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Tuesday, 28 February 2012
Page: 2123


Mr FLETCHER (Bradfield) (20:27): I am pleased to rise to speak on the Personally Controlled Electronic Health Records Bill 2011. In principle, having a system of electronic health records is of course a very good idea. According to the National e-health strategy paper issued in 2008:

… E-Health is the means of ensuring that the right health information is provided to the right person at the right place and time in a secure, electronic form for the purpose of optimising the quality and efficiency of health care delivery.

Of course this sounds like an extremely attractive vision. The question before the House this evening is not whether in principle this is a good thing. The question before the House this evening is whether the method being used by the government to deliver on this vision, as embodied in the provisions of the bill before the House, is appropriate and makes sense—particularly in light of the fact that, while this government may be strong on vision and aspiration, as we know, implementation is very far from being their strong suit. In that regard, I want to focus on three issues in the brief time available to me to comment on the provisions of this bill.

The first question is: how do you get take-up of the electronic health records system? Secondly, is the timing proposed for the implementation of these arrangements realistic and is there a risk that this government is falling for one of the most obvious and repeated errors in information technology policy, which is: go for the big bang, the big system that is going to change everything and solve every problem?

The third issue I want to speak about is whether the business model underpinning this system is a realistic one or whether it is a wholly unrealistic one and, therefore, there is a huge gap between the funding which is required and the funding which has been allocated.

Let me turn firstly to the question of how to achieve take-up of this new system, this new application. I think it is an uncontentious proposition that, unless there is a high rate of take-up of this application—particularly by doctors and other health professionals in choosing to use it—this policy will have failed and the money spent to deliver this system will have been wasted. Against that backdrop, I would argue that there are several critical problems with the approach that is being adopted.

The first problem, in my view, is the approach of opt-in rather than opt-out. There is a privacy question which has informed the particular approach which has been taken. I do not want to deal with that issue. I want to deal with another issue, which is a corollary, a consequence, of the approach which has been taken, and that is: how many people are likely to use this system? How many people are likely to agree to their records being incorporated within this system? It is absolutely and plainly obvious that, unless as many as people as possible have their records contained within the system, the prospects of the system being a success are not high. Unfortunately, because of the decision to make the system opt-in, the power of inertia will work against most people having their records included within it. The power of inertia will cause people to keep their personal health records out of the system, and that is not good news if you want to maximise take-up of the system.

The second issue, which is a critical problem, is that the approach which has been taken permits patients to view and then to modify their own records. That is a decision with a critical consequence, and that consequence is that doctors and health professionals cannot have confidence that the record of the patient which they access electronically is in fact comprehensive, complete and accurate. If doctors and other health professionals do not have that confidence, if they fear that the record which they are looking at might have material and relevant information omitted from it because an individual has chosen to have that information excised then they are very unlikely to use that record in the way that the architects of this system would hope that they do.

The related point that I think can be made here is that the approach in designing this system makes an absolutely classic error in the field of information technology, and that error is to assume that all you need to do is implement a new system and then behaviour will change; that once you put the new system in the hands of users, users will automatically take it up. That is a deeply flawed assumption because what you actually need to do is achieve behavioural change on the part of users.

Who are the key stakeholders who are going to determine whether or not this system is used and whether or not this system is a success. The key stakeholders are doctors and other health professionals. If they are uncertain, if they are unpersuaded, if they are unconvinced about the merits of this system, then you can spout all the rhetoric you like about the potential of electronic health records but you will not achieve anything meaningful. Against that backdrop it is surely relevant to mention that the peak bodies representing health professionals, particularly the Australian Medical Association, have raised, amongst other things, serious concerns about the medico legal risk to which doctors may be exposed if they rely on electronic records which are subsequently discovered to have key information missing from them. It is a reality that doctors in particular and, to a lesser extent, other health professionals are key in the health system. They are the gateway to significant decisions and significant behaviours. Unless there is buy-in by doctors and other health professionals, this system will not achieve its objectives, and we will have simply wasted a substantial amount of public money.

There are similarities between the error this government is making with this particular IT system and another major IT system that it is implementing—the National Broadband Network. There is a failure on the part of this government to think about the marketing issues involved. How do we sell people on the use of this system? How do we persuade, in this case, doctors and other health professionals that it is in their interests to use this system? You cannot simply assume that, if you make the system available, you can force people to use it. That assumption is a grave misreading of the organisational behaviour of key groups of people within the health system, particularly doctors and other health professionals.

Let me turn to the second serious concern I want to identify, which is that this government is seeking to make a big bang change in information technology applicable to the health system and to do so in a huge rush. The near universal view in the sector is that the timetable for implementing these reforms is absurdly and unbelievably tight. The date which has been specified, 1 July 2012, is widely considered to be ludicrous. We have seen this government make this error in area after area. They impose a deadline so that they can announce it in a media release, without thinking through the complex implementation issues. We have every reason to suspect that the same error is going to be made again. I note, for example, that the Medical Software Industry Association, whose members include Cisco, Microsoft and iSOFT, made a very critical submission to the Senate inquiry, noting that the government's approach on this issue has not followed normal business practices in the IT industry and that the documents issued by the National E-Health Transition Authority to software developers were manifestly inadequate.

So if one issue is the unrealistic timeframe, a second issue which compounds that is the naive belief that we can create here a brand new system which will completely transform everything: 'This is going to be year zero. This new system will solve every problem.' That error has been made time after time when it comes to the application of information technology in both the public sector and the private sector. We are well on the way under the approach embodied in this bill to making the same error again.

Why is it that when the government's consultants, Deloitte—commissioned by the Australian Health Ministers' Advisory Council in 2008 to develop a plan to guide the national approach to e-health—recommended 'an incremental and staged approach', they proposed seeking a specific application which was manageable and achievable and which would deliver early benefits. The one they proposed was an electronic prescriptions transfer service between health carers and pharmacies. In their view, a quick win could be delivered at relatively low risk.

They argued that the first step was to connect the care providers, the next was to enable key information flows and only then to go to the third step of building repositories to accumulate the information contained in those information flows. Unfortunately, this government has chosen to reject that very sound advice. On this point, a witness to the Senate Community Affairs Legislation Committee, Dr Ian Colclough, had this to say:

It makes good sense to move away from large scale, all encompassing national ehealth projects and focus on projects which are more modest in scope and geography.

He went on to say:

In that regard it is a mystery why the Deloitte Recommendation to establish a National ePrescription Exchange Service has not been embraced by NEHTA and the Department.

And I can only agree with him.

The third point I would like to make in the brief time available to me is to ask: what is the business model under which it is envisaged that the personally controlled electronic health records system will operate? If you ask any large private sector organisation—it could be Qantas, Telstra, National Australia Bank, or any one of a host of large private sector corporates—about how they run their IT systems, they will say to you that they assume a cost per customer per year, which is often in the range of several hundred dollars, to encompass all of the costs involved in managing, maintaining and, where necessary, upgrading that IT system. There is no way around the fact that the ongoing costs of running a large IT system are enormous.

A one-time allocation of $467 million for a system that is designed to meet the electronic health record needs of all Australians is manifestly inadequate. We do not know the answer of where the ongoing spending is going to be sourced from. Where will the money come from to keep this system operating over successive years? The amount of money being proposed here has been described, for example, by Sydney University surgery professor Mohamed Khadra as 'a drop in the ocean'. It is well known that the UK spent some £12 billion on their equivalent scheme to introduce e-health records before the program was scrapped late last year as unsuccessful. That should be a warning to all of us.

I regret to say this is yet another example of the Gillard government espousing a worthy objective, rushing out a media release, setting an unrealistic timeframe and showing that it has manifestly failed to deliver a credible and implementable robust plan to deliver and execute on its aspirations. For that reason, we on this side of the House have very grave concerns about this bill.