Originally Printed in the Australian Financial Review:

How's this for a truly awful example of everything that's wrong with the health system: Patient A is a 57-yearold customer of health insurer nib. She had 19 hospital admissions over a two-year period, costing nib in excess of $85,000, "due to her multiple chronic ailments, lack of care co-ordination of her healthcare needs and siloed communication across primary care, hospitals and specialists involved in her care," according to the insurer.

Mrs A, who had a history of pulmonary hypertension, diabetes, back pain and many other chronic diseases, is the archetype of the high-care patient at the centre of the Turnbull government's big new plans for primary health care in this country.

Only on Thursday Prime Minister Malcolm Turnbull and Health Minister Sussan Ley said care for the chronically ill will be overhauled under a new system of Health Care Homes, in which electronic records will be a key component.

Australians with high-care needs see up to five different GPs a year. About 20 per cent of the population live with two or more chronic diseases, and half of all avoidable hospital admissions in 2013-14 were due to chronic conditions.

"There is still far too much evidence of overservicing, overcharging and avoidable treatment," nib managing director Mark Fitzgibbon says.

At the centre of this debate is a concern that the Federal government's much vaunted national My Health Record has failed to reach most Australians. Since it was launched in 2012, 2.5 million people have signed up, vastly less than is needed to make the system a truly national record.

In frustration private health providers are creating their own systems. While this is helping lift the number of people with easily accessed data, there are risks that the process will ultimately lead to a fractured national record.

"I think [the private health insurance] industry is making good progress on this front, but there is much to be done. At nib we're especially interested in helping people make better decisions around their treatment options and choice of health-care provider through initiatives such as TripAdvisor style [website] Whitecoat," Fitzgibbon says.

New Medibank chief executive Craig Drummond said this week that the nation's soaring medical costs, which have pushed premiums up by 5 to 6 per cent a year for the last decade, are unsustainable.

Leading up to Friday's Council of Australian Governments meeting, South Australian Premier Jay Weatherill dismissed $5 billion of extra federal funding for state hospitals as "a Band-Aid on a much bigger wound."

One of the most egregious shortcomings is the failure to share and collect patient information. This syndrome, with its endless anecdotes of repeat orders for unnecessary tests and scans, and wasted medicines, has become a symbol of the waste and inefficiency endemic in the health system.

"We can't co-ordinate before we're connected," Calvary Health Care chief executive Mark Doran says.

"Ambulances don't talk to New South Wales Health, hi the ER [emergency room] they ring on the phone to tell you something is coming and they write it down on a piece of paper. It is crazy. Why wouldn't the ambulance be transmitting data to the hospital?"

Despite past failures, billions of taxpayer dollars are once more being thrown at e-health initiatives including a fresh $485 million injection into the federal My Health Record program.

But health-care providers like Calvary aren't waiting for the government to fix things. In fact the one-size-fits-all approach of government programs is arguably the very thing that damns them.

"We are great supporters of the My Health Record, the government system, but we see it as just a repository. We see a need for a live document that can dynamically portray where this person is on their journey," Doran says.

"GPs say they will use the system but what you've [government] given us isn't intuitive. It needs to be designed by the people who do the work."

John Sutherland, the chief information officer of Australia's biggest private hospital operator Ramsay Healthcare, agrees that the "top down" approach is flawed.

He says that the genesis of Ramsay's new MyPatient+ app - a real time mobile app that allows doctors to access patient information - came from doctors.

"Doctors have been fully engaged throughout the process. This is a business tool for them. It is making it easier for them, easier for Ramsay, and making it more convenient for the patient," he says.

"The mobile [app] is being rolled out nationally across all of our hospitals. This was very quick and put in place within a couple of months. Uptake is terrific." The contrast with government programs is stark.

Despite more than $1 billion in cumulative funding, just over 8000 health-care providers and 2.6 million patients - a little more than 10 per cent of the population - have registered with My Health Record.

Last month a group of rural GPs in South Australia wrote to SA Health chief executive David Swan criticising the state's $422 million Electronic Patient Administration System and asking for it to be overhauled or replaced.

The Grattan Institute's Dr Stephen Duckett says Australia's pursuit of e-health "has been a tragedy". "We are way behind other countries, such as Denmark, and we have started off in so many of the wrong places to the extent that the then-Labor government conceptualised success not in terms of meaningful use, but in terms of how many people signed up," he says.

While governments tinker and try to push systems on to doctors and patients, healthcare providers are finding solutions based on the needs of patients and clinicians. 

Calvary, a Catholic non-profit operator of 15 public and private hospitals, 15 retirement and aged-care facilities and 22 community care centres, has been rolling out its Vitro digital records and patient chart system following a successful trial last year at its 60-bed Bethlehem hospital in Melbourne.

Belinda Mcrae, the nurse unit manager on the St Teresa's ward at Bethlehem, says that despite initial "teething problems" it's been a success. "We were the pilot of MedChart, the online medication chart It has made a huge difference for being able to read medication orders and keeping track of doses. The reduction in incidence of missed medication is amazing," she says.

"From a workflow point of view, being able to access the same record at the same time [as other staff] is huge... I don't think we could go back."

It only takes about 10 minutes to teach new staff to use the system, and Mcrae says the Vitro record, which can digitally replicate the look and feel of paper, makes it easier to track shifts and pick up issues, such as missed or overdue medications.

However, Bethlehem's records do not communicate directly with other parts of the wider health system, such as General Practitioners, with chart print outs a throwback to the old ways.

This raises questions about the ability of separately developed systems to communicate and integrate. Could the current fracturing of medical information become entrenched as providers develop their own systems - albeit out of frustration with government record keeping programs.

Duckett says we must be careful not to create the health equivalent of "a new railway system with different gauges".

To illustrate the problem, NSW Health keeps electronic records, paper records, digitally scanned paper records, and databases developed by Local Health Districts.

The Baird government is spending $400 million over five years to fund its e-health strategy and is building 11 locally based electronic medical record systems and the statewide HealtheNet system.

The Turnbull government's new vision for chronic care also envisages a bigger role for private health insurers, who as a payer of medical bills are well incentivised to lower costs.

Medibank has been running pilots involving 3000 patients and 500 GPs with the governments of Victoria, Western Australia, and Queensland for its chronic care program, called CareComplete.

Nib has its own care co-ordination programs, which the insurer says have saved Mrs A from about six unnecessary hospitalisations, savings in excess of $22,000. The patient has also seen her extended family for the first time in two years.

In Newcastle Calvary is playing a key role in the My Netcare project to improve outcomes and care, and lower costs, for patients in their last year of life or suffering chronic disease such as diabetes.

More than 70 per cent of people want to spend their final year at home, but less than 20 per cent achieve this goal.

Patients can log into My Netcare, a cloudbased app product, from home and update information such as their pain on any given day. Family members with access can also use the records to help manage care. This should take away some of the anxiety family carers feel for vulnerable loved ones.

Critically, My Netcare medical files can be sent by secure message to GP software systems and hospital systems.

With government trials of the new medical home model of primary care to kick off from July next, an acid test looms for the integration of different data systems, and whether patients like Mrs A will stop falling through the gaps.

The government's national My Health Record has failed to reach most Australians.