Friday, 30 March 2012

Abbott a'Courting and Conservative? PPL, Nannies and the Nanny State

Tony Abbott has gone a'courting this year with big ticket policy proposals for women voters, and in the process has exposed confused purposes at the heart of Coalition policy formation and an ideological departure that will disappoint conservatives.

The extremely generous proposed Paid Parental Leave (PPL) scheme, and the recently announced plans to extend the child-care rebate to in-home nannies are policies designed to woo women voters to Mr Abbott and the Coalition. Both of Mr Abbott's proposed schemes have their merits and are likely to appeal to voters. But both policies are decidedly 'big government' initiatives, and are at odds with Abbott's attacks on the Government, most notably over the Carbon Tax and the NBN, and more broadly with 'small government' conservatism that underpins Liberal thought.  Recent weeks have produced friction and confusion for the Coalition party room accommodating the growing divide between the tenets of their faith and the approach of their leader. Does this change in policy sit with Abbott's political philosophy, or does it represent a divergence in favour of populism?

Abbott, the Conservative

The Liberal Party in Australia is the custodian of two ideological traditions -  Liberalism and Conservatism. One champions the importance of the individual while the other places faith in the importance of our society's institutions. The contentions of both philosophies create a natural contradiction, which continues to this day.  But with the emergence of socialism, to which both were opposed, a pragmatic union of the traditions occurred in the modern Australian context in the form of the Liberal Party.  Party members still identify as liberal or conservative, known as 'wets or 'dries', with Tony Abbott very much in the latter camp.

Damien Freeman wrote an interesting analysis of the the political philosophy of Tony Abbott in Quadrant in 2010, examining what Abbott saw as the obligations for a conservative politician to justify policy decisions. He notes that Abbott, in his book Battlelines, explains that a conservative is not burdened to produce a unifying ideological justification for policy in the same way as socialists or liberals.

Abbott argues that the other ideological traditions are obliged to impose and justify change based on their philosophical model on how they wish the future to be. He argues that progressive conservatives, rather than opposing change, accept the inevitability of a changing society and need to ensure that this change occurs in deference to the past and its institutions - “achievement is possible because ‘pygmies are standing on the shoulders of giants’”.

Whilst Abbott argues that an all-encompassing ideological justification is not required of the conservative, Freeman does enumerate a few ways Abbott believes policy can be explained. Firstly, the ideological explanation from either a liberal or conservative perspective. Secondly, an 'approach that transcends ideology' and goes to nationalism and the national interest. Thirdly, a purely pragmatic policy approach without ideological abstraction. And finally, what Freeman calls the 'counter-ideological approach' where policy is directed towards frustrating an opposing abstract idea rather than promoting one's own.

When Abbott defeated Malcolm Turnbull and Joe Hockey, both liberals, for the leadership of the party, he restored a conservative approach to politics and brought with him his political philosophy. Through the prism of Freeman's analysis, one can identify where Abbott would justify his efforts up until this year. He opposes the Carbon Tax on counter-ideological grounds, takes a hard stand on asylum seekers on what he sees as nationalistic grounds and could justify his opposition to pokies reform on liberal ideological grounds. But when one considers recent policy announcements, it is difficult to explain these using Abbott's own methods.

The Nanny Scheme and Paid Parental Leave

This week it was announced that a Nanny scheme would be referred to the Productivity Commission by a new Abbott Government as a matter of priority.  It would entail extending the non-means-tested child-care rebate to nannies, who are not currently covered. The child-care rebate increased under the Rudd Government to 50% of costs to a maximum of $7500 per annum per child with child-care subsidies already costing $3 billion dollars a year. The nanny scheme threatens to increase this burden.

While it is likely to produce some migration of children from centre to nanny care, thus ameliorating the expense, it will still be a costly undertaking for the tax-payer.  Mr. Abbott has said the scheme must come from within the constraints of the "existing budget envelope", but given that he rejected the proposal at the last election due to its sizeable cost, this does not seem a realistic expectation. More recent comments from Liberal sources have suggested that Abbott knows this.

The other key policy announcement by the opposition recently was the PPL scheme, which is more starkly contrary to their aims of minimising government spending. The Coalition's PPL scheme will pay a new mother a full replacement wage for 6 months, including superannuation, of up to $150,000 per annum and is expected to cost $3.2 billion.  Counter-intuitively for the Coalition, it will sting its natural business constituency to pay for it. Under the scheme, a levy of 1.5% tax will be applied on businesses earning over $5 million.

In this sense, it is not dissimilar to the Carbon Tax which Mr Abbott has lambasted as overreaching government interference in the economy, and has routinely warned will drastically increase the cost of living with flow-on costs to consumers. Perhaps this is not lost on some members of the Coalition with the scheme drawing uncharacteristically public opprobrium from the Liberal backbench and mixed signals from the front bench.

Abbott, the Populist

So lets return to Abbott's methods for explaining conservative policy. These policies are contradictory from a conservative point of view with government funding of the family unit via the PPL, only to disband it with incentives for carers to return to work through the Nanny scheme. Neither scheme is easily justified through nationalism, nor pragmatism when there are adequate existing schemes. And they can hardly be described as counter-ideological as each are 'big government' policies which will spend more on these issues than the social-democratic government of the day.

The Abbott opposition has spent much of its tenure attacking Labor for imposing a nanny state on Australians.  Yet now, they have introduced two cornerstone policies, which have been described as close to Abbott's heart, which are closer to socialist in philosophy than liberal or conservative. As Emma Alberici put to Barnaby Joyce on ABC's Lateline programme, if "the Coalition in government would reverse the nanny state,  [why are you] saying the state should pay for nannies?"

The answer lies with Abbott, and a departure from the political philosophy that guided him this point. Perhaps a still personally unpopular Abbott, faced with a re-united Labor Party, even with a recent thrashing in Queensland and abysmal polling at present, senses that he must lift his efforts to personally appeal to voters. The PPL and Nanny scheme are policy for populism's sake, and we may see more of it yet before the next election.




Friday, 23 March 2012

All Subject to the Human Condition

Poignant Shot of Whitlam at Margaret's Funeral. Courtesy: ABC News and AAP 
On the final day of a bitter election campaign in Queensland, and a Twittersphere full of bitterness and occasionally personal hatred towards politicians, it is worth at times reflecting that they too are all subject to the human condition.

Wednesday, 21 March 2012

Guns,Germs and Spiel - The Coming Immigration Debate


Last week, a 30 year old Postmaster in Sydney was arrested with two others having allegedly illegally imported 220 glock pistols into Australia over the last three months. Police discovered the syndicate's activities after tracing one such weapon used in a shoot-out in Sydney in January of this year. It is believed that the pistols, manufactured in Austria, were being imported from Germany via airfreight into Sydney.The story entered national debate when NSW Police Commisioner, Andrew Scipione said, "this isn't just a border security issue, this is a national security issue", and the cause was taken up by the Coalition in Parliament.

Today's Daily Telegraph published an short Op-Ed piece penned by Scott Morrison, the Opposition's Immigration spokesman. In it, he linked the illegal weapons seizure in Sydney last week to reduced federal Customs funding, and in so doing aimed to attack the Government's border protection credentials. With Border Security returning to the agenda, Scott Morrison is likely to have an increasingly important role in the final year and a half of the 43rd Parliament, and his recent efforts provide insight into the flavour of the debate to come.

The Coming Debate

With the passage of the Clean Energy Bill (Carbon Tax) last year, and the MRRT this week, Julia Gillard allowed herself a moment to "go scoreboard", reflecting on successfully navigating two key policies though torrid political waters.

Irrespective of whether one supported these pieces of legislation, and there are sound arguments why both taxes will not meet their lofty aims, they have now passed in to law.  This will not hinder ongoing Opposition pressure on these issues, however, particularly as it plans to campaign at the next election on repealing both taxes.

Four months after the Carbon Tax has passed the Senate and three months before it its implemented, Question Time this afternoon was still largely given over to Opposition probes into the effects the Tax will have on small business. Tomorrow, a 'Global Warming Hoax Rally' is planned for the lawns of Parliament House to call for its abolition.  After implementation in July, the Coalition will no doubt seize every power bill increase and every job loss as a means to attack the Government over the Tax.

However, it will be Labor's hope that come July 2012, voters will find themselves adequately compensated for expected costs arising from the flow-on effect of the Carbon Tax and the issue will lose some of its political potency for the Coalition. Meanwhile, despite its high-profile detractors and a potential legal challenge, the MRRT is more broadly popular with the public and Labor will expect it to prove less vulnerable politically.

After years of fierce debate on these issues, there is a sense of an impending shift in focus toward other, though no less volatile, concerns; heralded this week by the Coalition's 49th attempt to suspend Standing Orders over the issue of  Border Security.

Border Security

The phrase has been appropriated euphemistically by both sides of politics when responding to voter fears surrounding illegal immigrants, most notably those who arrive by boat. Despite receiving a comparatively small number of asylum seekers by boat each year (in 2009 - Australia received 2726, and Yemen received 77310), the issue carries significant electoral weight, particularly in key marginal seats in Western Sydney and in regional Queensland. It is one of few issues that appears to ignite political passions in Australians, for better or worse, and is therefore a powerful tool politically.

To date, the Coalition has wielded Border Security policy far more effectively. It is generally recognised that John Howard's strong-man response to the Tampa incident helped save his Government in the 2001 election, and later his Pacific Solution consolidated his resonance with Howard Battlers on this issue. Opinion polls routinely continue to report voters trust the Coalition over Labor on border protection. This perception has not been helped by the early Gillard foray into Border Protection policy with the hasty and ill conceived East Timor Solution. More recently, the High Court overturning the proposed Malaysian Solution has left policy progression at a stand still, with all asylum-seeker processing currently occurring on Australian soil.

The major parties have been left circling each other with spurious attempts at compromise. Scott Morrison was busy in Nauru, and urging Gillard to "pick up the phone" to re-activate the detention centre there. Later, Tony Abbott offered Christmas Day talks with Immigration Minister, Chris Bowen over Manus Island; and finally, Bowen produced zealously over-budgeted Nauru costings which could only be rejected. At all times, the debate has been marred by vitriol and emotion, but has until recently, been on the back burner.

Morrison re-enters the fray


Morrison was embarrassed at the beginning of last year after it became public that he had been urging shadow cabinet to make political mileage from community divisions over Muslim immigration. It compounded an already tense situation for him arising from ill-timed questions in the House regarding tax-payer funded compassionate flights for relatives of the victims of the Christmas Island boat disaster. He was criticised by moderates from within his own party for perpetuating 'hysterical rhetoric' and the politics of fear and division.

Looking at Morrison's efforts from the beginning of this year, one can read that he has not changed his approach to immigration politics and that he is liable to once again lower the tone of already pretty tawdry political debate on this issue.

Germs


On the 27th of February, Morrison produced a press release entitled 'Typhoid cases on latest boats highlight the risk of Labor's border failures'. In it, he is quoted, "when illegal boats turn up in our waters there will always be the risk that people on these boats will carry serious communicable diseases. The more boats there are, the greater the risk of serious diseases presenting" and goes on to raise fears of an "outbreak on Christmas Island or the transfer of these diseases to the mainland". Finally he lists various diseases and the number of infections detected, including 4 cases of Chlamydia.

It is worth noting the incidence of Chlamydia has tripled over the last decade in Australia, though thankfully Mr Morrison does not attribute this to illegal arrivals. It is a poor reflection on the level of debate this topic engenders that this release was barely mentioned in the press, much less derided as the the grubby spot of fear campaigning that it is.

Guns


Question Time on the 14th of this month had focussed on the Sydney weapons seizures and how Government funding cuts had reduced X-ray scanning of airfreight coming into Australia. They drew on Andrew Scipione's comments that an influx of pistols into Sydney could not be stemmed at the state level, and that responsibility lay with the federal Government, where he described it as 'the elephant in the room'.

Indeed, there have been 60 shooting incidents in the year to February in Sydney, a number of hand-guns had been imported and all but one is still unaccounted for. Moreover, Customs was unaware that this had occurred until it was discovered by the NSW Police. At this level, it is a pertinent line of inquiry.

But when Tony Abbot rose to move a motion to suspend Standing Orders on the topic, it became apparent that the Sydney Glocks were a preamble to re-opening the Stop the Boats campaign. Both Abbott and Morrison, when he seconded the motion, concluded (as he did in today's Op-Ed) that "when you cannot stop the boats, you cannot stop the guns". On face value, the attack is focussed at Government funding of the Customs Service, but the implication of its words, reminds voters of the boat people issue and links the fear of guns felt in Western Sydney streets to fear of boat-borne refugees that may end up living there.

Spiel


Painting refugees as vectors of disease, or implicating asylum seekers in Western Sydney shoot outs is not good policy debate. It will not go to creating a humane and workable solution to our role in a global refugee problem that balances Australians' general compassion with a need for control along our vast borders. As Border Security returns to the legislative agenda, the challenge for both sides of the House is to disavow Morrison's style of divisive politics.

Tuesday, 13 March 2012

Kandahar Massacre and the Strategic Corporals


There is a concept taught to aspiring officers in military colleges around the globe that puts the state of world affairs in the hands of their most junior leaders. They are often referred to as the 'Strategic Corporal'. The tragic events in Kandahar this week highlight the broader implications of this concept and exposes the fragile mandate on which Western powers rely for foreign expeditions.

Strategic Corporal

The concept of the Strategic Corporal has existed in military thinking for some time, but the phrase was coined in the Marines Magazine in 1999 by General Charles Krulak while examining the concept of a 'Three Block War' and called for a rethink of the way junior commanders in the US Marine Corps were trained. The concept has subsequently been adopted a number of Western militaries.

Krulak recognised the changing nature of international conflict in the post-Cold War period which he described as a "troubling age characterised by global disorder, pervasive crisis, and the constant threat of chaos". The 'Three Block War' idea, drawing on contemporaneous mid-level conflicts in Somalia and Bosnia among others, identified the new requirement for Western militaries to be able to conduct warfighting, peacekeeping and humanitarian operations all within the space of three contiguous city blocks.

Krulak also acknowledged the implications of increased media, and therefore public, scrutiny of military actions at the tactical level. He identified that in these high-stakes, asymmetrical battlefields, the junior commander, or indeed, rifleman will be required to make quick, sound tactical decisions "that will likely be subject to the harsh scrutiny of both the media and the court of public opinion". He concluded that "in many cases, the individual Marine will be the most conspicuous symbol of American foreign policy and will potentially influence not only the immediate tactical situation, but the operational and strategic levels as well'.

Events this week in Afghanistan highlight that the individual conduct of soldiers beyond the scope of purely tactical situations is having an increasing effect on strategic goals.

Last in a line

This has been a bad year for US-Afghan relations.

The methodical murder of 16 Afghan civilians, including children, by a US serviceman earlier this week is the last in a series of incidents placing strain on the relationship. In February, copies of the Koran were among seized religious literature burned at Bagram Air Field prompting deadly protests and an apology from the top US commander. And, in January,  a video of US soldiers urinating on Taliban corpses was published on YouTube, again prompting bloody protests in Kabul.

The number of Afghan civilian casualties has been increasing over the last 5 years, with 3021 killed in 2011. The majority of killings have been at Taliban hands (2332), but the largely inadvertent deaths at coalition hands have fuelled growing Afghan foreign hatred and exasperated the Afghan government.

This most recent incident has prompted a stern resolution from the Afghan parliament stating that the government had  "run out of patience with the arbitrary actions of foreign forces" and calling for a halt to further negotiation on the strategic partnership agreement needed to ensure a legal platform for ongoing US operations until the planned withdrawal in 2014.

They went further to "seriously demand and expect that the government of the United States punish the culprits and try them in a public trial before the people of Afghanistan". This unlikely to happen. The military-technical agreement signed with the Afghan government ensures that any US personnel charged with wrongdoing are to be handled under US military law. Moreover, the prospect of a US soldier, regardless of the heinous nature of the alleged crimes, facing trial and capital punishment under the Afghan legal system would be untenable domestically in the US, particularly during an election year.

In an environment where ongoing US-Afghan partnership is under threat, and where even hawkish US politicians were already increasingly pessimistic (or realistic) about their country's involvement in the conflict, this incident may prove a turning point for the viability of ongoing foreign intervention in Afghanistan.

Forming Public Opinion

The task of projecting force into foreign fields is expensive financially, in lives and ultimately in political capital. A recent report published by Brown University placed the financial cost of the Iraq and Afghanistan Wars at nearly $4 trillion and, using conservative estimates, the human cost at 236,000 war dead and 7.8 million people displaced.

Governments have always been beholden to public opinion for ongoing support of foreign military expeditions. Research suggests that the public are relatively tolerant, or at least apathetic, about the benefits versus costs of war provided the cause is perceived to be just. Support has been shown to erode quickly however, if the costs escalate and there is not consensus amongst political leaders in upholding the justness of the cause.

Foreign wars, particularly in the modem context, are not generally wars of direct national defence and so there is the perception of an elective quality to involvement. Governments engaged in costly and protracted foreign military interventions inevitably face the point at which the costs outweigh what remaining benefit there is, and public opinion turns against them.

The role of the war reporting in precipitating this turning point is not new. The Crimean War (1853-1856), which can be viewed as among the first 'reported' foreign wars, heralded intense public reaction to military setbacks. The Snowball Riots in 1855, in which 1500 were dispersed by baton charge from Trafalgar Square, were a response to dissatisfaction with the war, including the failure of the Charge of the Light Brigade.

News of war, however, was slow to make its way home. A public sense of the course of war was based on strategic and operational failures. Sir Douglas Haig's strategy of attrition at The Somme, for example. Or, more recently, the convincing early successes of the Tet Offensive only a month after US General Westmorland had said that the Viet Cong were "unable to mount a major offensive" and invited them to "try something, because we are looking for a fight".

The Three Block War

In the age of the Three Block War, however, with the advent of television and Internet,  more instant and vivid reportage of war takes us to the individual level, and to the importance of the strategic corporal.

The three most reported incidents of the Afghanistan War this year have not been new offensives, heavy casualties, or peace talks; they have been the actions of junior soldiers, acting alone or in small groups, and off their own initiative.

Incidents like these, which in the past, may have been lost in the grubby business of war, are now each strategic way-points in the conflict. Most recently, the Kandahar massacre has derailed strategic talks and promises further instability in the form of protests, which will undoubtedly cost lives. Domestically in the West, each incident dents further the political will and public support for ongoing war.

Ultimately, in a war where it is widely recognised that military victory is unachievable and political resolution unattainable, it is the cumulative cost of the actions of these Strategic Corporals and the ones that follow that will bring this war to an end.

Friday, 9 March 2012

Kony2012's Invisible Millions and Top-Down Populism


The leader of the Lord's Resistance Army, Joseph Kony.


Invisible Children's #Kony2012 campaign has been made 'famous' overnight and won praise, but it does it signal an uncomfortable change to the way political interests are championed online. #StopKony is being hailed by some as a continuation of the movement started by the crowds in Tahrir Square, citizen reporters in the streets of the Homs and the Occupy activists; that is, utilisation of the Internet via social media to circumvent the traditionally inaccessible or oppressively restricted political discourse.

An important distinction should be made when it comes to the origin of the Kony Campaign. Progenitor movements have been born of shared adversity and have relied on grass-roots users to collaboratively develop a message; Invisible Children, however, defined a target issue, created a polished marketing campaign to generate awareness and feeling, and developed a (literally) pre-packaged response for people to employ. This 'top-down' method creates a precedent for a populist approach to future issues that is open to corruption and cynical misuse.

The Knowledge Gap

Despite a proliferation of sources available in the last decade, and several foreign conflicts in which Western nations have been involved, public understanding of foreign issues remains superficial. Where much of people's knowledge of international issues come from short TV news stories, or a 3 page 'World' section in the tabloids, there is undoubted virtue in efforts to bring light to sometimes neglected issues, including the actions of the Kony's Lord's Resistance Army (LRA).

Joseph Kony has been active in Central Africa since 1987 in a conflict border-hopping between the Central African Republic, Uganda, Democratic Republic of Congo (DRC) and South Sudan. The ease with which he traverses these borders has gone some way to ensuring that he has not been pursued and conclusively defeated. The number of atrocities is well documented, and beyond the victims, and the brutalised and traumatised child soldiers, there is a more broad-reaching humanitarian crisis. In the DRC, since 2008, more than 280.000 people have been displaced by the conflict with many seeking refuge in UNHCR camps. With the Kony2012 video receiving dozens of millions of views and the resultant commentary in the media, there is at least an awareness now of some of the horrors occurring in Central Africa.

One of the criticisms of the Kony2012 video is the oversimplification of this conflict. It does not, for example, describe the conflict in the DRC between 1998-2003 during which 5.4 million people died, mostly from disease or starvation. The import of this conflict become apparent when one considers that among the belligerents in this conflict are Kony's four 'home countries'. Nor does the video volunteer that during the conflict, the Sudan supported the LRA among other militia groups active in Uganda in retaliation for Ugandan encouragement of the Sudan People's Liberation Army.

The stated aim of Invisible Children is to re-arm and upgrade the technology of the Ugandan army. It should be noted that when the Ugandan military last crossed the Sudanese border in pursuit of Kony, it was accused of killing and kidnapping civilians. The idea of unevenly arming one national military in a destabilised region to pursue a target that frequently crosses the border into surrounding, and still wary, neighbours should raise concerns.

For its part, Invisible Children acknowledges that their video cannot give a full account of decades-long  conflict in 30 minutes, but in answering its critiques it writes, 'the film is a first entry point to this conflict for many', and offers links for further information. In an age of dwindling attention spans, it is reasonable to ask how many people will keep reading more into the issue once they've re-tweeted, or clicked 'Like'.

Charity or Lobby Group, or both?

Towards the end of its emotional and uplifting video, Invisible Children implores people to donate a 'few dollars'. One would assume from the flavour of the video that this would flow back to aid projects in Africa. Invisible Children has come under criticism for the distribution of its charitably collected donations. Specifically, that only about one third is actually spent on aid programmes in Central Africa. By contrast, UNICEF managed 90.3% on programme services. The remainder of Invisible Children's funds are spent on awareness programmes, 'awareness products' like bracelets and graffiti aids, and media and management.

There is a suggestion of a false premise emerging from their viral video campaign. Of course, charities need to compete for donations with advertising and well constructed media campaigns, particularly in the current economic climate; and the Kony2012 campaign will no doubt enter the pantheon of marketing triumphs.   Certainly, this organisation conducts good works, but the majority of its revenue is spent on lobbying and awareness products and this is not made explicitly clear in the video.

Donating to a lobbying group has a different connotation to donating to a charity, and before millions of potential donors part with their funds, this should be made more evident. The idea of making money from people's charitable urges is not new, but this is on an unprecedented scale and opens the door for future abuse.

"Crowd-sourcing Intervention"

Jack McDonald in a blog from King's College London, argues well for resisting the urge to 'crowd-source intervention'. If the Kony2012 campaign is successful and there is continued US mentoring of the Ugandan military leading ultimately to the killing or capture of Joseph Kony, what lessons will the world learn?

A cynic may think that irrespective of Invisible Children's efforts, it may have already been in the US interest to develop a presence in Central Africa. It is established that a redux of 1890s Neo-imperialism in Africa is developing, with competing US and Chinese efforts to increase their spheres of influence. A small, but meaningful US military presence in the mineral rich part of Africa is probably not without its benefits geopolitically.  Perhaps not in this case, but campaigns such as these could be well used in the future to develop a 'crusade of convenience' for nations seeking popular support for foreign interventions.

The conduct of foreign affairs, perhaps more than in other areas, is a subtle and nuanced game.  Often conducted in quiet rooms away from the glare of media and public observation, it is often a difficult balance of competing interests and usually guided by the practice of restraint. It is not well served by those driven by purely populist intentions using 'megaphone diplomacy'. By the nature of this campaign, a complex issue has been simplified into a 30 minute presentation, and further still into hashtags and 'Like' clicks.

The concern is that a riled-up and compassionate, though under-informed, public could push an electorally weak government into pursuing a populist aim for political ends. If campaigns like this catch on, we may all be re-tweeting our way to a fresh military intervention.




Wednesday, 7 March 2012

Electronic Health Records

Known Unknowns 

In life, there are 'known unknowns and unknown unknowns' as Donald Rumsfeld once put with questionable eloquence. For those practicing in emergency medicine, this aphorism resonates, particularly in the busy first few minutes of a patient's arrival in a resuscitation bay. With the roll out of the summary-format Personally Controlled Electronic Health Record (PCEHR) due later this year, consideration should be given to the reasons for its inception and whether a more comprehensive Electronic Medical Record system could prove a critical step in improving patient care.

The first few minutes of a gravely ill patient's admission to an Emergency Department are a period of controlled chaos. People, in varying degrees of distress or consciousness, are borne in, with a cursory history from paramedics or a relative. "He has some cardiac history, but can't remember the last time he came to hospital".

Doctors and nurses in small teams swarm around the bed and with a flurry of examinations, investigations and interventions occurring in parallel begin to assess the patient. Amid a background din of chirping machines, the quiet flow of instructions and the hiss of the oxygen, attempts are made at obtaining a history. Between coughs or gasps, or muffled through an oxygen mask, patients give some account of their current illness and, to varying degrees, a precis of their medical history. A slightly fuzzy picture begins to emerge of why this person is here, and what state they are truly in. And then, we wait for the chart to arrive from medical records or send to GPs or other hospitals for information.

Unfortunately, this often where the information flow stops. The story given often lacks critical information. Patients are unconscious, or often not in full command of their faculties at times like these due to pain, drugs or hypoxia. Others can simply not recollect (or have not been informed) of results of important investigations and aspects of their medical history. "I had a heart test a year ago at another hospital, but I don't remember what they found". "My GP changed my blood pressure medication this week, but I'm not sure which one is new".

It is these known unknown that can be critical to developing a diagnosis and guiding the direction of emergency care and the answers to these known unknowns that are frustratingly sometimes out of reach of the emergency clinician. The answer lies with a comprehensive electronic medical records system.

Medical records contain valuable medical information for the treating clinician, including detailed notes of previous presentations and admissions, discussions of multidisciplinary care plans, discussions with patients and carers, detailed investigation results and importantly, description of specialist consultations and advice. To any emergency clinician at the bedside, but particularly to junior doctors who staff our emergency departments, these are critical details that allow for informed diagnosis, enhanced, safer immediate care and timely disposition.

Present systems


Presently, state health departments have a number of e-health systems employed throughout their hospitals; for example, to access pathology or radiology results and reports. Increasingly, these are being integrated across state-wide facilities; that is, results from one public hospital can be viewed from a station at another public hospital. This distribution does not extend private sphere, nor are private investigation results available publicly.

There are also information systems with their own electronic medical record systems employed by different departments within the same hospital. These do provide a source of readily accessible clinical information. Unfortunately, there is little or no integration between these systems. Clinical notes written in the Emergency Department cannot be viewed electronically at another campus, off-site by a GP, or even on the Medical ward of the same hospital. In emergency situations, often notes from other hospitals must be located in medical records and pages faxed to the treating facility. GP surgeries have being using electronic record and prescription systems for some time, but again their distribution is only practice-wide with no capacity to electronically share information. 

A comprehensively distributed medical record system would go some way to reducing these redundancies and improving patient care. Confused purposes and limited scope mean that PCEHR appears unlikely to be able to meet this need.  

PCEHR

The Federal Government announced a $466.7 million (now $760 million) investment over two years for a national PCEHR system.  The PCEHR will 'not hold all the information held in your doctor's records but will complement it by highlighting key information'. The premise behind the system is to allow better patient interaction with their health records to encourage patient empowerment and participation in their own health care, and to provide a summary of key health information to clinicians in the shared care setting.

In effect, the PCEHR will produce a dot-point summary of a patient's medical history, medications and allergies, and some investigation results (if entered) and possibly letters from specialists (again, if entered). Information will be added to the record by the patient, or at the clinician's discretion. The concern for clinicians is that the completeness, accuracy and relevance of the data be maintained, so that ultimately, it does provide benefit in clinical decision making. At present, a summary-style care record has not proven to be useful in this regard. 

The PCEHR bears resemblance in many aspects to the HealthSpace Summary Care Record (SCR) system adopted in the UK in 2007, which has been assessed as not meetings its objectives of patient empowerment, or of improving information sharing. An important feature of the PCEHR, like the UK's HealthSpace, is that it will be an 'opt-in' system. Results from the UK show very poor uptake - between 2007 and 2010, only 172,950 people opened a basic account, and 2,913 people opened an advanced account (only 0.13% of those invited). Among reasons for its poor uptake was a requirement for patients to enter medical details, a perception that it would be of limited value to clinicians, and the level of technological expertise to derive full benefit from its features. It is likely that uptake in the Australian context will be similar, raising concerns as to its power as a healthcare-wide tool. 

If as it appears at present, a summary-style system does not appear to confer significant benefit to patients and is under-powered as a decision making adjuvant for clinicians; then the cost in personal privacy, not to mention its high infrastructure and implementation cost, may outweigh the benefits of the PCEHR. 

Where's the chart?

It is generally recognised that the implementation of a comprehensive, widely distributed electronic medical records system will deliver true benefits to clinicians and patients. Some have argued that the PCEHR is a 'stepping-stone' to this eventuality, but it may prove a diversion instead. 

At the crux of this issue is the question of purpose. Who are we developing national e-health system for? At a time of an ever increasing burden of chronic disease, engaging patients with their own long term health care is laudable and based in good evidence. But, in a system where patients are cared for by a number of different clinicians, and are expected to traverse the interface between primary care, private specialists and hospitals and the public system with increasing frequency, the capacity of an e-health system to share important clinical details, results and specialist interpretations is of far more value to clinicians and ultimately, to the patient. 

State- or nation-wide IT systems have a track record of being cumbersome, costly and unreliable (witness the Queensland Health payroll issues). It is understood that the infrastructure and logistic costs of implementing a full electronic medical records system would likely be significantly higher that of the PCEHR, but the long term benefits may justify the expenditure. 

We will see PCEHR deployed in July 2012, and no doubt enjoy some good outcomes from it. But there should be continued commitment to develop a comprehensive, widely distributed electronic medical records system if we want to unlock the real potential of e-health. 


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