ACRRM SUBMISSION ACRRM response to the ehealth PIP consultation

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1 ACRRM SUBMISSION ACRRM response to the ehealth PIP consultation October 2015 Organisation: Contact Person: (ACRRM) Marita Cowie, Chief Executive Officer Contact details: Level 2, 410 Queen St, PO Box 2507 Brisbane Qld 4001 Ph.: Page 1

2 ACRRM response to the ehealth PIP consultation Rationale for our involvement The (ACRRM) recognises that funding incentives linked to specific measures can drive change and the College seeks to ensure that changes to Practice Improvement Program (PIP) incentives progress better outcomes for patients and are supported by valid education and support arrangements for clinicians. The College is engaged in the ehealth reform agenda because ACRRM considers that a clinician led implementation of the MyHealthRecord (MyHR), can help overcome the fragmentation of health information, improve the availability and quality of health information, reduce the occurrence of adverse medical events and duplication of treatment, and improve the coordination and quality of healthcare provided by different healthcare providers. We have seen some evidence of such outcomes and clinicians (members) support in the Northern Territory and look forward to a clinically relevant National system. ACRRM is devoted to the advancement of medical care in rural and remote communities. The College progresses this through the provision of quality vocational training professional development education programs, setting and upholding practice standards, and through the provision of support and advocacy services for rural doctors and the communities they serve. ACRRM s Fellows are characterised by their broad scope of practice and clinical acumen, fit for purpose use of technology and reliance on teamwork. In order to service the needs of members the College continues to be innovative in the development and delivery of distance education, including the creation of collaborative e-networks and use of technology to bridge distance. ACRRM is one of two Colleges recognized by the Australian Medical Council, providing vocational training towards Fellowship in the specialty of general practice. The ACRRM programs are specifically designed to prepare Fellows for the extended skills required to provide the highest quality care in rural and remote communities characterized by a dearth of face-to-face specialist and allied health services. ACRRM fellows are eligible for vocational recognition and access to both the MBS and PBS, and access to A1 item numbers as are fellows of the RACGP, however the ACRRM credentialed GP is certified by ACRRM to provide a far greater range of services and to deal with complexity in ways which are different to other GPs who have not met the ACRRM standards. This extended range of services and assessment measures is defined in the ACRRM primary curriculum. This range of services includes fit for purpose use of ehealth and Telehealth in providing better access to care and improved continuity of care for patients. There is clear expectation that ACRRM rural generalists are able to care for complex conditions within their competence and to be discriminating in their use of specialist referrals, prescribing and diagnostic tests. ACRRM provides educational resources and programs to support registrars and fellows to provide safe and quality practice, however targeted financial arrangement and measures, which recognise and reward quality complex practice and improved patient care are lacking. ACRRM is keen to emphasise that a reassessment of funding arrangements including the MBS is required, including a way of recognizing and rewarding GPs who work at the top of their Licence. Whilst redesigning the entire primary care financing arrangements is outside the scope of this consultation, tweaking the ehealth PIP may assist short term in recognizing the practice and care improvements associated with meaningful use of shared records for patients who access a range of health services. The current ehealth Page 2

3 descriptors do not contribute to improvements to care of patients or use of the system for their benefit. ACRRM acknowledges that whilst there has been significant uptake of the current epip by practices this has not been associated with meaningful use. However this this is partly a result of lack of engagement of specialists and AHPs who also need to access the data in order for the act of sharing to become meaningful. The lag in some states in uploading discharge summaries meant that there was little benefit or meaningful use to be derived by the GP and his/her patients. It important to recognise that there is minimal uptake of the ehealth Record system outside of primary care and that meaningful use needs to be more than GPs sharing patient data without a purpose. PIP The Practice Incentives Program (PIP) was initiated to encourage short and long term changes to general practice through a form of blended payment. It was designed to complement fee-for-service by providing another funding stream for eligible practices, which met quality and accreditation standards. The PIP provides incentive payments to accredited general practices and Aboriginal Community Controlled Health Services (ACCHSs), on the assumption that incentivising enhanced quality of care, in addition to fee-for-service, will facilitate improvements in health outcomes. The College welcomes the re-examination of the PIP to better align incentives with general practice activity related to improved benefits to patients. ACRRM emphasized in recent submissions, 1 that we consider improvements in the management of chronic disease to be of major importance toward improving the health of the people of Australia s rural and remote communities. The role and potential benefits of ehealth tools such as My Health Record (MyHR), Point of Care Testing and advice, self monitoring devices and Telehealth have not yet been realised. The opportunity and case for their implementation is most compelling in communities characterized by the dearth of face-to-face health services and high incidence of chronic diseases. This position is in accordance with our position expressed in Parliamentary inquiry to the management of chronic and complex conditions and the PHCAG consultation and which will be further explored at our conference in the policy discussion segments at RMA15 in Adelaide on the 24 th October The modification of the epip to link with meaningful use of MyHR for patients with chronic disease is a good start; however other innovative strategies must also be developed and implemented ACRRM participates in the PIPAG, which is currently debating the new attributes of the amended epip incentive. ACRRM generally supports the move from rewarding GPs for establishing the ability to connect to the MyHR to active and meaningful use of such health information. 1 ACRRM response to the Parliamentary inquiry into Chronic disease management and our Submission to the Primary Care review Page 3

4 The wider context ACRRM contends that meaningful use is predicated on an efficiently configured, clinically relevant, secure and operational system. Meaningful use comes from the curation and sharing of appropriate health information and the use of that information by clinicians to who provide clinical care for these patients and by the patients themselves and their support network in improving self management of their conditions. The epip can be amended to encourage and incentivise participation the MyHR, by rewarding uploading Shared Health Summaries (SHS) by general practice as an early step in establishing meaningful use of clinical information. However meaningful use will only occur when all the relevant organisations and clinicians are participating, and this is outside the remit of the PIP. Further complications, associated with opt-out trials occurring only in some parts of Australia, will need to be managed to ensure equity for practices (outside the trials) in participating in a national ehealth Practice Improvement Program that is predicated on patient registration. In addition, the arrangements and agreements regarding health provider participation are changing. These will need to be clearly understood by participants, as some members saw previous arrangements as a barrier to participation. Currently healthcare provider organisations (and other entities) are required to enter into a participation agreement with the PCEHR System Operator. Health Legislation Amendment (ehealth) Bill 2015 is currently before Parliament, and changes to the PCEHR Rules, which will affect matters currently addressed in the participation agreement, (such as intellectual property and data breaches,) These are all external to the epip deliberations but will all impact on the success on the measure, as will the outcomes from the commissioned review of the End-to-End Security Review (in accordance with Recommendation 16 of the PCEHR Review) ACRRM response to the ehealth PIP consultation questions ACRRM s response to the epip consultation paper is based on 1. Advice from the ACRRM ehealth clinicians working group 2. Consultation with other members (via the ACRRM ehealth site, Country Watch Newsletter and website and other professional networks 3. Congruence with existing published policy position and submissions 2 and approved educational standards for IMIT (curriculum 4 th edition) 3 2 Diabetes Submission; Parliamentary inquiry into management of chronic and complex conditions, Primary Care Review; Royal Commission, Electronic Health Records and Healthcare Identifiers; Legislation Discussion Paper All located at 3 ACRRM Primary Curriculum (IMIT statement) nformation%20management.htm#_toc %3ftocpath%3d6.8%2520%2520information%2520management %2520and%2520Information%2520Technology%7C 0 Page 4

5 Whilst industrial issues are not the main game for ACRRM we are very keen to see incentives focused on activity that improve care for patients in rural and remote communities. This is the perspective that we hope to bring to this discussion. The College agrees that more comprehensive patient records would be most useful for individuals with complex and chronic conditions and/or individuals who see multiple healthcare providers, and that the revised eligibility requirements will need to be objective, measurable and require active use of the My Health Record system from general practices. Proposal 1 Criteria for change - questions: Do you agree to maintain the existing criteria 1 to 4? Requirement 1 Integrating Healthcare Identifiers into Electronic Practice Records Requirement 2 Secure Messaging Capability Requirement 3 Data Records and Clinical Coding Requirement 4 Electronic Transfer of Prescriptions Requirement 5 Personally Controlled Electronic Health (ehealth) Record System ACRRM response: Requirement 1, 3, 4 should remain, however the specific indicators for 2 and 5 need adjustment: Requirement 2. Secure messaging: Currently Vendors are being supported to provide products that do not meet agreed specifications. GPs have therefore been funded to purchase products that are not fit for purpose. Government should ensure that certified products meet requirements. Should criteria 2 also be changed to include demonstration of active meaningful use of secure messaging? Meaningful use of secure messaging requires participation at the other end which is outside of the control of the Practice. In that you need hospital capability to send you an electronic discharge summary and the hospital has to have the ability to receive your electronic referral. If these aren t in place because the hospital doesn t have the capability yet then it s unlikely the practice could influence and make this happen. Secure Message Delivery remains inconsistent and poorly utilised for the communication and sharing of information. The current system of security and IT infrastructure is complex and not easily implemented. Concerns exist about the privacy and security of patient data and its use outside direct clinical indications (by Government, regulatory Authorities, and law enforcement and research institutions). Do you agree existing criteria 5 is the most appropriate criteria to move towards active and meaningful use consistent with the recommendation of the PCEHR Review? ACRRM agrees that Requirement 5 is the most appropriate criteria to move towards active and therefore meaningful use consistent with the recommendations of the PCEHR review. However there is concern expressed from the ACRRM general practice community about the issues of consent, the ability to remove oneself from the system (opt-out) and use of data held by the system operator, and the significant penalties including criminal sanctions that apply to current sign on. These perceptions unless clarified or ameliorated will affect uptake. It will be important to clearly communicate changes to participation arrangements resulting from the current Bill. Page 5

6 Other specific requirements for consideration The NASH certificates need to be readily and easily accessible and valid (i.e. not expired) MyHR/ PCEHR (ehealth system) Compliant Software installed by the practice needs to be no more than one version older than the current released software Software should only be deemed compliant if it meets the reasonable recommendations of the system operator (informed by clinical working group) within the specified timeframe Criteria 5 should be expanded to create meaningful use metrics Proposal 2 Demonstrating active and meaningful use: ACRRM agrees that active and meaningful use of the My Health Record system by general practice and GPs should in the first instance require the uploading of clinical information in the form of the Shared Health Summary. Engagement of, and use by other health professionals will be essential for meaningful use. Methods out side the epip will need to be determined to achieve this critical engagement. We reserve the opportunity to comment on whether active and meaningful use be revised to include other document types and viewing of records in later years of the PIP ehealth Incentive (e.g. referrals), DI, etc. As the MyHR system is evolving (under appropriate clinical governance arrangements) and more document types become available more ways of demonstrate meaningful use. Choosing the Patient Base ACRRM agrees that linking the PIP ehealth Incentive requirements to patients where a Chronic Disease Management (CDM) Item is ethically claimed is a feasible and valid move towards meaningful use to benefit patients with the most to gain. The generation of a Chronic Disease management plan and upload of a Shared Health Summary could be linked. ACRRM recommends that the usual GP /Provider generate the Plan and that the trigger for the epip should be a generation of a 721 (CDM care Plan) and a subsequent 732 (Review) to demonstrate not only that a care plan was generated but that there has been meaningful review of that plan by the same GP/Provider/Practice. In the future it may be appropriate to consider adding other providers to demonstrate team care has occurred. ACRRM considers that in a perfect world with all providers (specialists, allied health etc.) and organisations participating that this this should eventually be routine for all consenting patients who require a care plan, however in the first instance in an immature environment, and with an evolving system ACRRM recommends participation and active use by sharing health summaries.. In areas outside of the epip trials this may (in practice) require assisted registration of some patients Measuring active and meaningful use: ACRRM considers that PIP ehealth Incentive be linked to designated training and activity designed to examine clinical outcomes, quality of care for patients supported via SHS and Quality improvement of the practice. (See ACRRM Chronic Disease and diabetes and Primary Care Review Submission 4 ) ACRRM considers that epip should be structured as an improvement program rather than a 4 Page 6

7 compliance program (Quality Intervention/Quality Improvement rather than Quality Assurance). Having an arbitrary percentage of SWPEs with a MyHR is not meaningful to a practice. A more appropriate measure would be the percentage of those patients who have had a Chronic Disease Management Item number or Health Assessment claimed who have had a Shared Health Summary uploaded or updated and a review of outcomes for those patients. Participation should include monthly or quarterly feedback on this measure, with practices expected to demonstrate improvement year on year. Collated measures across participating like -practices would demonstrate the level of success of the overall program. Review of cases and linkages and understanding of population/practice data is relevant, as meaningful use requires that the patient will benefit. Links to the management of complex and chronic disease, with demonstration of appropriate clinical use by the provider and the extended team could be demonstrated by engagement in education such as that proposed by ACRRM in recent submissions (Diabetes and Chronic Disease submissions) Meaningful use is more than just uploading a summary; it s about using the data and involving other members of the team. At present there is no significant ehealth community outside general practice to enable appropriate targets. Education should focus on improved quality of care for patients. ACRRM is keen to deliver and tailor such education as part of our Vocational training and Professional development programs. Choosing a timeframe: The quarterly cycle should be maintained, as this will allow practices to measure and adjust their meaningful use strategy as time goes on. Page 7

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