or ambivalent about engaging with the service undergo phone triage leads to an extraordinary number suddenly not requiring service. At least in the past there was some mutual respect between GP and local services”

Another Rural GP reports:

“A clinic patient with a diagnosis requiring treatment with Clexane. As a result needs to be taught how to self-inject Clexane for a few days before continuing for the required 6 weeks. Was told I need to put in a referral for MyAgedCare but…. the webpage was down. And my nurse can’t sit on the phone that long relaying all the relevant information because (a) she has other patients booked and (b) it is an expensive way to use a nurse. An alternative was to directly and privately private refer to RDNS but that was well over $100 and patient stated she couldn’t afford it.
So, patient had to come in and have her first few doses of Clexane admin by my nurses at the clinic’s expense. In the old system, RDNS would’ve been there that night. The tip of the iceberg”

And from yet another Rural GP:

“Elderly lady just coping at home with dementia. Husband – new diagnosis metastatic cancer, short life expectancy. He and I agreed to refer ACAT for her.
I rang ACAT 2 weeks after referral – ‘with the case manager,’ ensured they were aware that she lacked capacity to consent.
Now, husband is in hospital and deteriorating, wife is with relatives, no record of contact from ACAT. She is now with relatives in *city*, so not our area to refer to.
Rang ACAT – ‘Lady declined assessment because it was a bit much while her husband was unwell.’
And now she is in *City* will need to be re-referred, by her family, to a local ACAT assessor, or alternatively can come back here (where she has no home to g to as can’t cope alone) where she could be placed back on the local waiting list.”

And a final one from yet another Rural GP:

“Elderly chap in hospital. Likely to go home Monday. Planning discharge and ward round this AM. One thing that would REALLY help him would be meals on wheels and perhaps a community nurse visit later in week

Sit down with hospital staff and discharge planning. Apparently the hospital staff are NOT ALLOWED to refer to community services anymore – it HAS to come from the family via the MyAgedCare portal. Cue poor harrrassed daughter trying to arrange services for her father – not as if she doesn’t have enough on her plate, her partner being diagnosed with cancer a fortnight ago and radiotherapy/chemo starting Monday…hence the need for father to have Meals on Wheels on Monday when he is discharged and she is in the Big Smoke with partner…

But here’s the best bit – poor daughter finally gets through to MyAgedCare call operative – who tells her that, as dad is in hospital, there is NO WAY her father can be referred for meals-on-wheels as he is an in-patient…

…and no, they won’t organise it for Monday when he is discharged and she is on the mainland with partner.

So…I will be driving over on Monday to cook his dinner myself”

The Disabled

Most disabled patients is in some sort of Centrelink Benefit. Invariably this requires a lot of forms to be filled out on a regular basis and while we all hate it we recognise the importance of it and do it.

We usually make things easier by having templates in our Electronic Software that will pre-populate most fields and facilitate our ability to fit these tasks into a busy schedule.

Centrelink has now however discovered e-health and we are receiving reports that they will no no longer accept any paper based forms from GPs.

On face value this does not seem like an onerous task for GPs but let’s have a closer look at what this involves:

  1. Each GP must have an individual PKI certificate – this involves submitting a stack of forms to the Department of human services before you finally get a USB Token/Dongle that you should insert in your computer before logging into the so-called HPOS portal website. The reality is unfortunately that most GPs do not have these devices and in fact a large number of GPs are completely unaware of the entire process.
  2. Not all GP clinics have the resources, financially or otherwise, to have an IT team on-site or on-standby. The process of preparing each and every computer that a doctor might use for logging into HPOS is immensely complex. It involves downloading and installing software that needs to be selected according to the type of computers and versions of operations systems, the installation of multiple security certificates manually in different ways depending on which browser is being used and complicated passwords where an error can result in the PKI Dongle being locked and the installer having to spend extended periods on the phone to the Department o unlock/re-issue the Dongles.

Even if one has gone through all of the above there are still certain types of computer networks where this system simply cannot be installed – are we truly now in a world where a patient will need to change their doctors because their doctor’s computer system is incompatible with the Governments’s software?

I have luckily not had to use this system to do Centrelink paperwork as yet (and I would be the only doctor at our clinic that would have a clue how to do this) but the experience of other GPs are not promising:

From a few City based GPs:

“I have completed a DSP report for Centrelink online 3 times. All 3 times the patients were told that Centrelink hadn’t received it (How? Its direct into their bloody system!) and then that there wasn’t enough information (but more than anyone would have written by hand, and the boxes of “will supply on request” ticked, but no request made).”

“What is the point of filling out DSP forms anyway. They say no every time. Even for people so disabled they can’t even manage basic self-care. Last 3 I did all rejected for severely unwell people.”

” I have a poorly controlled Type II Diabetic, with severe peripheral neuropathy, severe peripheral vascular disease-causing bilateral leg claudication after 10 metres, and 6 months since a CVA causing dysphasia and left-sided weakness.
He wasn’t disabled, apparently.”

The Rest

Over the years the Government has paid GP clinics various e-Health Incentives.

In my sixteen years in Australia I have seen it being given for may reasons:

 

Online Claiming

A few years ago the Government offered us a payment if we put systems in place that enabled to patients to claim their Medicare rebates back at the GP. This made sense to us in terms of saving our patients a trip to the Medicare Office, was a good customer relationship exercise and off course saved the Government a fortune in human resource expenses.

After a few years they simply stopped the payments – we were set in our ways, were functioning as de-facto Medicare offices and they could not care less about our ongoing expenses in maintaining the systems required to do patient claiming for them. They also cleverly understood that it would be a very bad Public Relationship exercise for us to stop providing these services.

It also did not help us that the act of assisting patient in this way strengthened the erroneous belief by many that we were being paid by Medicare to see patients (as opposed to simply facilitating the process for patients to use THEIR rebate to pay for our services)

The PCEHR

More recently Practice Incentive Payments were offered to Practices to be e-Health ready. This invariably involved significant administrative and infrastructure expenses but did not require active participation in the flawed PCEHR system – approximately 70% of GP Clinics undertook this process.

Very few hospitals and other providers took part in an effective way and anecdotes where the process actually made any worthwhile contribution to patient health were/are far and few in between. The only winner in the entire system seemed to be the Government who continues, as we speak, to gather a massive amount of health related data of Australian Citizens.

Last week the Health Minister announced that the rules were once again being changed – no longer would the system be an opt-in process; no longer could GPs just be passive observers of the PCEHR.

How can we be expected to trust that these predicted enforced changes would be done competently give what I discussed in the preceding paragraphs? How can patients expect that their health records would be accurate and secure if the simple act of a referral process can be butchered and bungled as described.

I despair for the future of General Practice in Australia – the Government, of both political persuasions seems hell-bent on implementing the worst features of failed systems in Countries such as the UK in Australian Primary Care while we at the same time have the worst features of the US managed health system being implemented by Private Insurers.

Dark days lies ahead.

This entry was posted in Medical, Medical Admin, Medical ethics, Medical IT, PCEHR and tagged , , , , . Bookmark the permalink.

One Response to E-health: The Saviour of the frail and the elderly – or not?

  1. DrKP says:

    Reblogged this on karenpriceblog and commented:
    So tragic what is happening to primary care in Australia. This is what taxpayers should know about the waste of their money. Away from primary care away from nursing away from community health supports and into the pockets of petty useless bureaucrats.
    It is unbelievable that both sides of politics are so ignorant of the benefits and strengths of primary care that they seek to bring the WORST of the UK system (petty bureaucracy) and the WORST of the USA system (private & corporate insurance)

    Meanwhile on of our great colleagues is out showing off our primary care standards to Japan who want to emulate our world class system.
    Taxpayers should note that both sides of Government care not one whit about standards but Australia’s General Practitioners do. Watch this space. It may well turn out that future young Doctors will shun careers in the greatest discipline of them all primary health care.
    It’s happened in the U.S. And it’s happening in the UK.
    Appalling and patients are already suffering.

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