ACEM2011 Day 4

E-health record plenary

Mukesh Haikerwal:
Went through the design, and the implementation plan of the NEHTA PCEHR.

Sally McCarthy
Downsides of PCEHR
It’s opt-in: is anyone actually going to use it?
Patients can edit important stuff out!
Ensuring reports are available with radiology images
Pathology will require authorization from patient or GP to get uploaded –  too many steps.
If there’s an “arbiter” or nominated provider (eg GP) are they liable, are there medico-legal consequences for outcomes related to ommissions or mistakes in record?
Permissions on who can view the data: access in an emergency
Currently on an institution basis – once a hospital has access, everyone at hospital can access it…   
Legal role in evidence.
It’s a parallel system, that won’t replace hospital/GP/specialist records, but will lead to duplication
Privacy issues

ED Issues:
Availability of ECG – not included in 1st roll-out
Sally mentioned the minimum info that would be useful for ED’s:
     Med list, allergy list, problem list, advanced care directive
Efficiency issues: ie we don’t need anything that slows us down…
We need   
    Ease of access
    Ease of editing/input
Training issues (to use system)
Funding for continuing development/maintenance

Focus on Patient controlling, patient editing needs to be balanced with what WE as clinicians need
The volume of information is going to be huge, and need big servers to cope with it.

Stuart Stapleton
Another e-health juggernaut?

Getting patients more autonomous is a great ideal, but the ones that end up in ED are often there because they can’t look after themselves!

Stuart feels very strongly that this system should be “opt-out”,
If you want free healthcare via medicare, then you have to have a record
If you want to charge medicare as a provider – you have to interact with the record
This got applause from the audience!

ED Physicians are used to accessing lots of info from lots of sources

Stuart isn’t concerned about people cutting things out of records, because they are already doing that, by being selective with what they tell us

Feels that every patient who:
Goes into a nursing home
Is on home O2
Is in Pall care
…should mandatorily have an advanced care directive linked to their record

Process delays in uploading of path results – need to be addressed

Templates for “event summaries” are good

In ED: We’re not going to be expected to write an event summary AND a discharge letter, you just do the letter like you do now.

Gave example of Quakers Hill nursing home fire, and how none of the patients they received had any advance care directives/health information available.

No medical imaging (and possibly not reports even) in 1st edition of record

No ECG in 1st edition

Improved access to information:
Is unlikely to affect immediate care:
More effect on subacute care & Refinement of Rx

Main benefit will be providing communication between providers:
GP, specialist, hospitals, allied health.

Managing clinical cynicism
In the UK: NHS IT “shutdown”
IOM report on Health IT & Pt safety (192 pages – read exec summary)
There is NO good research on how these systems affect patient safety
Everyone in NSW’s favourite EDIS: Cerner Firstnet

Ongoing funding (not yet fully committed at federal level)
User uptake:
Need a critical mass of users
We need to push it from the ED
Huge change & adoption process

Big concern for ED: Work practice & work flow
Will it slow us down??
Event summary vs d/c summary
You can adopt a method that works for you in your ED

Key issues yet to be addressed:
Emergency access to information
Linkages through EDIS’s

Items not in version 1
Advanced care
Medical images

Planned implementation 1st July 2012
Feedback is needed
We need to learn from other processes (UK, Singapore, Canada)
Wave 1 & Wave 2


In a nutshell, it’s a great idea, but has raised hundreds of issues, and has a very high potential for being a very, very, very expensive white elephant.

Audience Discussion:

Reliance on opt-in in a patient group who notoriously don’t give a shit about their health.

Reason it’s opt-in = political = Believed to have a better chance of getting through parliament.
Consumer groups want it to be opt-out!
Clinicians want it to be opt-out, & want info to be available
There will be many avenues/access points to get people registered.
Eg: GP, hospitals, centrelink offices

Re-iteration of dysfucntionality of ED population & unlikeliness of opting in.

How much money is being spent on this, and is the cost justified?
Could it be better spent elsewhere in the health system, especially when there is no evidence of better outcomes!!
UK spent 12 billion pounds on a system that they didn’t use!
= 60,000 nurses wages for a decade!!!
Mukesh explained why the UK system failed, and how NEHTA has analysed the UK failings and how they’ve learned from it.

There is analysis of benefit & value being undertaken.

There is improving political will.

The cost now will hopefully put infrastructure in place for the future…

Unfortunately due to time constraints the discussion was truncated!!!!

ACEM2011 E-learning seminar

Katharine Ebbs
One of the 2 ACEM e-learning managers

Learning strategies: Old vs New

Old: Didactic Seminars
New:Virtual conferences/webinars
At ACEM they use Webex, Adobe connect software

Old: Textbooks
New: Online Information
ACEM Learning Management system
Software for delivering content, tracking students, managing training
Access to online materials & communication tools:
Using: moodle

(can host internally, or externally – benefit of external is technical support/backup)

Old: Collaborative group work on document
New: wiki – edit collectively
Google docs is another
ACEM uses its education site as a wiki

Old:Written exams
New: Online exam
Feb 2011 – 1st online primary exam.
August 2011: 430 candidates for primary sat the online exam!
Separate exam website.

Old: Different learning tools at different locations
New: mobile learning
Now: 10 trainees trialing online paeds logbook
Aiming to develop iphone app for this soon.

Old: Role plays/simulations
New: Virtual worlds
Second life, OpenSim, Unity
Can put together “virtual worlds”
ACEM not doing this yet, maybe in future for virtual training

Old: Bookmarking textbooks:
Social bookmarking/browser bookmarking
Resouces aren’t shared, but “tagged” for others to search.
Tools: RSS Feeds, iGoogle

Social networking:
Twitter, facebook, linkedin, many more.

Around 60 EM blogs noted by ACEM
(including LITFL)

ACEM E-Learning:
Allana Killen – director of education

Go to e-learning tab of ACEM website

Emergency Medicine Certificate resources:

Fellowship Exam Preparation Toolkit

Many other resources there…

Mike Cadogan quoted: online resources are “curatorial”

MedEdWorld: Ronald Harden’s blog

Health services & hospitals find e-learing too hard

Publishing guidelines for those who want to put information out from their public hospital web-pages are MENTAL!!! Pages & pages & pages of forms to fill out, hoops to jump through…
–    seen as “voice of the health service”

Therefore director generals of health services are worried about how it’s regulated & how it comes across

Simple operational challenges
–    access & enrolment

Role & Scope are conflicted
Rigid structure put onto a dynamic system – doesn’t work

You can’t fit everything people in your health service need to know for their education on one website
Someone needs to take responsibility in bureaucracies – imagine the “army of approvers” you’d need in a public service system

Example: QLD Health
Had a go at providing a resource for interns…
So WHO gets to endorse the information?
Need to have some standards!
Can also lead to competition – “I can do it better” – one hospital/site vs another…

Uptake of online platform was woeful: 1.2 logins per intern per year!!!

BUT: some hospitals – had enthusiastic educational people pushing it and encouraging use at their sites, so uptake was much higher

To “fix it” the bureaucrats got involved & offered a solution… But this raised the issue that  “buying expertise” can lead to problems – eg conflict as they’re trying to sell you something…  This “solution” is still pending…

After all the extra work – the uptake was the SAME!

Top down approaches don’t really suit online learning/technology solutions, as one of the defining features is that learning is INDIVIDUAL!

Lesson learned was that uptake & usefulness is only as good as the enthusiasm on the ground and when it’s related to what people are doing on the ground.
Homogenous approaches don’t really work.

A Cautionary Tale: Vicrtoria’s experience with the Crime & Misconduct Commission
She & some ED consultant colleagues discussed departmental issues on a password protected forum, without realizing that guest users could access posts in a non-obvious way. Some of these conversations were leaked to management, apparently it was a “code of conduct” violation with mandatory reporting to Crime & Misconduct Commission, requiring the “offenders” to get legal representation, and caused a huge amount of stress.
Eventually led to apologies from management, and nothing came of it.

But: They “dodged a bullet”
They hadn’t noticed ability for guest users to get access to “protected” information…
A worthy tale and note of caution for those creating online content through or within public hospitals… 
Know the rules. Know your technology.

Suggests every doctor that is involved in online activity looks at:

When designing his blog, he did a lot of research into how “not to stuff it up” – had to pay lawyers for this.
Also looked at some successful blogs:

Talked about “persuasion architecture” – how to get people to use their content.  They paid consultants to tell them how to get it people to use it.
But the main thing they learned was IT’S ALL ABOUT CONTENT!
If you have good content, people will use it.

To blog you need to be:
Expert and/or Passionate and/or Opinionated

You have to live it, & love it

What’s your “thing”
Stick to what you’re passionate about
Be careful what you write, & how you treat people
Be nice – “I’ve invited you into my living room”
Leave your kids out of it – there’s werido’s out there

Users are afraid to leave comments! But not afraid to send emails.


The future of Peter’s endeavours:
EM Education supersite – covering the full emergency syllabus
Videos, Audio, pdf lectures, fellowship stuff, webinars
Interactive community