Australasiaâ€™s First and Only eHealth and Health IT Magazine
7 APRIL 2014
NATIONAL E-HEALTH AGENDA Setting the agenda
Progress and setbacks in implementing the building blocks for Australiaâ€™s connected healthcare system.
The paper route
Secure electronic communication between clinicians should be prioritised over further development of the PCEHR.
Clinical Document Architecture CDA is the basis of all clinical documents in the PCEHR and its use has implications for both clinicians and developers.
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Looking Ahead Pulse+IT welcomes feature articles and guest editorial submissions relating to the nominated edition themes, as well as articles relating to eHealth and Health IT more broadly. In addition to our daily eNewsletter service, Pulse+IT is produced in print seven times per year with the remaining five editions for 2014 to be distributed for release in: • Mid-May 2014 - Aged care • July 2014 - Hospitals • Mid-August 2014 - Practices • October 2014 - New Zealand • Mid-November 2014 - mHealth and devices
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About Pulse+IT Pulse+IT is Australia’s first and only Health IT magazine. With an international distribution exceeding 35,000 copies, it is also one of the highest circulating health publications in Australasia. 32,000 copies of Pulse+IT are distributed to GPs, specialists, practice managers and the IT professionals that support them. In addition, over 5,000 copies of Pulse+IT are distributed to health information managers, health informaticians, and IT decision makers in hospitals, day surgeries and aged care facilities. ISSN: 1835-1522 Contributors David Freemantle, A/Prof Heather Grain, Grahame Grieve, Dr David Guest, Simon James, Dr Heather Leslie, Dr Vincent McCauley, Kate McDonald, Katrina Otto and Dr Nathan Pinskier. Disclaimer The views contained herein are not necessarily the views of Pulse+IT Magazine or its staff. The content of any advertising or promotional material contained herein is not endorsed by the publisher. While care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information herein, or any consequences arising from it. Pulse+IT Magazine has no affiliation with any organisation, including, but not limited to Health Services Australia, Sony, Health Scope, the New Zealand College of General Practitioners, the Rural Doctors Association of Australia, or the Kimberley Aboriginal Medical Services Council, all who produce publications that include the word “Pulse” in their titles. Copyright 2014 Pulse+IT Magazine Pty Ltd No part of this publication may be reproduced, stored electronically or transmitted in any form by any means without the prior written permission of the Publisher. Subscription Rates Please visit our website for more information about subscribing to Pulse+IT.
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Simon James introduces the second edition of Pulse+IT for 2014.
SELECTED BITS & BYTES Government yet to commit to releasing PCEHR review, rejects FOI request
General practice is drowning in scanning as the barriers to greater PCEHR uptake remain.
NASH project “still going backwards” as clinicians told to renew by fax
eRX QR codes available from most prescriber software this month
Divining the future for eHealth is tough as chicken scraps are scarce.
NATHAN PINSKIER eHealth is still a paper route with SMD on the backburner.
SECURE MESSAGE DELIVERY
PCEHR CLINICAL DOCUMENTS
Medibank cancels $7.5m healthbook personal health record “Instagram for doctors” app launches in Australia
VINCENT MCCAULEY Poor governance arrangements mean private sector expertise in eHealth has been under-exploited.
Accessibility problems plaguing the PCEHR provider portal
Cardiac app lets patients graph test results and email them to specialists
Telstra sponsors Zed Technologies to put film in a bag
Providing patients with a view of pathology results
The Pulse+IT Directory profiles Australasia’s most innovative and influential eHealth and Health IT organisations.
DocAppointments launches repeat script request and customised apps service
Up and coming eHealth, Health, and IT events.
PCEHR PROGRESS REPORT PCEHR release 5 was to include pathology results and advance care directives, but may be delayed.
Interoperable secure messaging seems to have become lost in the focus on building the PCEHR.
Problems continue to dog the chequered career of the National Authentication Service for Health.
The electronic transmission of prescriptions (ETP) market has been steadily evolving.
SNOMED CT-AU is slowly being implemented in clinical IT systems, but it is still in its early stages.
Lessons learned from the use of Clinical Document Architecture for documents in the PCEHR.
For EHRs to become interoperable, they need agreed clinical data patterns such as archetypes.
IN SEARCH OF AN E-HEALTH AGENDA This edition of Pulse+IT takes a look at the status of many of the initiatives identified as eHealth priorities when the National E-Health Transition Authority was first established in 2005. Nearly a decade on, several of these initiatives are still in their early stages, but measurable progress has been made, despite the heightened focus on the PCEHR.
SIMON JAMES BIT, BComm Editor: Pulse+IT firstname.lastname@example.org
Perhaps more so than at any time since the establishment of NEHTA and its task of “leading the national vision for Australia’s eHealth future”, the specifics of how this vision will be executed in the latter half of 2014 and beyond are increasingly unclear. With reviews into both the PCEHR and the performance of the Medicare Locals still being considered by Health Minister Peter Dutton and his department, one may be forgiven for speculating that the longer the sector has to wait for these reviews to be made public, the more structural and significant the changes will be. Given the large sums of money the PCEHR project has consumed, coupled with the lack of awareness and indifference patients and their providers have respectively shown to the initiative, a review into the fledgling system certainly makes sense.
About the author Simon James is the editor of Pulse+IT, one of Australia’s highest circulating health publications of any kind. Prior to founding the publication in 2006 he worked in an IT support capacity for various medical practices, and subsequently for both clinical software and secure messaging developers.
As this edition of Pulse+IT went to press, over three months have transpired since the review into the PCEHR was submitted to Mr Dutton, but the document has not yet been released publicly. In response to what is turning out to be a prolonged wait for any eHealth direction from the Minister or his department, Pulse+IT, and coincidentally a range of IT publications and newspapers, have filed
FOI requests for the PCEHR review report. All of these requests have been rejected on the grounds that the PCEHR review document is under deliberation and the public interest would be best served by the document remaining confidential at this time. Beyond the ultimate outcome of the PCEHR review, there are many other factors coalescing that are adding to uncertainty in the sector. The coalition government’s looming first federal budget will no doubt be significant for many sectors and households, but as far as eHealth at the national level is concerned, this budget will be particularly interesting for a range of reasons. Firstly, the end of the current financial year marks the conclusion of NEHTA’s existing funding allocation, and while it is unlikely that the organisation will cease to exist come the first of July, the federal Department of Health has been progressively assuming responsibilities once undertaken by the agency, leading one to assume that historical levels of funding and responsibility are unlikely to be maintained. June 30 also marks the conclusion of the existing tranche of funding allocated to the operation of the PCEHR, but it is probably
safe to assume that with so much money spent on the initiative in its development and fledgling operation so far, ongoing funding for the health record system is unlikely to be withdrawn despite the scant results that have been achieved to date. The Department of Health’s contracts with the Medicare Locals for eHealth-related services also finish at the end of this financial year. Coupled with the uncertainty the ministerial review into Medicare Locals has created, it comes as no surprise to this author that many Medicare Local staff have been expressing concern about the effects the uncertainty is having on their ability to perform their duties. Collectively the Medicare Locals employ several hundred staff involved in eHealth activity, with most of these people currently responsible for pursuing the Department of Health’s mandated KPIs for consumer registration and provider interaction with the PCEHR. Beyond the obvious effects such a situation may have on organisational morale, many tangible aspects of the role of Medicare
“... the PCEHR review document is under deliberation and the public interest would be best served by the document remaining confidential at this time.” Simon James
Local eHealth officers are reported to be suffering, such as the ability to forwardplan visits to practices to promote the PCEHR and other eHealth initiatives. With many Medicare Locals already reporting that the PCEHR provider registration targets for their respective catchments are unlikely to be met, it is apparent that the uncertainty is futher hampering their chance of succeeding in their role. The PCEHR, of course, is not the only eHealth initiative of national significance, with this edition of Pulse+IT presenting an overview of many others. The history and status of the Secure Message Delivery
specifications is reviewed, as is the National Authentication Service for Health. This edition also features contributions on the state of ePrescriptions in Australia and background on the SNOMED CT terminology, the advocacy of which was one of NEHTA’s early directives to the software vendor community. An evaluation of the use of clinical document architecture in the PCEHR is also included, along with an explanation of the basic clinical data patterns required for EHR interoperability on a national and international scale.
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BARRIERS TO PCEHR UPTAKE ON THE FRONTLINE Misinformation and hype have dogged the PCEHR throughout its development, and many doctors are still confused about its purpose. It’s very early days yet, but in the meantime, general and specialist practices are drowning under the load of scanning of clinical documents send by fax or post. While we wait for the PCEHR to become embedded in medical practice, we must begin to tackle secure messaging.
KATRINA OTTO BEd (Adult), DipBus, Cert IV Principal, Train IT Medical email@example.com
As we wait for the federal Health Minister to reveal his plans for the PCEHR, it is worthwhile to look back and assess how far we have come with the system, and how far we still have to go. Having trained hundreds of clinicians and practice managers in the use of healthcare software over the last 15 years, I know from practical experience just how hard it is to get any consensus on how a system should look and feel, and the eHealth system is no different. I remember running some training sessions at a software conference some years ago when NEHTA gave a presentation on the concept of the PCEHR. In those early days, the negativity about the concept was extraordinary. That has dissipated somewhat, especially when clinicians actually begin to use the system, but some negativity is still there.
About the author Katrina Otto is owner and principal of Train IT Medical and offers software training and practice management consultancy services across Australia. An experienced practice manager, she is also a qualified teacher and has been delivering accredited qualifications in medical administration and technology for the past 20 years.
I will detail the main barriers to wider adoption as I see them, but first I would like to emphasise that I have seen huge progress in the last year as doctors have begun to discuss not just the concept, but the practical use of the system. There is no getting around the fact there will be a lot of work for clinicians and practice managers, either cleaning up data or adding clinical data, and things do not move quickly in the medical world.
However, the more we rush it the more likely it is that it’s going to end up as a failure, whereas it could be fantastic. I have trained people who have been using eHealth tools for many years, and they are far more accepting of the PCEHR than most. They can see that it is not taking up more time, but actually saving time in other areas and improving safety. That being said, here are some of the barriers to more widespread use of the system. 1. GPs are not being remunerated for their time and effort Every doctor I have met agrees the PCEHR ideally would be helpful for accessing patient’s up-to-date medical information. The problem lies in who will keep that information up to date. It predominantly falls on the GPs, but to keep it up to date in their software is a constant, ongoing workload, particularly for patients with chronic illnesses. Every time that patient sees a specialist or allied health professional or is discharged from hospital, the GP ideally updates that patient’s health summary, even though they may not see the patient again for a year or even possibly ever see them again. And they don’t get paid to do that. The other option is to wait until the patient makes an appointment to get their
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shared health summary uploaded, which GPs can only charge for if it is part of a consultation, and even then they must spend the time updating it. Doctors often say patients already often attend with a long list of health issues to address, that this is going to add one more task to that already long list, and it will also affect their waiting times. Without the Practice Incentives Payment for eHealth, I believe few GPs would have taken part. I believe that in addition to that incentive, there should have been an item number added to the Medical Benefits Schedule for creating a shared health summary, and that would have gone a long way to getting GPs on board.
2. Many GPs and patients do not have a clear understanding of what the PCEHR is A lot of the resistance from doctors relates to two common beliefs. One is that they will be sharing their progress notes and the second is that patients can change or omit information. Once I explain that the PCEHR is not progress notes but rather a list of documents, and that sharing a health summary, for example, means the emergency department or after hours clinic may be able to see their patientsâ€™ medication list, allergies, medical history and immunisations, there is certainly less resistance. Most tell me at the moment that it is very common to receive telephone calls or requests to fax this same
information. I explain that while patients may change their mind and remove a whole document from their PCEHR, they cannot edit a document a clinician has uploaded. This usually leads to an interesting discussion on patients knowing their own health information and perhaps playing a bigger role in their own health. This is a big change in itself and change needs time to adjust. When it comes to viewing a shared health summary, I have found that 50 per cent of doctors would like that information (medications, past history, immunisations and allergies) to synchronise and go straight into their own clinical software program so they have an immediately
populated health record. The other 50 per cent are quite horrified at the very idea of synchronising this information because of the integrity of that data collection, when was it collected, who by, and its medicolegal implications.
“To get all GPs on board, however, I believe we should first have concentrated on solving the problem of secure messaging interoperability.”
3. Practices are still not set up for it The education and support practices across Australia have received has been widely variable, due in part to the staggered rollout of Medicare Locals. Some areas, mine included, were in the last stage of getting Medical Locals established and many practices are still now not yet set up to upload. Most GPs may have been to education sessions by now or certainly read about the PCEHR, but practice staff have often totally missed out on any education. Patients are asking the staff and they can’t answer patients’ questions – misinformation is spreading like wildfire. While every practice has said a patient has requested a shared health summary to be uploaded, the practices were not ready and told the patients ‘not yet’. This is especially so if the practices are not accredited as there was no incentive. One GP I visited saw the button called PCEHR in his software and thought that meant he was set up. Interestingly, he was computer savvy and didn’t see any issue with sharing the information at all. When I explained what a shared health summary was, he said he thought it sounded like a great idea as it would save him printing them and faxing them. 4. Database cleansing is needed One question I get asked regularly is, “What is the best medical software?” My answer is that you can use any software badly – it’s about learning how to use it well. Now that many patient records have been populated, we can see that a lot are
unusable in their present state. Many doctors previously added insignificant health conditions as ‘inactive’ or ‘nonsummary’ items. They also previously entered free-text diagnoses instead of choosing from the coded diagnostic list. This now has to be changed to ensure a cleaner, non-ambiguous list of patient medical conditions. Cleaning up patient lists now is an enormous job for many practices; cleaning up one patient’s record could literally take an hour. This is one of the largest barriers, as I see it.
Secure messaging Last year felt like we were put on speeddial with all the reports saying the roll-out of the PCEHR was not happening fast enough, and that the whole thing was a failure because of the small amount of shared health summaries uploaded. I became concerned because I see what gets shared now on computer-generated summaries and how inaccurate it often is. I believe it is better to slow down and build this properly. I am pleased to report there seems to be more excitement in NSW, especially recently, because in some areas discharge summaries are being received electronically. This is something practices see as extremely helpful. While I am told discharge summaries are also being uploaded to patients’ PCEHRs, it is the
secure messaging delivery that I see practices excited about. To get all GPs on board, I believe we should first have concentrated on solving the problems related to secure messaging interoperability. If the goal of eHealth is to benefit clinicians and the patients, we should have streamlined interoperability by now. Secure messaging is the key to streamlining communication between care providers. That’s why this would have been the smartest way to start because when that works, it’s fantastic. It saves both time and money for practices while benefiting patients as treating clinicians have important information available to them quickly. Many practices are drowning in scanning, and every day practices are complaining about the scanning workload. The doctors are also complaining about having to pay staff to scan as scanning is a job now. Faxes are often now not printed but are faxed to file (imported), again a manual process that brings with it risk. Once it is coming in electronically, hopefully it will become a seamless process. I often say to practices we’re not going to go back to paper records so we may as well keep moving forward and embrace technology, embrace change and focus on sharing accurate information in the most streamlined way so it is advantageous to us and our patients.
DIVINING THE FUTURE OF THE PCEHR The wave of giddy enthusiasm that greeted the election of the Rudd government in 2007 and the subsequent development of the PCEHR has not been mirrored with the advent of the Abbott government in 2013. A sterner, economically rationalist approach and a ‘feeding the chooks’ attitude to public disclosure means it is difficult to divine the future for eHealth beyond an increased focus on point-to-point communication.
DR DAVID GUEST MBBS General practitioner firstname.lastname@example.org
In April 2008, flushed by its landslide victory in the November 2007 election, the new Rudd government brought together a range of people prominent in their field to examine 10 critical areas for the future of the nation as part of the 2020 Summit.
This time around there has been no lovein. The National Commission of Audit will report in a few weeks and provide the overall framework for the government’s spending options. It is unlikely to be released to the public before the budget.
The first seven of the areas featuring in the 2020 Summit had direct clinical or business impacts for rural medical practitioners.
These were exciting times, full of great hope, and there was a sense that significant change was on the way. In May 2010, the final report was released. Of the 138 recommendations put forward, just three were adopted. Tony Abbott and the Liberal National coalition swept to power in September 2013. Like others, the new government has initiated a number of reviews to set the agenda for the future. Since the financial landscape has changed significantly in the last six years, the new government’s focus is on cost cutting and efficiency.
About the author Dr David Guest is a GP at the Goonellabah Medical Centre, near Lismore in northern NSW, and has a long interest in eHealth to improve patient management. He is a former social media director for the APCC’s eCollaborative project and helped launch an early shared health record through the Wedgetail project.
A number of agencies and commissions have been closed and many of the reviews have already been delivered to the government so that they can be digested by Treasury and the Expenditure Review Committee prior to the Coalition’s first budget, due in late May 2014.
In the health portfolio, the Royle report into the troubled PCEHR project, which was delivered before Christmas, has also not been made public. Options for tinkering with demand for GP services by introducing a small co-payment have been much discussed in the media but may turn out to be a furphy. Rumours about means testing the Commonwealth Seniors Card have surfaced more recently. This too would have an impact on demand for medical services. Ironically, AMA president and co-author of the PCEHR report, Dr Steve Hambleton, has called on the government to release the Seniors Card report. “The whole thing should be released so people can assist the government in making appropriate decisions,” he says. It would appear the government does not need any help. The Abbott government’s approach to public discussion has been compared to the Bjelke-Petersen government’s communications strategies of the 1980s.
However, in these modern times, ‘feeding the chooks’ involves battery farming and a marked reduction in feed allotment.
Auguring the outcomes So what does the future hold for electronic medical communication in Australia? We have peered deeply into the entrails but have not divined a pattern. The PCEHR’s main premise was that communication would flow from point to portal. While noting claims to the contrary, it is entirely feasible that the PCEHR could have been the ultimate source of truth for some aspects of medical care such as medication management. However, despite the best technical and legal efforts, it is now obvious that a portal can never be as secure as locally held records. Point-to-point communication appears to be back in favour, at least for this revolution of the political cycle. It might be dull and traditional but is a model well understood by medical practitioners and fits with their concept of medical care.
“The challenge for the new government will be to leverage the significant investment already made in the health authentication infrastructure and to find a workable model for message exchange.” Dr David Guest
The challenge for the new government will be to leverage the significant investment already made in the health authentication infrastructure and to find a workable model for message exchange between the companies providing “last mile” message delivery. Many of the financial issues in this area have parallels with general data exchange on the internet. However, the market has failed to resolve these issues for over 10 years under both Labor and Liberal governments.
Strong leadership is needed to find a solution to this vexing problem. With a background in small business, Health Minister Peter Dutton espouses the Abbott government’s ethos of hard work, selfreliance, independence and productivity. Politics may well be “the art of the possible,” but conversely, “war is the continuation of politics by other means”. It remains to be seen which outcome eventuates when, or if, the Minister begins dealing with the big end of town.
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E-HEALTH STRATEGY IS STILL A PAPER ROUTE The failure of the national eHealth strategy to focus on the needs of the community sector means that paperbased communications are still the norm. To realise a point-to-share environment, in which healthcare information can be fully shared in real time through national databases, we must first fix the problem of point-to-point communications.
DR NATHAN PINSKIER MB BS, FRAGCP, Dip Prac Man, FAAPM, FAAQHC Chair RACGP NSC - Health Information Systems firstname.lastname@example.org
We live in a world surrounded by technology – widgets, gadgets and apps. The impact this technology is having on our day-to-day business and social lives is considerable. The changes have occurred almost by stealth and have become an essential staple of daily life. We don’t think twice about how our communications devices, phones or banks interconnect – we just expect it to happen. So it begs the question: why hasn’t this same degree of interconnected functionality been achievable in the health sector? Some 10 years ago I wrote an article entitled “On the e-highway but where is the navigator?” I mounted a case at the time for the development of a strategy to drive the adoption of electronic medical records and connectivity across the broader healthcare sector. A decade later, it seems appropriate to review and reflect as to what has been delivered and what has really changed.
About the author Dr Nathan Pinskier is a Melbourne GP and the current chair of the RACGP National Standing Committee for Health Information Systems. He was the deputy head of the NEHTA clinical leads team until August 2013. The opinions in this article are his own.
In 2005, that navigator, NEHTA, was established under the sponsorship and direction of COAG. A series of core foundation eHealth technology services were funded, developed and released under the overarching umbrella of the national eHealth strategy. Some of those foundation services are now in place to facilitate the delivery of a range of “e” requirements in both the
hospital and community sectors. These services were essentially focused upon providing the capability to facilitate seamless communications between healthcare organisations and to national repositories, in what is generally referred to as interconnectivity. It is analogous to standardising the rail gauge to allow for the movement of any train to any station on the rail network. The national eHealth implementation strategy has been primarily focused on levering existing “e” activity in the hospital, community pharmacy and general practice sectors. In other words, it focused on those who had an existing level of capability in order to achieve early wins, the so-called early adopter and fast follower approach. It was anticipated that the remainder of the sector, once having been made privy to and recognised the benefits of this new technology, would climb on board and abandon the paper record in favour of these “e” solutions. The unfortunate reality is that whilst some parts of the healthcare sector have implemented and embedded electronic capabilities for both administrative and clinical purposes, the majority of providers are yet to be convinced of the compelling business case and value proposition. This is not the fault of the provider community; the fault lies in the failure to develop a whole of
healthcare “e” local adoption strategy. The national strategy was developed by COAG and NEHTA, with its core focus being on reforming the public hospital sector and developing national document repositories. In the journey, the voice of the community sector was either drowned out or not adequately acknowledged.
“The national eHealth strategy failed to identify what community providers both wanted and required to support their existing clinical and business transactions.”
Paper remains the norm So if we were to re-prioritise the “national” eHealth strategy, where should we begin? If we commenced with the recognition that the overwhelming majority of clinical consultations and associated messaging transactions occur in the community sector, it would seem prudent to focus community sector efforts on the enabling of two essential deliverables, these being: 1. A strategy for transitioning the specialist and allied healthcare sectors from paper-based records to electronic records, and 2. A strategy for implementing universally available, seamless interconnected secure message delivery (SMD). The rationale behind this approach is relatively simple. It recognises that in the rollout of the eHealth product suite, an important and critical step was not addressed: the development and delivery of a compelling change and adoption strategy which addressed the needs of the community healthcare sector at the provider and practice level. Call it the base requirement or priority use case.
Dr Nathan Pinskier
The national eHealth strategy failed to identify what community providers both wanted and required to support their existing clinical and business transactions. Almost every referral from a primary care provider to a specialist or allied provider generates an outbound clinical message and a corresponding inbound message. Whilst in general practice the capability widely exists to create and send these messages electronically, the majority are still sent by the old-fashioned paper route (either snail mail or fax) because there is either no available or easily accessible or discoverable secure electronic endpoint. In the specialist and allied health sectors, the issue is both the lack of widespread adoption of electronic record systems and a broader inability to transmit electronically. So despite the massive investment to date in “e” technology, services and solutions, paper‑based transmission remains the norm.
Implementation and adoption of community sector electronic medical records combined with an availability of interoperable SMD will achieve the dual outcome of supporting improved electronic communications between all healthcare providers – “point to point” communication – and promote the creation of useful and shareable clinical documents. If we can deliver and support the priority use case, then as more clinical documents are created and transmitted electronically, it becomes a relatively small step to progress from the “point to point” to the “point to share” environment of national databases, allowing for some of the existing national strategy to be potentially realised. Some might call that a win-win scenario or perhaps you might say, “One small step for a clinician, one giant leap for the healthcare sector”.
Government yet to commit to releasing PCEHR review, rejects FOI application
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The Department of Health (DoH) has confirmed it has received a copy of the Royle review into the PCEHR, but the government has not committed to releasing it publicly.
Senate Estimates that the department did not have a copy at the time the FOI was lodged. “It was not provided because the department did not have the report on that date,” Ms Powell said.
“Having regard to the content of the report there is no doubt that disclosure of it, or any part of it, would disclose deliberative matter within the meaning of section 47C(1) of the Act.”
At a Senate Estimates hearing in Canberra in February, Assistant Minister for Health Fiona Nash could not answer a question on whether the report would be released to the public and took the question on notice.
Pulse+IT lodged an FOI submission for the full report in mid-February, which was also refused.
She said that as section 47C is a conditional exemption, she considered whether it would be contrary to the public interest to grant access to the report.
Health Minister Peter Dutton, who ordered the review in early November last year, received the panel’s findings on December 20. Technology news website Delimiter then submitted an FOI request for the review to the department on January 6, which was subsequently rejected. Scan this QR code to receive eHealth news delivered to your email inbox each week.
Linda Powell, first assistant secretary for the eHealth policy, change and adoption division, told
Linda Jackson, assistant secretary of the eHealth policy branch at DoH, gave as her reason section 47C of the act, which concerns conditional exemptions for documents that are part of an agency, minister or the government’s deliberative processes. “The report addresses issues dealing with implementation and uptake of the PCEHR and includes analysis of those issues together with recommendations,” Ms Jackson wrote. “The recommendations are presently under consideration.
She said she had taken legitimate levels of interest into account, along with the objective of the FOI Act to increase public participation and scrutiny of government processes, but decided that if the contents of the review were to be made public now, the matter “would be prematurely exposed to scrutiny which would undermine the integrity of the decision-making processes of government”. “I have decided that, on balance, disclosure of the report would be contrary
to the public interest. The importance of ensuring the report’s contents can continue to be considered within the confines of confidentiality to the Minister and to those public officials who have a need to know its contents is considerable.” At Senate Estimates, the department revealed up-todate numbers on consumer registrations for the PCEHR and how many clinical documents have been uploaded. Ms Powell said that as of mid-February, 1,431,097 consumers had registered, spread evenly throughout the states and territories. There have been 19,227 discharge summaries uploaded, and 15,544 shared health summaries. There were also 32,979
consumer-entered health summaries and over 11,000 consumer notes, she said. DoH deputy secretary Paul Madden said there were also 89,000 documents uploaded for dispensed drugs, through the National Prescription and Dispense Repository (NPDR).
“It was not provided because the department did not have the report on that date.” General practice software vendors are now releasing a view of the NPDR through their clinical software. It will give doctors and pharmacists a view of all drugs prescribed for that patient and dispensed.
Ms Powell said consumer registration promotion had predominantly been done through Medicare Locals and state hospitals, with hospitals becoming more active recently as they begin to connect and upload discharge summaries. Hospitals are encouraging people to sign up when they are admitted or as part of their pre-admission procedures, she said. DoH secretary Jane Halton said the department was seeing three or four thousand registrations a day, which she also attributed to state hospitals starting to connect. Funding for the operation of the PCEHR runs out on June 30. Senator Nash would not be drawn on whether further funding was planned, saying it was under consideration.
Tasmanian hospitals connect to PCEHR, WA to follow Tasmania’s four major public hospitals are now connected to the PCEHR and are uploading discharge summaries, with Western Australian hospitals shortly to go live as well. Royal Hobart Hospital, Launceston General Hospital, North West Regional Hospital and Mersey Community Hospital are now linked to the system, joining over 100 Queensland hospitals, 27 in NSW, 10 in South Australia and one in the ACT. A NEHTA spokesperson said the four Tasmanian hospitals were using the Healthcare Information and PCEHR Services (HIPS) middleware product, which was developed by SA Health and a vendor partner as a way to connect to the PCEHR in the absence of conformant clinical information systems. Tasmania has gone to market for a number of new IT platforms to replace legacy products recently, including a new integration engine to replace Java CAPS, an upgrade to the master patient index, an outpatients referral tracking system for Royal Hobart Hospital and a statewide emergency department information system. The Department of Health and Human Services (DHHS) plans to go to tender in April for a child eHealth record solution that must link to the PCEHR. WA is also very close to connecting with the PCEHR but has been delayed somewhat due to the differing clinical software products used for discharge summary information and the ageing TOPAS patient administration system still used in some hospitals. Hospitals that use WA’s Notifications and Clinical Summaries (NaCS) system, through which they can view discharge summaries generated by systems such as Royal Perth Hospital’s TEDS, are understood to be the first to go live.
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Zedmed releases v23 with additional PCEHR features Zedmed has launched version 23 of its clinical and practice management software, featuring an in-built assisted registration tool for the PCEHR and the ability to send scripts to the National Prescription and Dispense Repository (NPDR). Zedmed users can register a known patient for a PCEHR through the software after the patient signs a consent form, which can be scanned into Zedmed and attached to the registration submission, or posted and a copy stored according to practice specifications. Patients can elect to receive their identity verification code (IVC) – which is required when accessing their PCEHR for the first time – by SMS, email or a response returned through the doctor’s software. The patient’s IVC is not stored anywhere within the Zedmed system. Zedmed’s marketing manager, Rosemary Lloyd, said the software now has an ‘Attach signed registration form’ button, which prompts users to browse to where the scanned document is stored and select it to be attached to the registration submission. Zedmed users will also be able to send prescribing records to the NPDR, which will enable authorised clinicians to view up-to-date records of medicines that have been both prescribed and dispensed. Doctors wanting to use the new function will have to ensure that the Global settings within Zedmed Clinical are enabled, Ms Lloyd said. “Then while prescribing the medicine, the doctor will have to make sure that the ‘Send prescriptions to NPDR’ checkbox is ticked. This will send the prescriptions to NPDR.” Scripts can now also be printed with QR codes for eRx’s new Express app.
NASH project “still going backwards” as clinicians told to renew by fax Healthcare providers who applied for a National Authentication Service for Health (NASH) PKI certificate to participate in the PCEHR have begun receiving renewal notices for individual NASH tokens that require them to fax in an application form to Medicare. Former NEHTA clinical lead Mukesh Haikerwal (pictured) has vented his frustration at receiving a renewal notice in the post, saying it was an arduous process to get the NASH PKI certificate in the first place and the expiration date was too short. Known at the time as the eHealth record PKI certificate for individual access to the provider portal, the subsequently renamed NASH PKI certificate for healthcare provider individuals did not begin to be made available to clinicians until December 2012, almost six months after the PCEHR went live, Dr Haikerwal said. That month, the then Department of Health and Ageing announced that all practices wanting to take part in the eHealth Practice Incentives Program (ePIP) had to apply for NASH certificates – in addition to a number of other steps – by February 1, 2013, causing a huge amount of confusion for many practices.
Dr Haikerwal said “gigantic efforts” were made to let ePIP practices know about the three different forms that had to be filled out manually, and the sequence for applying for them in time. “It was actually a very arduous process, and our practice did pretty well to get across the line on that date,” he said.
“The NASH project is over six years old, and yet they are still going backwards.” Now, renewal notices for the individual NASH token have started to be sent out as they only last for a year. The renewed tokens will last for two years, but
Dr Haikerwal said many doctors would be reluctant to bother reapplying, as many were not using the PCEHR system at all. Applications for a renewed NASH PKI certificate must be faxed in to the Department of Human Services (DHS), which will then post out a new token, which takes the form of either a smart card or USB token. Digital identity and authentication expert Stephen Wilson described the need to renew NASH tokens by fax as “bizarre”, saying it showed the sixyear long NASH project was going backwards. Mr Wilson, principal analyst at Constellation Research, said a manual renewal system that still used a fax
machine “rather takes the ‘e’ out of eHealth”. Mr Wilson said renewing by fax was bizarre, but that the deeper problem was the need for manual renewal. “Healthcare practitioners shouldn’t need to do any renewal, by fax or email or anything,” he said. Mr Wilson worked on a new form of certificate registration nearly a decade ago called relationship certificates, which are specific to different industry sectors and can be renewed with reference to definitive membership databases.
In the case of healthcare, this would most obviously be the Australian Health Practitioner Regulation Agency (AHPRA). “The first relationship certificates were (ironically) piloted with Medicare nearly 10 years ago; the technique is approved by the Gatekeeper PKI Unit in the Department of Finance,” he said. “NASH certificates should be relationship certificates, defined by the AHPRA database. A NASH certificate could be automatically renewed so
long as the holder is still current with AHPRA. “This is what AHPRA is for, so it’s nuts that certificate holders have to do anything at all.” Mr Wilson said the project had taken so long it seemed the wheel was constantly being re-invented. “NEHTA do not seem aware of PKI best practice,” he said. “They are not making best use of this technology at all. The NASH project is over six years old, and yet they are still going backwards. It’s tragic.”
eRx QR codes available from most prescriber software this month QR codes that can be scanned into patients’ smartphones through eRx’s new Express app will be able to be printed on scripts from the vast majority of GP software by the end of April. The eRx Express app was launched late last year and allows patients to scan in their script through their smartphone and send it to their pharmacy for dispensing, as well as to choose what time they want to pick it up. The QR codes replicate the eRx Script Exchange barcode on a patient’s prescription. Patients must still present their paper scripts at the pharmacy
when picking their medications up. The codes will now appear on scripts printed by users of Medical Director, Genie, Zedmed, practiX, Totalcare and Houston Medical that are registered for ePrescribing through eRx Script Exchange. A spokesperson for eRx said the functionality will also be available through Best Practice and Communicare – which are both close to releasing major new updates – as well as Stat and Medtech32 in their next releases. Paul Naismith, CEO of eRx’s parent company Fred IT
Group, said the addition of QR codes gives doctors the ability to pass on a free service providing greater flexibility and convenience, and improving the experience for patients. “This will make it significantly more convenient for people to manage their prescription medicines,” he said. eRx Express is available for iPhone, Android and Windows smartphones. The app is free for patients, while pharmacists using the system receive the script information on a Windows tablet, and pay a subscription.
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Opinion sought on layout of cumulative pathology reports Clinicians are being consulted on the design and layout of pathology reports as part of the Pathology Information, Terminology and Units (PITUS) project. Last month, a survey was distributed to gauge clinical opinion on the layout of pathology reports, particularly the question of identifying the most recent result in cumulative reports. The PITUS project, which is being managed by the Royal College of Pathologists of Australasia (RCPA) in association with a number of groups including NEHTA, the RACGP, the Medical Software Industry Association (MSIA) and Standards Australia, aims to help assist the implementation of new standards for requesting and reporting. It is an extension of the Pathology Units and Terminology Standardisation project (PUTS) that developed reference sets of terminology for pathology requesting and reporting and preferred units of measurement for results, which has been gazetted as the Australian Pathology Units and Terminology Standard (APUTS). PITUS is concentrating on the implementation of the standard in working medical practices and pathology providers in their pathology and desktop systems. The work is also informing the development of a way to ensure pathology reports are uploaded to the PCEHR in a clinically safe format. The RCPA said highlighting of the most recent results is being considered to mitigate against the risk of misreading. “Because there is anecdotal evidence that existing variation in report formats has led to the misreading of results, some elements of the layout of pathology reports are being considered for standardisation,” the college said.
Medibank cancels $7.5m healthbook personal health record Health insurer Medibank has announced it is closing its personal health record healthbook, which was developed with $7.5 million in government funding as one of the Wave 2 sites for the implementation of the PCEHR. healthbook was one of nine projects announced in March 2011 for the second wave of funding for the PCEHR implementation, receiving $7.5 million out of a total pool of $55m. Designed internally by Medibank with systems integration advice from IBM, healthbook aimed to test whether consumer-entered health data for patients with chronic disease could integrate with the national system. Launched in May 2012, it initially targeted a group of 16,000 Medibank members who were on a Better Health program. Medibank intended to allow customers to access the record through their smartphone and to upload medical data from devices such as blood glucose and blood pressure monitors. In August 2012, Medibank CIO Terry Snyders told Pulse+IT that initial uptake was “pleasing”, with eight per cent of targeted customers agreeing to take part in its three months of operation. However,
according to notices placed by Medibank in newspapers last month, while it received “strong take up” initially, interest waned.
“It has become clear that the need for this service is not as highly sought after as originally expected.” A Medibank spokesperson said that only 1500 people were currently healthbook users, and only a small percentage of those were active users. “[A]fter considerable evaluation, it has become
clear that the need for this service is not as highly sought after as originally expected,” Medibank said. The Medibank spokesperson said participants will receive a copy in the post. There are strong rumours that Apple is planning to release the next version of its iPhone operating system with in-built health and fitness tracking capabilities, as well as a new application to track vital signs such as blood pressure and glucose levels. Coincidentally, the application has been codenamed Healthbook, healthbook is a trademark registered to Medibank in Australia.
“Instagram for doctors” app for sharing medical images launches in Australia Canadian start-up company Figure 1 has released a free app for sharing medical images that some are calling “the Instagram for doctors” in Australia. Figure 1 is a free app for the iPhone that allows healthcare professionals to view, share and comment on medical images. It includes an algorithm that ensures the patient’s face is blocked out, a manual block allowing users to remove identifying marks such as tattoos, and a photo editor to allow users to crop images and to add arrows to highlight points of interest. Users can share images with specific people or the whole community of users,
and each image includes a caption to explain what the image is or to ask questions. There is also an image library that is searchable by anatomy or specialty. It has an optional verification tool that at the moment is restricted to licensed doctors but which the company hopes to expand to other healthcare professionals. In North America, users are verified through the networking tool Doximity or by an email to the doctor’s institution. As the images don’t have identifying details and are not attached to any patient information, most privacy regulations can be avoided, the company says. However, as most medical
Personal data found on recycled hard drives
facilities require written patient consent before a photo is taken, Figure 1 also includes an in-app ‘tap, type and sign’ consent form.
Internal emails and attachments from a government medical facility that list personal contact details for medical staff have been found on randomly selected recycled hard drives in Australia.
Figure 1 spokeswoman Annie Williams said the Australian version of the app contains an Australianspecific consent form.
The Australian branch of the US National Association for Information Destruction (NAID), an industry group representing information destruction companies, recently commissioned forensic investigation firm Insight Intelligence to do a two-month study of recycled computers to highlight the potential for data breaches by not erasing hard drives correctly.
The app was first launched in North America in the middle of last year, and it has received a good review on iMedicalApps. The company hopes to develop a large community of healthcare professionals to share images, knowledge and clinical insight. The Australian version is available from the App Store and has been optimised for the iPhone 5.
The study involved randomly buying second-hand hard drives from a number of sources, including eBay. Of the 52 hard drives purchased, 15 contained confidential personal information, including five from a government medical facility. A spokesperson for NAID-ANZ said there had been attempts to delete the data from the medical facility but these had not been very effective. “The material included detailed information about the facility’s funding, lists of personal contact details for doctors and complete mail boxes from various employees,” the spokesperson said. Insight Intelligence MD Mario Bekes said where personal information was found, there were signs that someone had attempted to remove the information but failed to effectively do so. Mr Bekes said proper removal of data from computer hard drives requires more than just pressing the delete button. “Even if they try to do it properly, private individuals and businesses take a big risk by attempting to erase hard drives themselves,” he said. “It is not really a doit-yourself project.”
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Medicines app to email meds list to healthcare providers NPS MedicineWise has launched a new app for Android and iOS that can be used to store or email a list of medications and to record medical test data. Called MedicineList+, the app can also handle multiple user profiles so parents and carers of older family members can keep track of more than one person’s medicines list. Users can also scan in the barcode of their prescription drugs straight into the app, as well as setting reminders to take their next dose. NPS first launched a MedicinesList app in 2011 but it was restricted to the iPhone. The MedicineList+ app is completely new, has more functionality and can work on Android as well as iOS devices, the organisation said. It is available from Google Play and the App Store. The MedicineList+ app includes a number of features, including the ability to: • Generate a list of medicines which patients can email, print or save for sharing with family members, carers or health professionals • Scan the barcode from the medicine’s packaging to enter it straight into the medicines list, or enter details manually • Create multiple user profiles, each with personal details • Set a reminder for individual medicine doses or for general medicine reminders such as the next due dose of a vaccine • Record medical test data such as. blood pressure, weight, height and INR, and graph these over time • Add free text and notes such as details of health professionals, and create notes and general health reminders including allergies and emergency contacts.
Accessibility problems plaguing the PCEHR provider portal Clinicians attempting to access the healthcare provider portal into the PCEHR reported serious issues with the system recently, including an inability to log on through any web browser and receiving instructions to try to use their iPads, despite the fact that provider access requires an individual NASH token and the iPad has no USB ports. The ehealth.gov.au website states that the provider portal is compatible with Internet Explorer 8 and 9 and Firefox, although clinicians say they have used other common browsers like Chrome and Safari in the past. Port Macquarie GP and former NEHTA clinical lead, Trina Gregory, said she and her practice manager had spent most of one afternoon on the phone to the PCEHR helpdesk, which is staffed by Medicare/DHS, and the NASH division. Dr Gregory said the PCEHR helpline operative told her to download Firefox if she wanted to use the provider portal, but she queried why the system had not been built to be browser agnostic. “They said to my practice manager maybe you can access the provider portal using Firefox as other web browsers may not be
supported, or it should be able to be accessed using mobile devices,” she said. “We did explain that we had accessed the provider portal using the same computer and web browser previously and were not aware of any changes to this. “Then they said you can only get on the provider portal using Firefox or your iPad, and I said, how am I supposed to stick a NASH token in an iPad?”
“How am I supposed to stick a NASH token in an iPad?” Dr Gregory said she was incredibly frustrated at the problems plaguing the system, which she still hoped could be fixed. “We have spent so much money on this thing with no meaningful use,” she said. “I am one of many passionate people who really want this to work. I am passionate about eHealth and have been involved with NEHTA for six years, building the foundations. We all want this to work but we need to find out what can be done to fix this.” Dr Gregory’s former colleague on the NEHTA
clinical leads team, Nathan Pinskier, said he too was receiving the same messages when attempting to log in to the provide portal. Dr Pinskier said he had tried to access the portal in IE, Safari, Chrome and Firefox, but all were either saying the browser was not supported, or rejecting his authorisation credentials. The portal has been established to enable allied health practitioners to view the PCEHR and upload event summaries to the system in advance of the roll-out of conformant clinical software. Several clinicians, including the former head of engagement for NEHTA, Mukesh Haikerwal, have said they often preferred to use the provider portal rather than directly accessing the PCEHR through their clinical software as the interface was much more user friendly. The Department of Health rejected the claims, saying the issues reported were caused by the use of unsupported browsers. A spokesperson for the Department of Health said the portal remained operational, although there “were reports of problems with the use of nonsupported browsers, as
well as issues with loading new NASH certificates”. “Healthcare providers are aware of the browsers which are supported and they are notified on the eHealth website,” the spokesperson said. “When healthcare providers access the PCEHR through
their clinical information systems, there are no issues related to the type of system or browser they have. “The issue with the loading of new NASH certificates is being followed up with [the Department of Human Services] and the specific user.”
The spokesperson said it was important to note that healthcare providers will mainly access the PCEHR through their clinical software, and the provider portal was developed mainly to support those providers that don’t use or have access to PCEHR compliant clinical information systems.
Cardiac app lets patients graph test results and email them to specialists A South Australian cardiologist has developed an app that allows patients with heart conditions to track, store and graph key data such as blood pressure, cholesterol, INR
and medications and to send it through the app to their doctor. Called What’s Wrong with My Heart, the app has been designed by Alistair
Begg of SA Heart based on a DVD he helped develop with a cardiology rehab group from Ashford Private Hospital in Adelaide and available through the Heart Foundation. It contains information about cardiac conditions, procedures and risk factors and provides links to videos clips from the DVD and on Vimeo and Youtube, and also has handy graphing features so patients can keep track of their measurements. In addition to graphing key data, the app allows patients to create a journal and to assess their response to medication. Data can then be emailed to the cardiologist. The app costs $4.99 from Google Play, and Dr Begg is currently waiting for an iOS version to be released on Apple’s App Store.
MedicAlert Foundation to launch online member portal Medical emergency information and identification service provider MedicAlert Foundation is building new functionality for its members that will allow them to view and add to the medical and other data the organisation keeps for them in the case of an emergency. The not-for-profit organisation has also joined the Medical Software Industry Association (MSIA) with a view to networking with software vendors to see how information flow can be improved for both members and clinicians. The foundation supplies medical jewellery with the internationally recognised emblem featuring the Rod of Asclaepius enclosed by the words MEDIC and ALERT. On the rear of the emblem is an engraving of a 24/7 hotline number – which in Australia is run by RDNS SA – as well as a unique member number and pertinent information such as medical conditions, allergies and special needs. The emblem can also advise of advance care instructions. Sandra Turner, CEO of the Australia Medic Alert Foundation, said the organisation had been working on a member online project for some time, and hoped to have the service available in the next couple of months. “At the moment a member who joins online does have the ability to order a product online but they still can’t check their data, neither can members who joined by other methods,” she said. “From a technical standpoint we didn’t want everybody to be accessing the database proper for security reasons, so we’ve spent a lot of time and effort setting up a system that will be separate to our database.”
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Blood pressure monitoring to CATCH hypertension Country South SA Medicare Local is loaning home blood pressure monitors for free to patients referred by GPs to the Country Access to Cardiac Health (CATCH) program, which aims to improve cardiac rehabilitation in patients in the area who have had a cardiac event or uncontrolled hypertension. The CATCH program is a joint effort between the Integrated Cardiovascular Clinical Network South Australia (iCCNet), Country Health SA and Country South SA Medicare Local (CSSAML) for the prevention of cardiovascular disease and improved cardiac health through rehabilitation. Patients referred to the program are offerred the opportunity to participate in an ongoing monitoring program in which they register on the CATCH website and use it to record blood pressure readings. A suite of web-based tools was launched in August last year and allows patients to work with their GP, pharmacist and allied health providers such as dieticians and exercise physiologists. The website includes tools for users to record and self-monitor specific risk factor activities such as alcohol intake, blood pressure, blood glucose, smoking, physical activity, cholesterol and weight. Records are displayed in table and graph form so users are provided with a visual picture of progress toward managing their risk factors. Graphs are equipped with recommended normal ranges and use a traffic light colour system to assist users to identify when levels are acceptable or indicate a specific risk. The ultimate aim of the project is to ensure that every patient who has experienced a cardiac event is identified, referred to and completes cardiac rehab.
Telstra sponsors start-up Zed Technologies to put film in a bag Melbourne-based radiology company Zed Technologies will use the resources provided by Telstra’s muru-D start-up accelerator program to develop My Film Bag, a new technology that will allow patients to easily access all of their radiology images when they are on the go. Zed Technologies is one of 10 start-ups chosen for the first round of Telstra’s muru-D program, a sixmonth accelerator that will provide ongoing business support and mentoring, as well as a $40,000 investment in return for a six per cent stake. Zed Technologies already has some runs on the board, having developed the Zed Link DICOM viewer
that is used at several large radiology practices as well as Royal Melbourne Hospital and Western Health to allow access to images and reports from any computer.
“What seemed to us was an obvious next step was to offer image access to patients rather than walking out with a great big pile of film under their arm,” Mr Wright said.
It also delivers images to external referrers, and can extract scanned documents from RIS systems and insert them into PACS.
He said that while patients are given films or more commonly a CD, they are still physical media and require person to person contact. Referring doctors themselves dislike CDs as they take time to load up.
The company also has a collaboration with MediNexus’s messaging solution for radiology and pathology reports and images in general and specialist practice. Founded by Ross Wright and Ronald Li, Zed Technologies is now looking to develop a patient-centric viewer called My Film Bag.
“This will mean that you can share it with someone on the other side of the world.” He said that with previous experience integrating with Agfa, Carestream, GE and Intelerad, he and Mr Li are confident they can bolt on to any PACS system.
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Prototype to provide patients with a view of pathology results Adelaide-based eHealth technology expert Eric Browne has developed what he believes is the first method to take coded data from HL7 messages and render it into meaningful information that can be read by clinicians and patients. What began as a way to improve the quality and safety of HL7 messages has now developed into a prototype viewer through which patients themselves can read their pathology results and see diagnostic images. The viewer also has the potential to be used to display and store data on personal health records such as the PCEHR. No great fan of the PCEHR, Dr Browne said it was his partly his concerns over the safety of the system, particularly what he calls a lack of scrutiny of the quality of data in CDA documents that are being posted, that led him to develop what he is calling the Healthbase Results Viewer for viewing existing pathology and radiology messages. Dr Browne, who manages the Healthbase Australia website for health information technology, had already created a pathology message validator that he has now adapted into a viewer. As he manages a large database of the
different coding systems used in healthcare, his technology is able to “intercept” codes in HL7 messages, decode them and then render them so clinicians and patients can understand them. The viewer can display embedded reports coded as HL7 formatted text, PDFs, RTF and HTML, and even render images in PIT or JPG format directly.
“Patients themselves can read their pathology results and see diagnostic images.” “I have tables and tables of codes like SNOMED and LOINC and AMT and various other code sets,” Dr Browne said. “There are probably 100 of them that need to be looked up in an HL7 message. The message itself is very cryptic, but I keep all of those codes so I can pull them out and decode them and present them in what I think is a meaningful way.” Dr Browne said the viewer was not yet overly patientfriendly, although it is clear enough for clinicians to understand. What it can do for patients is
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add value to pathology reports by inserting links to online resources such as LabTestsOnline – a site managed by the Australasian Association of Clinical Biochemists (AACB) that explains what the many pathology tests are and what they are testing for – and the RCPA manual. This would allow patients to cross-reference their results to better understand why the test has been taken and what the results mean. For clinicians, the idea of building the viewer was not necessarily about any need to view common HL7 messages that they receive in their clinical software every day, but to improve safety and quality. Dr Browne said there was a lot of anecdotal evidence that there is a great deal of variability in the quality of the data being extracted from GP systems. And in the hospital setting, there are tens of thousands of HL7 messages being sent every day, but again, no one was looking at the quality of those messages. Interested parties can test drive the viewer at www. pathology.healthbase.info to see how it can convert the coded data in HL7 messages to a meaningful view of results and images for clinicians and patients.
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Leecare rolls out PCEHR assisted registration Aged care software vendor Leecare Solutions has rolled out assisted registration functionality for the PCEHR in its Platinum 5.0 software, having received its notice of integration (NOI). The company is also preparing for the imminent launch of a new medications management module for its web-based software after testing in pilot sites. Leecare Solutions director and CEO Caroline Lee said that while she had no figures on exactly how many of her clients were using assisted registration for the PCEHR, it was now widely available. Most organisations using it seem to have decided on assigning one nurse or a quality manager at each site to sign residents up for the system, she said. Dr Lee said while the future of the PCEHR was not assured, she was keen to see it go ahead for the aged care industry, particularly for the sharing of information between the acute and aged care sectors.
MBS co-payments could ensure sustainable telehealth market A new telehealth industry group has recommend that a co-payment capability be introduced to the telehealth MBS item schedule, as well as a broadening of the range of clinical services available under publicly funded home care packages and hospital in the home, to extend the use of telehealth and ensure a sustainable market. The One In Four Lives industry group recommends that a national telehealth strategy be developed to take full advantage of the potential of telehealth, which it says can dramatically cut hospital admissions for chronic conditions and as a result slash public hospital costs by around $4 billion a year.
The idea is that the document would contain an up-to-date list of medications and diagnoses as well as behavioural observations that acute care clinicians could quickly refer to when an elderly person is admitted to hospital from residential care. It would also include new or altered medications.
The group launched a white paper recently, written by Lisa Altman of BT, Shehaan Fernando of Philips, Anywhere Healthcare’s Sam Holt, the University of Western Sydney’s Anthony Maeder and George Margelis, executive director at MPT Innovation Group Gary Morgan, and Suzanne Roche, general manager of policy and government relations at the Australian Information Industry Association (AIIA).
Such is the need for a transfer document that several regions have devised their own, Dr Lee said, but it would be beneficial for all concerned if the PCEHR was used as the prime mechanism.
The authors argue that it is time to move beyond pilots and funding for individual programs, and “instead support a more
The aged care sector is still hopeful that a transfer document can be created and added to the PCEHR to facilitate the sharing of information about elderly people as they move between hospitals and residential aged care facilities.
flexible funding model for telehealth that will allow the whole of the health industry to develop cost effective models of care”. “The real challenge in telehealth today is not the development of the appropriate technology, which is already widely available,” the paper states. “The real challenge in telehealth today lies in creating sustainable, profitable business models that can meet the needs of governments, services operators, clinical practice and patients.
“A hybrid of government and user pays funding for telehealth to be sustainable and scalable.” “Any new model will need to utilise a hybrid of government and user pays funding for telehealth to be sustainable and scalable.” It makes six recommendations, the first of which is the development by the federal government of a national telehealth strategy for a sustainable market. It also recommends that MBS telehealth items
continue to be supported for consults provided by GPs, specialists and residential aged care facilities, but with a co-payment capability introduced otherwise. “[We recommend] the introduction of the ability to claim the Medicare rebate at point of consultation – as with the traditional model – with the patient charged only the gap between the specialist fee and the rebate.” The group argues that the healthcare industry cannot expect to operate telehealth services that are 100 per cent reliant on government funding. “They must develop services that offer consumers an improvement on existing models of care that will warrant some level of co-payment in lieu of other costs that may be associated with long waiting times, travel or worsening health. “The introduction of some level of co-payment is likely to have a positive effect both in terms of industry’s willingness to invest in the sector and on the value consumers place on telehealth services,” although it warns that without well-devised government funding decisions the costs of telehealth will become too great for providers to
deliver and for patients to afford. “With appropriate high level direction setting driven
by a national strategy or set of sectoral strategies, telehealth could be marshalled to play a major role in enabling changes to
the service models and the delivery required to respond to the needs of both the primary and acute sectors,” they write.
DocAppointments launches repeat script request and customised apps service DocAppointments has added a new prescription request function to its online appointment booking service for GPs. DocAppointments is offering it for free to patients and as part of the monthly subscription for practices. Founder Calin Pava said other systems required credit card registration, which can act as a deterrent. “On our system people just log on with their usual registration details and request the script,” Dr Pava said. “Instead of clicking on ‘make an appointment’, they can request a script for themselves or for a family member.”
Patients are able to select the family member and their doctor and simply type in their medication and dosage. They then click the ‘request prescription’ and the request is sent to the surgery. The patient receives a confirmation by email that the request has been sent. Practices can choose for themselves what happens at their end. Doctors and receptionists can open the admin screen and check for script requests, or the receptionist can print a list off for each doctor. Dr Pava said the script request function was now available on all of the platforms that
have integrated with DocAppointments, including Best Practice, PracSoft, Zedmed and Stat. The company has also launched a customised apps service and online presence management. Dr Pava said the app service was a direct request from surgeries using the DocAppointments app, which already has the ability to include the practice’s logo. However, it also allows patients to see other practices and their doctors’ availability. Customised apps can provide just that practice’s information and contact details.
Call for investment in big data and a bionic brain The Australian Academy of Science has released a report calling for an investment of $200 million over 10 years to build a computer system that has the capacity for thought and intelligent decision-making; in effect, a bionic brain. The report also calls for consideration to be given to the creation of a purposebuilt storage system to act as a national repository for the big data generated from neurogenetics research. The report, Inspiring smarter brain research in Australia recommends the establishment of an initiative called AusBrain to improve and better coordinate Australia’s efforts in brain research. The artificial intelligence, maths and modelling group recommends that Australia invest in building a bionic brain, a thinking machine built on biological principles. This would provide a computational platform with which to test hypotheses about biological brain function and the basis of mental illness, and to understand pathologies and test new therapies, the report says. “We estimate that the total cost of creating a bionic brain would be approximately $200 million, distributed over 10 years.” The report proposes that Australia undertake a national review of neurogenetics data science to estimate growth rates in the generation of big data, and to achieve a consensus on what neurogenetics data needs to be captured and how it should be stored and shared. This would lead to the establishment of a national repository to store big data, such as setting up a cloud-computing platform that can safely store vast amounts of genomic and clinical data together with dedicated computing systems.
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HIMAA calls on Curtin to reinstate master’s degree The Health Information Management Association of Australia (HIMAA) has called on Curtin University to reconsider its decision to withdraw its graduate entry master’s degree in health information management (HIM). HIMAA CEO Richard Lawrance said the course was the only graduate entry health information management qualification by distance learning available in those states that offer no university education in the occupation, including NSW, Tasmania, the ACT and the Northern Territory. Mr Lawrance said the decision will see an end to nationwide access to professional credentialing for health information managers and clinical coders. Last year, the university announced it was reviewing its academic workforce to create two new specialist positions, one focused on teaching and the other on research, as part of its plans to become a more prestigious, research-intensive institution. Mr Lawrance said Curtin had given the impression that only poorly or nonperforming courses might be under threat from its workforce review, but the HIM coursethe School of Public Health’s most successful master’s degrees. He said information management provides the key to the systems improvements necessary in Australia’s health services if the country is to address the spiralling cost of healthcare. “Government has recognised for over a decade that continuity of quality care is crucial to the reduction of healthcare expenditure,” he said. “Continuity is not possible without the transfer of high quality, accurate and timely information between health practitioners, and between hospital and primary care sectors.”
Test results acknowledgement system gets a perfect response A study of an electronic test result acknowledgement system in use at a hospital in Brisbane has shown that of the thousands of tests conducted over a year, all of the test results were viewed by clinicians, the majority within 24 hours. While the study could not be compared to rates of viewing or follow-up before the introduction of the system, it does show that health IT has the potential to reduce the amount of delayed or unreviewed results. The study, led by Andrew Georgiou and Johanna Westbrook from the Centre for Health Systems and Safety Research at the University of NSW, looked at the introduction of a results acknowledgement (RA) system through IP Health’s Verdi software. First developed and used at the Peter MacCallum Cancer Centre in Melbourne, the Verdi suite is also used by the Mater Health Group’s three hospitals in Brisbane. The new study, published in the Journal of the American Medical Informatics Association (JAMIA), was conducted in the 249-bed Mater Mothers’ Hospital from data collected between August 2011 and August 2012. Mater implemented Verdi at Mater
Adults, Mater Children’s and Mater Mothers’ between 2008 and 2012 as the first step towards providing an EMR for Mater clinicians. Verdi provides a portal to view data extracted from 15 separate systems and enabled the development of an RA system to allow clinicians to electronically document their reviews of test results. The RA solution was developed in-house using .Net web services.
“Verdi provides a portal to view data extracted from 15 separate systems.” Mater Mothers’ uses an electronic request form (ERF) for ordering results through Verdi, but as the pathology and imaging department systems do not interface with the results acknowledgement system, a hard copy of the ERF is printed out and sent to the lab or radiology. Sara Graham, a senior project manager with Mater Health and a co-author of the study, said the organisation was currently working with the pathology service provider to automate this process. “The hard copy of the electronic
request form does currently need to be printed to go with the specimen/patient to the service provider,” Ms Graham said. “On receipt of the form though, the barcode is scanned in by the provider. “The barcode contains the unique identifier which is then associated manually with the patient in the service provider system and the details of the test are entered manually. An HL7 message is then returned from the provider system to the clinical data repository with the unique identifier on the report, which allows RA to occur.” Ms Graham said Mater Health knew when setting up the system that it was an interim step to full automation, but decided to undertake it anyway due to the patient safety benefits the hospital is now achieving. When the test result is ready, it is displayed in Verdi. Results are then acknowledged by the responsible clinician, who just needs to tick a box in the system. If the result is not electronically acknowledged within three days, email or pager alerts are sent out. There were some significant differences in acknowledgement rates by patient DRG category
and by the day of the week. Obstetric or cancerrelated test results were acknowledged faster than others, and the percentage of acknowledgements outside of three days was
significantly higher on Fridays than other days. However, “the findings of this study show that after the implementation of the RA system, all inpatient
test results within the hospital were recorded as acknowledged, a result never previously reported from reviews of test followup using paper-based systems.”
$10m to plant the seed for better aged care services through ICT A one-off investment of $10 million from the federal government will help the aged care industry to implement a plan for better ICT services across the sector, enabling it to introduce new models of care, improve productivity and reduce waste. Launching a blueprint outlining its vision for ICT in aged care, the Aged Care Industry Information Technology Council (ACIITC) said it believes the investment of $10 million
should be looked at as seed money to enable aged care providers to begin investing more in ICT, similar to previous investments made in the primary care sector for GPs and pharmacists. ACIITC chair Suri Ramanathan said that while the industry had put forward a firm figure, it well understood that the current focus was on tightening budgets rather than expanding them. However, the aged care industry was arguing that in
addition to the investment, the government and the industry can together look at reducing waste. “What we’re saying is this is our canvas, it is not prescriptive about what should happen, but that eventually we’d like to liberate the consumer to become a participant in their care, not just be recipients of care,” he said. “They take ownership of themselves and we will then help and enable them.”
Zedmed to allow sharing of progress notes Clinical and practice management software provider Zedmed is set to launch a new function called Clinician GroupShare, which will give users the option to restrict access to progress notes across different clinical groups. Currently in beta testing, the new feature is designed for multi-disciplinary settings. Zedmed sales and marketing manager Rosemary Lloyd said Clinician GroupShare would also enable clinics to better comply with patient confidentiality requirements. “In a multi-disciplinary setting where patients are all accessed from one database, it may not always be necessary or even appropriate for some clinician groups to see the progress notes written by clinicians of other clinician groups,” Ms Lloyd said. “For example, GPs will typically choose to share the patient progress notes with other GPs in their practice, but they may consider it unnecessary for the allied health practitioners to see the GP notes. Conversely it will remain appropriate for the GP to see what the physios record in their progress notes.” The new function will give users the option to group practitioners and share or restrict access to progress notes across groups. Ms Lloyd said the new feature had been requested by several multi-disciplinary sites and is expected to be released in May. “A further enhancement to this feature is currently in development for those situations where it is entirely appropriate that the complete patient record is accessible to only one clinician. Called the Record Lock, this feature is anticipated for release later in 2014.” Clinician GroupShare will also provide users with the ability to produce financial and revenue reports for each group.
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Independent advice for practices to ImproveIT Bayside Medicare Local in Melbourne has set up a program to provide free, independent assessments of ICT capability for GPs, pharmacists and psychologists in its catchment. BML is working with community notfor-profit Infoxchange to conduct full assessments of individual practices’ ICT capabilities through the ImproveIT project, which was trialled last year with five general practices, three psychology practices and three pharmacies. BML eHealth support officer Suzy Canadi said the organisation was looking to work with up to 100 practices to help them understand their basic IT requirements. She said that while many had an IT support contractor, most were not familiar with the requirements of eHealth, including secure messaging and the PCEHR. BML’s eHealth portfolio manager Brendon Wickham said the idea was to provide practical assistance to practices to get them ready for eHealth. “A lot of providers probably aren’t ready for eHealth at the basic level, so what we decided to do was to try and help them with that first step up, before you talk about things like NASH certificates and HPI-Is and HPI-Os,” Mr Wickham said. “We have contracted Infoxchange to do the assessments, as they have developed a methodology about going into a provider, assessing their business and then analysing it and reporting on it. It involves completely independent advice.” The assessment includes the creation of a network diagram that shows the practice what their current set-up includes. It also provides recommendations and suggestions for improvement that are prioritised to guide the practice on making decisions regarding future planning.
Pharmacies join up to medAdvisor medication compliance system Sigma Pharmaceuticals, owner of the Amcal and Guardian chains of pharmacies, has signed on to use the new medAdvisor patient medications compliance program, joining the Chemmart, PharmaSave and Terry White groups. medAdvisor is a digital platform including an iOS, Android and a web app that provides patients with a list of prescription medications and allows them to order refills from their regular pharmacy. They can receive reminders on when to take medications as well as when they need to refill repeats or to contact their GP for a new script. For pharmacies, it creates the ability to better communicate with regular patients taking multiple medications and more easily keep track of patients
with chronic illnesses who leave their scripts at the pharmacy.
medAdvisor estimates that 1500 pharmacies have now signed up.
medAdvisor has been developed in Australia by Irish pharmaceutical company Actavis, the new name for Watson Pharmaceuticals, which last year also acquired Warner Chilcott.
medAdvisor’s technology platform consists of a mobile app that can be used on an Apple or Android phone or device, or as a web app accessible from common browsers. Patients who don’t have an internet connection can receive alerts through GuildCare’s SMS script reminder service MemoCare.
medAdvisor has worked with the Pharmacy Guild on the product, and it requires that pharmacies use the GuildCare software platform, which integrates with most dispensing software. medAdvisor managing director Josh Swinnerton said the program has been available in pharmacies since October last year. With Sigma announcing that its 450 Amcal and Guardian pharmacies were formally endorsing the program,
Features include a medication list detailing medication name, brand name, repeats left, days’ supply left and colour indicators if action is required. Similar functionality is also available for OTC medications or vitamins. It has a Fill-My-Scripts function that automatically reminds patients to fill repeats, and alerts them if they forget. It also automatically detects if scripts are filled as it is linked to the pharmacy system. A See-My-Doctor function reminds patients to visit their GP for a new prescription after the final repeat is filled, with reminders sent several weeks prior to running out. Mr Swinnerton said medAdvisor was mainly aimed at patients with chronic conditions or who take regular medications.
AMA says urgent action needed on real‑time drug monitoring system AMA Victoria is calling on its state government to implement the Electronic Recording and Reporting of Controlled Drugs (ERRCD) system, which the federal Department of Health says is operational and ready for all jurisdictions to use. AMA Victoria has joined other state bodies in urging the jurisdictions to act, asking for an allocation of $55 million over four years to implement the system as part of its 2014-15 prebudget submission. The AMA is also urging governments to facilitate the legislative changes required to replace the manual, paperbased reporting of controlled drugs with the electronic system and to permit prescribers and pharmacists to access the records. A spokeswoman for the federal Department of Health said ERRCD, which is based on a system called DORA first developed in Tasmania, is available to states and territories to begin implementing. The federal government purchased licences for the system on behalf of the states in February 2012. “The Electronic Recording and Reporting of Controlled Drugs (ERRCD) system is currently installed on a secure host server and
is operational, waiting for each state and territory to commence utilisation,” the DoH spokeswoman said. “Regulating the prescribing and dispensing of controlled drugs is the responsibility of the states and territories. The ERRCD system has been handed over to states and territories for their use via complimentary software licence agreements.
“Regulating the prescribing and dispensing of controlled drugs is the responsibility of the states and territories.” “Advice on progress with implementing the ERRCD system should be obtained from the relevant state health departments.” A spokesperson for the NSW Ministry of Health said it was supportive of a national ERRCD system and “recognises that it will potentially provide numerous benefits to prescribers, pharmacists, regulators, and the general community, including a reduction in the harms brought about by the misuse of controlled drugs”.
“The NSW Ministry of Health is continuing to work through the financial and practical implications of implementation of the ERRCD system,” the spokesperson said. “Full roll out is likely to take three years. “There may need to be changes to legislation to require the provision of pharmacy dispensing records of controlled drugs and to enable access to records by medical practitioners and pharmacists. These factors will be considered as the Ministry of Health progresses the implementation.” Currently, prescriptions for schedule 8 drugs must be registered on dangerous drugs registers, or DD books, by pharmacies. In most jurisdictions, copies of the prescriptions are sent by fax or mail to state and territory health departments at regular intervals and they must be available for inspection by health departments and the police. However, the data is often analysed up to six to eight weeks after a dispensing event, meaning doctorshoppers and fraudsters can escape notice. Other states and territories are at very early stages in their preparations.
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Next step for Fred IT is pharmacy in the cloud Pharmacy software specialist Fred IT will launch what it says is Australia’s first cloud-based dispense and management solution in the second half of this year, following trials with a number of beta pharmacies. Called Fred NXT, the new solution will be a single, integrated system for dispense, point of sale, professional services and retail management. Fred IT Group CEO Paul Naismith said that while Fred NXT will be a fully cloudhosted package, he did expect it to be used in addition to locally installed software solutions in the short term, meaning it will initially be a hybrid cloud solution. Mr Naismith said the architecture underpinning Fred NXT was a “very powerful” Microsoft ERP core, which he believes will prove attractive not just to the banner pharmacy groups to provide a full end-to-end service but also to provide smaller, independent pharmacies with a shared infrastructure service. The ERP core will also allow Fred NXT to easily integrate with the many different systems used by pharmacies, he said. “With eRx and PBS Online, we have already taken that kind of communication out of the store so that it occurs from our data centre directly to those providers rather than from 5000 different points. “That is the preferred architecture for Fred NXT, but it all depends on the third party that we are connecting to. Those discussions are underway and our partners are already well aware of what our plans are.” He said moving to the cloud would also cater for the way consumers have adopted internet and mobile technologies to communicate with pharmacies.
Reining in the herd: introducing mobile devices to mobile hospitals It might be technology that belongs back in its heyday of the 1980s and that should have since been swamped by alternative devices, but the old-fashioned pager still has a role to play in healthcare – hospitals in particular – and it doesn’t seem likely to be leaving us soon. In fact, there is the distinct possibility that sales of oneway communication devices like pagers may even grow in the short term, according to Michael Clarke, senior healthcare consultant with mobility specialist Amcom Software. Mr Clarke told an industry webinar recently that when he first looked at smartphone adoption and mobility trends in healthcare when new devices started to become available, he “jumped the gun” and predicted the number of pagers used would decline reasonably rapidly, mainly due to the capability to do two-way communication easily through smartphones. “What we are actually seeing is the same amount of pagers, maybe even a slight increase in pager sales in healthcare,” Mr Clarke said. “That is because as more facilities roll out mobility strategies, they are actually seeing that paging still very much serves a purpose
in healthcare for people who only require one-way communication. “They require fast, robust, reliable technology for the quick delivery of important information. What you’ll find during a mobility rollout is that it is reliant on [external hardware, WiFi and telecoms providers]. Pagers will still form a key part of all mobility strategies.” The webinar was aimed at hospital and healthcare facilities that are looking at introducing a mobility strategy. Some organisations like Melbourne’s Cabrini took the plunge some years ago, most have developed an ad hoc approach and allow limited use of mobile devices, and yet others have not yet overcome the many challenges facing large organisations like hospitals – including security and
patient privacy – to develop their own strategy. However, that is beginning to change, even in the slow-moving public sector. Many clinicians will use mobile devices despite what hospital policy says. Clinicians don’t want to feel weighed down by carrying many different devices, Mr Clarke said. “A lot of them complain about having to carry a pager, a DECT phone or a WiFi handset, maybe a voice badge or a duress badge and then they have their own smartphone in their pocket. “This is true particularly for the junior medical staff who have probably had a smartphone in their hands all the way through med school and throughout their entire training, and it is also very true for a lot of VMOs who operate through different sites.
“They want to be able to have a single device, with all of the relevant information on that device.” So, how do hospitals “rein in the herd of mobile devices and bring order to the field?” Mr Clarke said. “Obviously there is no single correct answer, but we
work with many hospitals in this field and we’ve been able to put together a roadmap for designing and deploying a full mobility strategy, right the way from setting up a plan through to the end-user adoption.” On the issue of BYOD, Mr Clarke said this may be a
better option than issuing approved devices to staff, even if it means having to deal with integrating internal software with multitudes of devices and operating systems. People also tend to take better care of their own property than that issued by their employer, he said.
Best Practice aims high with Summit 2014 edition, featuring ART and NPDR view Clinical and practice management software vendor Best Practice has released its latest update, with features including full Tyro integration and assisted registration functionality for the PCEHR, along with a view of the National Prescription and Dispense Repository (NPDR). Best Practice showcased the new version at its Bp Sunshine Summit on the Sunshine Coast in March, and has decided to call the new version the Summit 2014 edition. Bp announced late last year that is would provide integrated EFT and Medicare transaction processing through Tyro Payments in the new version, which is now available. Practices must be using Bp’s practice management module as well as the clinical system, and simply have to contact Tyro to arrange for a terminal to be delivered.
The new version also contains Argus as the default secure messaging service and integrated MEDrefer, a third-party eReferral service that allows GPs to electronically refer to a number of specialists and to track the status of the referral. New PCEHR functionality includes the assisted registration tool (ART), which allows doctors to register regular patients for the system directly through the software, and a view of PCEHR-registered patients’ prescription and dispense history through the NPDR. Other features include a new dementia assessment tool, several device integration improvements, and a link to UHG, which helps practices with the processing and management of claims with health insurers. The UHG tool allows the GP to select certain patient data, including patient details and optional items like
immunisations, and then send it to UHG as an XML file. The dementia assessment tool has been designed to assist in the measurement, recording and reporting of patient information relating to dementia risk through a risk assessment prompt. It includes information for daily living, dementia risk factors, advanced care planning and referral information, and links to patient education materials.
Agreement on scanning incentive for pharmacies Community pharmacies will receive a small incentive payment to encourage them to boost the scanning rates for electronic prescriptions under an agreement between the Pharmacy Guild and the Department of Health. Pharmacies can receive at least $800 on meeting a target of scan rate of 15 per cent next month, and $1200 if they meet a 30 per cent scanning target by September. Pharmacies must be eligible for the eHealth section of the Pharmacy Practice Incentive (PPI) Community Services Support priority area program, which includes the use of appropriate dispensing software, broadband internet connectivity, PBS Online claiming and the use of an electronic prescription exchange service. The electronic prescription scanning incentive (ePSI) is an re-allocation of existing funds from the electronic transfer of prescriptions (ETP) budget in the Fifth Community Pharmacy Agreement (5CPA). The required scanning rate for each ePSI payment will be determined automatically through data transmitted via PBS Online.
Best Practice chief commercial officer Craig Hodges said work on the Summit 2014 Edition had been “exhaustive” and was the result of over a year’s work by the product team.
The guild has also negotiated with DoH to take over the direct administration of medication management programs funded under the 5CPA, agreeing to a cap on the provision of a number of programs such as home medicines reviews (HMRs), residential medication management reviews (RMMRs), and MedsCheck/ Diabetes MedsCheck.
“This really is a major update to our software products and we’re confident that Bp users will notice the addition of some fantastic new features and tools almost instantly,” Mr Hodges said.
According to the guild, this change is aimed at cutting red tape and streamlining processes by moving to an electronic claiming and payment system through the 5CPA website. The system has been designed by Fujitsu and will replace the current paper-based system for making claims.
HISA VIC COMMITTEE MEETING Melbourne, VIC p: +61 3 9326 3311 w: www.hisa.org.au/events
HISA WA COMMITTEE MEETING Perth, WA p: +61 3 9326 3311 w: www.hisa.org.au/events
BIG DATA Melbourne, VIC p: +61 3 9326 3311 w: www.hisa.org.au/bigdata2014
HEALTH INFORMATICS: NURSING IN THE DIGITAL AGE Brisbane, QLD p: +61 2 9745 7500 w: www.acn.edu.au/cpd
16-17 MAY HEALTHY PRACTICE CONFERENCE Canberra, ACT p: +61 2 6925 0157 w: www.maidalearning.com.au
10-11 JUNE THE NEW ZEALAND HEALTHCARE CONGRESS Auckland, NZ p: +64 9 917 3653 w: www.healthcarecongress.org.nz
23-25 JUNE ACTIVITY BASED FUNDING CONFERENCE 2014 Melbourne, VIC p: +61 2 9265 0700 w: www.abfconference.com.au
HISA WA COMMITTEE MEETING Perth, WA p: +61 3 9326 3311 w: www.hisa.org.au/events
HIMSS AUSTRALIA CONFERENCE Sydney, NSW p: +65 9220 9322 w: www.himssasiapac.org/aus14
ANZ HOSPITAL INTELLECTUAL PROPERTY CONFERENCE Sydney, NSW p: +61 408 165 062 w: www.hospitalipevents.org
7TH ANNUAL PHARMACEUTICAL LAW CONFERENCE 2014 Sydney, NSW p: +61 2 9080 4090 w: www.healthcareconferences.com.au
HISA NSW - THE STRENGTH OF COLLABORATION Sydney, NSW p: +61 3 9326 3311 w: www.hisa.org.au/events
HEALTH INFORMATICS: NURSING IN THE DIGITAL AGE Sydney, NSW p: +61 2 9745 7500 w: www.acn.edu.au/cpd
HISA WA STRATEGY WORKSHOP Perth, WA p: +61 3 9326 3311 w: www.hisa.org.au/events
THE 11TH ANNUAL FUTURE OF THE PBS SUMMIT Sydney, NSW p: +61 2 9080 4307 w: www.informa.com.au
HISA VIC COMMITTEE MEETING Melbourne, VIC p: +61 3 9326 3311 w: www.hisa.org.au/events
RURAL DOCTORS ASSOCIATION OF QUEENSLAND 25TH ANNUAL CONFERENCE Brisbane, QLD p: +61 7 3221 4444 w: www.rdaq.com.au
26-27 JUNE 6TH ANNUAL OBSTETRIC MALPRACTICE CONFERENCE 2014 Melbourne, VIC p: +61 2 9080 4090 w: www.healthcareconferences.com.au
July 22-23 JULY ITAC 2014 Hobart, TAS p: +61 8 8981 5119 w: www.itac2014.com.au
REDUCING HOSPITAL READMISSIONS & DISCHARGE PLANNING CONFERENCE Melbourne, VIC p: +61 2 9080 4090 w: www.healthcareconferences.com.au
4TH ANNUAL NATIONAL HOSPITAL PROCUREMENT CONFERENCE Sydney, NSW p: + 61 2 9080 4090 w: www.healthcareconferences.com.au
2ND ANNUAL ASSISTANTS IN NURSING CONFERENCE Sydney, NSW p: + 61 2 9080 4090 w: www.healthcareconferences.com.au
EHEALTH INTEROPERABILITY CONFERENCE Sydney, NSW p: + 61 2 9080 4090 w: www.healthcareconferences.com.au
25-26 AUGUST 15TH INTERNATIONAL MENTAL HEALTH CONFERENCE Gold Coast, QLD p: +61 7 5502 2068 w: www.anzmh.asn.au/conference/
25-27 AUGUST 15TH INTERNATIONAL MENTAL HEALTH CONFERENCE Gold Coast, QLD p: +61 7 5502 2068 w: www.anzmh.asn.au/conference/
28-29 AUGUST 28-29 JULY 6TH ANNUAL EMERGENCY DEPARTMENT MANAGEMENT CONFERENCE 2014 Melbourne, VIC p: + 61 2 9080 4090 w: www.healthcareconferences.com.au
28-29 JULY 13TH ANNUAL HEALTH INSURANCE SUMMIT Sydney, NSW p: +61 2 9080 4307 w: www.informa.com.au
6TH ANNUAL OPERATING THEATRE MANAGEMENT CONFERENCE Sydney, NSW p: + 61 2 9080 4090 w: www.healthcareconferences.com.au
17-18 SEPTEMBER MANAGING THE DETERIORATING PATIENT CONFERENCE Melbourne, VIC p: + 61 2 9080 4090 w: www.healthcareconferences.com.au
HIMAA AND NCCH 2014 NATIONAL CONFERENCE Darwin, NT p: +61 2 9887 5001 w: www.himaa2.org.au/conference
9-11 OCTOBER THE RACGP CONFERENCE FOR GENERAL PRACTICE Adelaide, SA p: 1800 472 247 w: www.gpconference.com.au
6TH ANNUAL CORRECTIONAL SERVICES HEALTHCARE SUMMIT 2014 Melbourne, VIC p: + 61 2 9080 4090 w: www.healthcareconferences.com.au
September 7-10 SEPTEMBER
NURSING INFORMATICS AUSTRALIA CONFERENCE Melbourne, VIC p: +61 3 9326 3311 w: www.hisa.org.au/hic2014nia
11-14 AUGUST HIC 2014 Melbourne, VIC p: +61 3 9326 3311 w: www.hisa.org.au/hic2014
2014 ACSA NATIONAL CONFERENCE Adelaide, SA p: +61 8 8981 5119 w: www.acsaconference.org.au
3RD ANNUAL REDUCING AVOIDABLE PRESSURE INJURIES CONFERENCE Melbourne, VIC p: + 61 2 9080 4090 w: www.healthcareconferences.com.au
21-24 OCTOBER AAPM 2014 CONFERENCE Adelaide, SA p: +61 3 6231 2999 w: www.aapmconference.com.au
Online Calendar: To view a comprehensive list of eHealth, Health, and IT events, visit: http://www.pulseitmagazine.com.au/events
NATIONAL E-HEALTH INFRASTRUCTURE WHERE FROM AND WHERE TO? GOVERNANCE IS THE KEY
Repeating the same process over again while expecting a different outcome is one definition of madness, and it seems to have infected decision making in eHealth over the last few years. Poor governance arrangements and a reliance on large consulting firms have meant that private sector expertise in eHealth has been under-used.
DR VINCENT MCCAULEY MB BS, Ph.D MSIA National eHealth Implementation Coordinator email@example.com
“If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot be carried on to success.” Confucius on the “rectification of names”. The Australian national eHealth public infrastructure consists of the Health Identifier (HI) Service, the Personally Controlled Electronic Health Record (PCEHR), supporting communications standards such as Secure Message Delivery (SMD), HL7 Clinical Document Architecture (CDA), PKI security infrastructure, and terminology such as the Systematised Nomenclature for Medicine (SNOMED) and the Australian Medicines Terminology (AMT).
About the author Dr Vincent McCauley is an acknowledged national and international expert in eHealth standards. He leads MSIA’s team assisting its membership of more than 120 leading eHealth software vendors and the wider vendor community in creating a richly interconnected, semantically interoperable eHealth environment.
There is also a rich private eHealth infrastructure connecting general practice, specialist practice and private hospitals. The latter has been in existence significantly longer and carries far more clinical information than the current public infrastructure, but receives relatively little government attention. It includes highly functional online electronic health records, with many offerings by MSIA members such as sophisticated care coordination and referral networks, secure communication between pathology laboratories and private clinicians for orders, results and images (HL7 V2 messages), access to diagnostic quality
images over the web and a mature set of medicines terminologies from a small number of expert providers. These components support complex decision support, enhanced ePrescribing, electronic referrals and discharge summaries as well as patient-accessible clinical records. It has long been the case that there has been a significant electronic barrier between the public and private health systems. Private systems are in general unable to access the public infrastructure and vice-versa. There is even a barrier to cost-effective communications such as webinars with inflexible IT policies and practices, especially in the public sector, restricting access to standard web tools for communication as well as regulatory requirements that appear to place a relatively low priority on clinical outcomes. In the past two decades, in which we have seen a huge growth in the reach and capability of eHealth, there have been a number of strategic lessons from international and local work: 1. Projects that are not clinically led have a higher failure rate 2. Projects that are government driven have a lower success rate 3. Projects that involve a “big bang” change in clinical care and/or work flow rather than incremental change have a higher failure rate
4. Projects that are standards based are cheaper and more flexible in the medium to long term 5. Rich interoperability requirements that facilitate best of breed modular software and encourage competition help control to costs and promote innovation.
“The partnership proved difficult, with most of the clinical leads in late 2013 resigning principally due to frustration with the lack of ability to influence outcomes.”
In response to the perceived need for better governance of the national eHealth landscape and following the lack of success of the federal HealthConnect project, NEHTA was established in 2005 to provide an independent body to promote eHealth, channel funding and lead national projects. While it was welcomed as a major step forward, it took some time to realise that its governance would prove problematic. The board was to consist of a representative from each of the states and the federal Department of Health. Even that vision was difficult to realise with only South Australia, Victoria and Queensland signing on as initial shareholders and directors, with Ian Reinecke as the secretary.
Dr Vincent McCauley
Whilst the rest of the states and the Commonwealth came on board over the next few years, there remained no representation from the private hospital sector, specialists, general practitioners, radiologists, pathologists, the medical software industry or consumers. The state health department board members tended to change frequently and although highly qualified administrators, they were not generally health IT knowledgeable, unlike the jurisdiction CIOs. In part to address perceptions of lack of governance, Peter Fleming replaced Ian Reinecke some years later, David Gonski was appointed chairman of the board, and an independent director with no health background was appointed. A number of years ago NEHTA attempted to redress the lack of clinical leadership by recruiting Mukesh Haikerwal and other clinicians as “clinical leads”. However,
the partnership proved difficult and in late 2013 we saw the mass resignation of most of the team, principally due to frustration with the lack of ability to influence outcomes. Their advice and views seemed to hold relatively little weight if it conflicted with state or federal political objectives and requirements. In consequence, a politically determined timeframe and policies for the PCEHR led to an implementation that was not ready for clinical use when it launched and which did not deliver sufficient value to the clinical community for wide adoption. The political expedient to “populate or perish” preceded an essential but less visible (and therefore less valued) program of work to ensure the system was safe, delivered clinical utility and was practical to use. Safety reports on the HI Service and the PCEHR by the NEHTA Clinical Safety Unit were (and continue to be) withheld from the implementation community and consumers. Unfortunately, in the process of expedient delivery, some “rectification of names” occurred. The National Authentication Service for Health (NASH) project failed to be delivered despite assurances from NEHTA two weeks prior to launch that it was on track. Instead, a further set of “special” PKI certificates were released by Medicare within a few weeks to allow the PCEHR to be used at all. These were called “NASH” certificates to distinguish them
from the eClaiming certificates already in use, which they resembled in every other respect. Governance of the HI Service has likewise proved problematic. The initial design was by NEHTA IT experts with little eHealth experience and apparently no knowledge of the Health Level 7 (HL7) international standard for such a service. Requests to review the specification of the design by the medical software industry prior to launch were refused. Requests to access the NEHTA safety report on the HI Service continue to be refused. In the lead up to launch, it became apparent to the medical software industry that the service was over-complicated and allowed unsafe searches, which could return an incorrect match between identifier and patient. The jurisdictions came to the same conclusion. This was demonstrated by an extensive IBM review of the service and led to eHealth stakeholders, including the medical software industry, insisting on mandatory restrictions on searching to be enforced by additional software conformance requirements. Further reviews of function and capability by the conformance, compliance and accreditation governance group (CCAGG) HI technical committee found that significant included functionality was potentially unsafe and impractical to implement and should not be used. A white paper published by the Medical
Software Industry Association in October 2011 detailed many of the shortcomings in the HI Service. However, it took until 2013 for these to start to be addressed, in large part due to the onerous governance arrangements for change control including the federal Department of Health, the Department of Human Service (DHS), NEHTA and the jurisdictions, but no private sector representation. It also became apparent that even small changes were extraordinarily expensive to take forward, which further delayed progress. In the meantime, uptake and usage of the HI Service is limited and many of the theoretical clinical benefits, championed by myself and many other clinicians and health informaticians, remain sadly unrealised. Similar issues have arisen with SNOMED and AMT, where issues that are barriers to implementation remain largely unaddressed years later. Early implementations of AMT have been hampered by inappropriate alphabeticisation of multi-ingredient medications and assignment of multiple and conflicting identifiers by different arms of government. When asked what were the current governance arrangements for AMT at a Department of Health-convened forum in 2013, NEHTA CEO Peter Fleming was able only to say they were currently “under review”. At the same forum no one was able to provide a description of the sustainable business case for the PCEHR – and no one in government or from the private companies that had been funded to connect to the PCEHR could articulate a business case for the private sector to self‑fund connectivity to the PCEHR. A path forward for governance in eHealth was demonstrated two years ago with a series of “four-cornered round table” meetings. These seminars brought together government, clinicians, consumers and the medical software industry on an equal basis and provided a forum for all affected parties as well
as those with technical and clinical expertise, to discuss issues and propose solution paths based on incremental change to existing, demonstrably effective, infrastructure. Unfortunately, such a process does not lend itself to large budgets and political ribbon cutting. It requires strong leadership and complex negotiation abilities combined with wide sector knowledge and cross-sector skills. University of NSW professor Enrico Coiera recently published an article suggesting that a lack of skilled personnel in eHealth was a major factor in the current state of affairs. However, Australia has a very vigorous eHealth software sector, both in the private sector and jurisdictions, is very well regarded in the international eHealth standards development communities and has an extensive pool of clinicians with eHealth experience. A different way of viewing the issue would be to note that those with wide sector experience and well-developed eHealth and clinical skills are poorly distributed in our national eHealth governance structures. Australia is not alone in having difficulty getting to grips with these problems. Canada InfoWay has struggled with similar issues, as has the UK NHS eHealth program. A way forward would include: • Formation of a “four-cornered round table” eHealth national taskforce • Formulation and publication of a National eHealth Service Architecture • Identification of improvements to existing capabilities which would improve clinical outcomes at low cost (“low hanging fruit”) • Harnessing existing local ehealth software industry capabilities and skills • Developing five- and 10-year realistic plans with reliable and mandatory outcome measures to gauge progress. In 2009, NEHTA developed a two-year strategic plan which included the following four objectives:
1. Urgently develop the essential foundations required to enable eHealth 2. Coordinate the progression of the priority solutions and processes 3. Accelerate the adoption of eHealth to increase the awareness and uptake of eHealth initiatives 4. Lead the progression of eHealth in Australia. Whilst these were all useful objectives, unfortunately the plan did not include any outcome measures. One of the intended deliverables was to “develop a governance regime which allows strong coordination, visibility and oversight of national eHealth work program activities”. Governance that fostered cooperation, effective engagement of eHealth skills, clinical leadership and real consultation was not mentioned. By building those objectives into our national eHealth governance arrangements, we are far more likely to deliver quality and clinical benefits in a cost-effective manner. The current arrangements have seen very significant investment by government with low cost-effective returns. Significant amounts have been spent on very expensive consultancies. The international consultancy firms have consistently milked the eHealth experts in the sector and repackaged that “knowledge” for government in a more palatable way to ensure further contracts. When a large investment has been made with little return, it is tempting to believe that by spending a little bit more it will all be worthwhile. The brain’s tendency to stick with the most familiar solution to a problem and stubbornly ignore or literally not see alternatives (the Einstellung effect) is rewarded and reinforced by current governance arrangements. Repeating the same process over and over again while expecting a different outcome is one definition of madness. Only by entering into effective, inclusive, cross-sector governance arrangements will that cycle be broken.
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PROGRESS REPORT FOR THE PCEHR Since its launch in July 2012, a small amount of new functionality has been added to the PCEHR, although progress has been marred by unforeseen difficulties. The next update, PCEHR release 5, was set to include the long-awaited facility to upload pathology results and reports, but again there have been delays, not the least of which is the new government’s review of the system.
KATE MCDONALD Journalist: Pulse+IT firstname.lastname@example.org
As this issue of Pulse+IT was going to press, a decision had not yet been made – publicly at least – on the future of the PCEHR. While it seems reasonably unlikely that it will be scrapped altogether, work on adding new features to the system seems to have come to a standstill for various reasons. These include major disagreements over how pathology results and reports are to be packaged and uploaded, and who would have the authorisation to release those results. Progress has also been stymied by the air of uncertainty about the whole project following the Coalition’s victory in the September 2013 election. The Liberal Party had long warned it would do a “stocktake” of the PCEHR should it win the election, and that exercise has since taken place, with a review panel convened to survey public submissions on the problems faced during the implementation, as well as to advise on what can be done to fix it.
About the author Kate McDonald is a senior staff journalist for Pulse+IT. Formerly the editor of Australian Life Scientist magazine, she has also edited industry titles Hospital & AgedCare and Nursing Review. Her interests cover health ICT, biotechnology and translational research.
PCEHR release 5, originally slated for midApril, looks likely to be pushed back until the government announces its decision. Release 5 was meant to include a number of new functions intended to improve the system’s value to both consumers and clinicians, including pathology and diagnostic images, advance care directives, and the merger of the Northern Territory’s My eHealth Record (MeHR).
Early releases When the system went live on July 1, 2012, functionality was minimal. A glitch in software specifications during the build meant that no GP desktop software vendor was able to connect to the system, and all were still working hard on designing their own interfaces within their clinical software. It wasn’t until October 2012 that the first GP software with full PCEHR functionality was released by Zedmed, with other vendors releasing their versions over the following months. The big two – Medical Director and Best Practice – released their PCEHR versions in January and April 2013 respectively. What that effectively meant was that the only information that could be added to the record on its release was consumerentered information such as next of kin details, allergies and personal notes. Needing to get something uploaded to populate the couple of thousand of records that were created in the first few months, PCEHR release 2 in August 2012 added details of MBS and PBS history going back to 2010, along with organ donor registry status and child immunisation records.
PCEHR release 3 That was the way it stayed until May 2013, 10 months after the launch date, when a
child development section was included, allowing parents to add details of their children’s health, growth and development. This was accompanied in June by the first app to interact with the PCEHR. Called the My Child’s eHealth Record and based on a similar app designed by Deloitte and NSW Health, the app is still restricted to NSW and Tasmanian users.
“PCEHR release 5, originally slated for mid-April, looks likely to be pushed back.” Kate McDonald
The May release also saw a view of the National Prescription and Dispense Repository (NPDR) in the PCEHR. While this was added to all consumer records, very little information was flowing in as the repository itself had just gone live.
Most contain functionality to create and send event summaries, and iCareHealth can also create and send shared health summaries.
the MeHR with the PCEHR. That merger was always predicated on the ability to include pathology results and reports, which are currently available in the MeHR.
PCEHR release 5
As a major data repository, the NPDR is being rolled out slowly throughout the country. It was originally centred around the Barwon region in Victoria and in Tasmania, with 200-odd pharmacists using the system as part of the project. Following its general launch, two of the major dispensing software vendors – Fred IT and Simple Retail – released versions of their software with the ability to send data to the NPDR included.
Release 5 was planned to a big one, with headline functions such as pathology results, diagnostic images and advance care directives (ACDs) to be included. These functions have turned out to be far more difficult than promised, and it seems likely that the ability to store electronic ACDs or images is some years away.
In addition to 60,000 users,the NT system has tens of thousands of clinical documents, adding immeasurably to the worth of the PCEHR, which still holds a relatively paltry amount – 15,000 or so – of shared health summaries.
For GP software, the functionality has taken a bit longer. Genie was the first to release an NPDR-enabled version last year, followed by Communicare, Zedmed and most recently Best Practice. The other GP software vendors are expected to include it in their next releases.
PCEHR release 4 PCEHR release 4, which went live in November 2013, involved some very minor enhancements for consumers and administrative staff, and the first round of feedback for software vendors following the establishment of a clinical utility program (CUP) by NEHTA to improve the way information is rendered in the system. Aged care software vendors such as iCareHealth, Autumn Care, Leecare, TCM and Commcare all now connected.
ACD capability was expected to prove a compelling reason for consumers to sign up to a record. One of the Wave 2 sites, the Cradle Coast project in Tasmania, has been working on the capability with software vendors including Alcidion for a number of years. However, the complexity of the work means it is not likely that to be available soon, so plans have been mooted to allow existing ACDs to be stored on the system in PDF format. While the PCEHR was never built to use PDFs, it appears to be the only viable option. PDFs have also been mooted for the pathology function, largely due to calls from the pathology sector to ensure that the full pathologists’ report, along with the results, be available to clinicians. The pathology sector insists that simply loading results is not only confusing but potentially very unsafe. Pathology is also a sticking point for the Northern Territory’s M2N project to merge
While the struggle by GPs to use the system and the workload required to curate shared health summaries has stolen the headlines, the acute care sector has begun to move in connecting some of its clinicians to the system. That is mainly due to NEHTA’s rapid integration project (RIP), which built on the experiences of St Vincent’s Hospital in Sydney, another Wave 2 site that has pioneered the uploading of discharge summaries. As each state uses different acute care systems – some truly ancient and completely unable to deal with the interoperability requirements of the HI Service and the PCEHR – an interim system was developed by the South Australian Department of Health and a vendor partner to allow public hospitals to create and send discharge summaries. All hospitals in Queensland, all metro hospitals in SA, 27 in NSW and the four big hospitals in Tasmania are now using this software to upload discharge summaries. Royal Perth Hospital is due to go live in the next month, and several in Victoria are also nearly there.
SECURE CLINICAL MESSAGE DELIVERY LOST IN THE MAIL?
The PCEHR has consumed much of the government’s eHealth focus, and indeed its budget, in recent years. Despite claims it would deliver “the right information about the right patient at the right time”, in its current state the PCEHR has done little to improve the ability of healthcare providers to communicate between themselves electronically.
SIMON JAMES BIT, BComm Editor: Pulse+IT email@example.com
Better means of secure electronic communication between healthcare providers has long been a priority, particularly in general practice where the benefits of electronic delivery of diagnostic results have for many years been appreciated by those who remember the paper-based alternatives. In fact, Pulse+IT’s own research conducted as far back as November 2006 highlighted just how important practices deemed improvements directly related to the reduction of both inbound and outbound paper correspondence.
was conducted, a PCEHR‑like concept described in the survey as a “centralised patient medical record” ranked just tenth on the general practice IT/IM innovation priority list. While the PCEHR project has been the most visible government eHealth initiative, this is not to say that the government has entirely ignored the need for improvements to the way electronic correspondence is transmitted directly between healthcare providers and their organisations.
When asked “What IT/IM innovations are going to make the greatest difference to general practice”, the top four selections as ranked by survey respondents were:
In 2009, a collaboration between the Medical Software Industry Association and NEHTA yielded Secure Message Delivery (SMD) specifications, developed by the eHealth PIP Working Group.
1. Specialist reports received electronically 2. Electronic discharge summaries 3. Ability to send referrals electronically from within the clinical software 4. Sending electronic prescriptions to a hub to be pulled down by a pharmacist used by the patient.
While a technical discussion of SMD is outside the scope of this article, the initiative was intended to provide software developers with access to specifications that would allow them to create products capable of communicating with other software built using the same specifications.
The seventh- and eighth-ranked responses also related to the electronic transfer of information between healthcare providers. Notably, given what has and hasn’t transpired in the years since the research
On a practical level, the intention was to foster an environment in which healthcare organisations could choose a single SMD‑capable solution from their vendor of choice, and communicate securely and
electronically with other organisations using an SMD-capable solution. This level of compatibility is expected when one sends a simple email to a friend or colleague, regardless of which email software each party uses. However, with only a few exceptions, the history of secure messaging in Australia has largely entailed both the sender and recipient using the same secure messaging solution to communicate electronically. And even then a successful transmission may not be feasible owing to the different ways in which clinical software products import and export electronic clinical documents. In April 2010, Integrating the Healthcare Enterprise (IHE) held a secure messaging connectathon, enabling software vendors to test their implementation of the fledgling SMD specifications. Prompted into action by impending changes to the eHealth Practice Incentives Program (PIP) at the time, nearly 50 software organisations signed a commitment to SMD, thus enabling their general practice customers to continue to receive incentive payments. However, without any tangible requirements – other than the placing one’s signature on a piece of paper – enforced on either practices or their software vendors at that point in time, SMD as an initiative largely stalled. With little discernible progress being made for several years, it wasn’t until the more recent 2013 eHealth PIP requirements were released in 2012 that the attention of both the software vendor and general practice communities returned to SMD. In June 2012, three secure messaging companies laying claim to 85 per cent of the market announced the formation of the Secure Message eXchange (SMX) to allow members to send messages via SMD channels to each other’s customers. At the time, the SMX partners said the initiative was something the industry
“... a PCEHR-like concept described in the research as a ‘centralised patient medical record’ ranked just tenth on the general practice IT/IM innovation priority list.” Simon James
had been working towards for a number of years, but prior to the adoption of the SMD specification, each different vendor had proprietary methods for packaging and addressing documents sent within their network. The vendors agreed to a wholesale interchange cost per transaction, with each member retaining the ability to decide how these costs are recovered from their respective customers. In support of the government’s ambitions for the current eHealth PIP, in November 2012 NEHTA announced it would provide a small amount of funding to secure messaging vendors to support their efforts to update their software to be SMD‑compliant, and to test it with the solutions of other market participants. NEHTA announced that the Secure Message Delivery – Proof of Inter‑connectivity and Deployment (SMD‑POD) project would “provide financial assistance to secure messaging vendors to provide proof that standardsbased secure messaging can be deployed in a scalable way”. By February 2013, under the new eHealth PIP requirements, general practices needed to obtain Healthcare Identifiers, a NASH PKI certificate, establish a written policy to “encourage the use of standardscompliant secure messaging” and engage a software vendor to install and configure a secure messaging solution listed on the
eHealth Product Register before the end of August 2013. Owing to the large amount of work this entailed for both practices and their software vendor, the latter deadline was ultimately pushed back by three months to the end of October. Despite the intervening six months since the eHealth ePIP deadline passed – and the much greater time period since SMD was first announced – at the moment it is difficult to identify many cases outside of testing environments in which messages are being transmitted using SMD technology. While several software vendors have developed SMD-capable solutions, the vast majority of message traffic is still being handled through their legacy channels. This is not surprising, with SMD depending on many underlying pieces of technology outside the control of individual companies, such as the Healthcare Identifier Service and its Healthcare Provider Directory, PKI certificates, interfaces to clinical software, as well as some level of access to the various software vendors’ customer address books. These technical considerations, coupled with the complexity of the commercial decisions secure messaging vendors must make in relation to SMD, make it unclear as to when this technology will start to be adopted in a meaningful fashion.
DEVELOPMENT PROBLEMS DOG NASH In March 2011, IBM Australia was awarded $23.6 million to build the National Authentication Service for Health (NASH), one of the foundations of the national eHealth system. In what has become a chequered journey, that first attempt at NASH failed, with Medicare Australia having to come to the rescue. Even now, however, problems remain.
KATE MCDONALD Journalist: Pulse+IT firstname.lastname@example.org
It is a characteristic perhaps of the rushed nature of the roll-out of the PCEHR that IBM’s deadline for the delivery of the National Authentication Service for Health (NASH) was a mere week before the actual system went live to consumers. As it turned out, IBM failed to deliver, the reasons for which have never been publicly explained and which remain under the cloak of confidentiality agreements. That wasn’t necessary a reason for halting the launch of the PCEHR, as clinicians couldn’t use the system on July 1 anyway, but it did point to a rocky road ahead for NASH. Highlighted by NEHTA in a 2011 blueprint as one of the foundations of a national eHealth system, secure, trusted authentication is essential to ensure only those qualified to access medical information can do so. DHS/Medicare was not asked to design a solution despite managing a Public Key Infrastructure (PKI) enabled authentication system for online claiming for some years, the reasoning being that Medicare’s location certificates are often used by more than one clinician. At the time of the PCEHR build, they were not supported by a smart card management system (SCMS). While Medicare’s PKI location certificates were being used for secure messaging, according to NEHTA’s blueprint there was
no national identity credential available that could be properly used to support NEHTA-compliant secure messaging standards. In 2011, NEHTA issued a tender for an external organisation to build NASH, subsequently awarding the $23.6 million contract to design, build and operate NASH to IBM. Little else was heard until NEHTA CEO Peter Fleming was forced to confirm on June 18, 2012, that NASH would not be ready for the launch of the PCEHR on July 1. In October that year, NEHTA confirmed it had “terminated” the contract with IBM. In the meantime, arrangements were put in place to provide an interim NASH through Medicare. NASH certificates began to be issued in late August to healthcare providers and organisations who had registered for the system. These certificates enabled authorised clinicians to access the PCEHR through conformant clinical software, which ironically had not yet been rolled out. Medicare also began to develop a NASH token for clinicians to access the PCEHR through the provider portal. These tokens were aimed at allied health professionals and some hospital-based doctors who did not have conformant software or who were accessing the system from different
organisations, as well as contracted service providers (CSPs).
Secure messaging NASH is important not just for accessing the PCEHR and using secure messaging but as the authentication system for a range of applications, including access control systems, client server applications, enterprise applications, identity management systems, operating systems, single sign-on and web services applications. When Medicare’s interim solution was rolled out, it was only for access to the PCEHR. However, with the inclusion of secure messaging as one of the five requirements of the eHealth Practice Incentives Program (ePIP), the certificates were also required to authenticate users of SMD. In late November 2012, NEHTA announced that the interim NASH certificates could now be used for secure messaging via compliant SMD products. This caused a bit of a rush for many practices to apply not just for NASH but to get registered as an HPI-O in the first place, according to former NEHTA clinical lead Mukesh Haikerwal. He in fact applied for a location-based NASH certificate as well as an individual certificate to access the provider portal, as part of his job at the time was to travel the country demonstrating the system to other clinicians. Dr Haikerwal is happy to go on the record to say that he far prefers the functionality and look of the provider portal to the view he gets through his clinical software, a position supported by other clinical leads who resigned from NEHTA in August 2013 along with him, including Trina Gregory, Nathan Pinskier and Kean-Seng Lim. Dr Haikerwal is also happy to openly criticise the bureaucratic hurdles to GPs wanting to use the system. For example,
“The NASH project is over six years old, and yet they are still going backwards. It’s tragic.” Steve Wilson
the NASH tokens for individual access to the provider portal were only issued for one year, and when informed that his was about to expire, he was also told that the only way to apply for a new one was by fax or post. Unlike PKI certificates for Medicare Online, NASH certificates cannot be renewed automatically through clinical software. As it turns out, hardly anyone is using the provider portal. According to figures from the Department of Health, 5154 individual NASH PKI certificates have been issued as of December 31, 2013, but actual log-ins to the portal using the certificates number less than a hundred a month. The department says that between January and mid-February this year, an average of 15 provider portal log-ins per week were observed. In January this year, for example, 36 providers accessed the provider portal.
NASH going backwards Stephen Wilson, a digital identity and authentication expert and principal analyst at Constellation Research, describes asking individual clinicians to renew NASH certificates by fax as “bizarre”, saying it showed the six-year long NASH project was going backwards. Mr Wilson believes renewal is part of a deeper problem. “Healthcare practitioners shouldn’t need to do any renewal, by fax or email or anything,” he says.
He believes a relationship certificate system should have been used, linked to the Australian Health Practitioner Regulation Agency (AHPRA), which also acts as the “source of truth” for the HPI-I element of the HI Service. “NASH certificates should be relationship certificates, defined by the AHPRA database,” Mr Wilson says. “A NASH certificate could be automatically renewed so long as the holder is still current with AHPRA. This is what AHPRA is for, so it’s nuts that certificate holders have to do anything at all.” He also says the NASH project had taken so long it seems the wheel is being reinvented. “NEHTA do not seem aware of PKI best practice. They are not making best use of this technology at all. The NASH project is over six years old, and yet they are still going backwards. It’s tragic.” Dr Pinskier says the problems with the NASH system were apparent some years ago, and that an automatic verification system should have been established. “Medicare already has a huge community of providers who were already identified and verified,” Dr Pinskier says. “Why couldn’t they use that for the NASH cert? “Basically you should have been able to log on to HPOS, identify who I am and say I want a NASH certificate. That would have happened had the NASH portal ever got up. That was part of the original planning but it never came to fruition.”
THE EVOLUTION OF
E-PRESCRIPTIONS IN AUSTRALIA The electronic transmission of prescriptions (ETP) market has been steadily evolving in Australia for over five years, with the last 12 months in particular seeing tremendous growth in usage. With the plumbing now in place, ETP can be used as a key platform for the delivery of effective electronic medications management programs.
DAVID FREEMANTLE General manager, enterprise solutions Fred IT Group email@example.com
So what is electronic transmission of prescriptions? ETP is the secure transmission of prescription information between doctors and pharmacists with the key benefits being: • Improved quality and safety of medication provision • Improved efficiency, particularly in pharmacy dispensing workflow • Reduced potential for errors of transcription • Creating a foundation essential to the wider eHealth system. ETP has been resounding proof that the medical software industry can work together to quickly deliver quality outcomes, with all of the major doctor and pharmacy vendors having integrated to ETP.
About the author David Freemantle is general manager for enterprise solutions at Fred IT Group, which developed and operates eRx Script Exchange. David was also responsible for managing the development of the National Prescription and Dispense Repository (NPDR), which is being rolled out throughout the country.
The creation of an integrated healthcare platform connecting doctors and pharmacists creates great potential to further enhance the communication between these members of a patient’s care team. The ETP platform has established a national infrastructure integrating health professionals in every corner of the nation to better communicate and share clinical information for the benefit of the patient. Australia’s first prescription exchange service, eRx Script Exchange, was officially
launched in 2009 and has grown steadily since that point. With approximately 83 per cent of pharmacies and 65 per cent of doctors across Australia using the service, eRx is now transacting an average of five million medications transactions per week or over 220 million original and repeat prescription dispensing messages per annum. There are currently two prescription exchanges active in the Australian ETP market: eRx Script Exchange and MediSecure. With the push towards an integrated eHealth environment, the development of a model of interoperability between the two prescription exchange services was an important step. Released in December 2012, the interoperability model allows for ePrescriptions sent to either prescription exchange service to be dispensed no matter which system the pharmacy uses where the patient presents. With the ETP infrastructure well established, there is enormous potential over time to support future eHealth concepts such as a paperless prescription process. In given scenarios, paperless prescribing is considered a significant driver of efficiency gains and clinical benefits.
Change management With the introduction of these eHealth technologies, as is repeatedly seen in eHealth, the change management implications for the users of the systems continue to be complex. Ongoing change management activities involve such things as: • Demonstrating clear benefits to both pharmacists and doctors involved • Demonstrating the safety benefits for patients as a key driver for doctors and pharmacists to use ETP • Working closely with pharmacists to adapt their dispensing workflows to scan the barcodes on the scripts presented • Investigating value adding processes utilising the ETP infrastructure as a means of further demonstrating the importance of widespread usage. One of the key findings from the development and deployment of ETP over the last five years is that there are no short cuts to changing behaviours, and driving uptake requires taking a long-term view and significant patience. Success requires approaching such projects as a significant change management exercise where the technical, procedural, legal, administrative, stakeholder incentives and political components of the project all need to be aligned. Significant and effective investment in change management will more often than not be the determining factor in whether or not such systems are utilised effectively.
Incentives for use Two key user initiatives to help drive ETP usage include the ETP being established as one of five requirements for GPs to receive their eHealth Practice Incentive Payment (ePIP) and the recent announcement by the Pharmacy Guild of Australia and the
“With approximately 83 per cent of pharmacies and 65 per cent of doctors across Australia using the service, eRx is now transacting an average of five million medications transactions per week.” David Freemantle
Department of Health of the Electronic Prescription Scanning Incentive Scheme (ePSI).
information was consolidated into patient histories from pharmacies, medical clinics and Barwon Health for the first time.
ePSI will be paid to pharmacies based on achieving particular rates of scanning ePrescription barcodes. These incentives continue to drive positive results in terms of both user numbers and scan rates.
This information is then viewable by authorised health providers including community pharmacists and doctors, hospital pharmacists and doctors and health practitioners within associated aged care facilities.
Whilst ETP provides both clinical and efficiency benefits, it is also becoming a key platform for the delivery of effective electronic management of medications (eMM) programs. eMM has long been seen as a vital service within the primary, acute care and aged care sectors. With the establishment of prescription exchange services over recent years, particularly within the community care setting, the ability to provide consolidated medications histories for consenting patients is fast becoming a reality.
National repository As one of the PCEHR Wave 2 projects, Fred IT Group was contracted to build MedView to provide medications histories for consenting patients. It was based initially on eRx Script Exchange and the Geelong Hospital (Barwon Health) providing prescription and dispense records. Focused initially in the Barwon region of Victoria, medications
Fred was later contracted to transition this concept to the PCEHR under the name of the National Prescription and Dispense Repository (NPDR). The roll-out of the NPDR continues with recruitment of pharmacies undertaken by Medicare Locals. Several general practice software vendors, including Genie, Zedmed, Communicare and Best Practice have now released versions enabling GPs to view the NPDR through their software. The current PCEHR review findings will be eagerly awaited by many as the outcome will determine future roll-out and implementation plans. What is certain is that the significance of the national eHealth infrastructure that is now in place should not be lost on anyone. One thing is for sure: there are wide and varying views on what has been built and how it was built, but fundamentally the
infrastructure or “plumbing” is now in place.
Decision support Moving ahead, significant benefits could be gained from the PCEHR and other eHealth infrastructure. To further enhance these benefits, developing the ability of end-point systems such as prescribing and dispensing systems to use PCEHR atomic data for effective and real-time decision support would be game changing. Relatively simple tools to enable automated alerts for interactions and allergies could be within reach, and the associated development of curation tools to provide a
level of analysis of the data presented could add significant benefit to individuals and the health system by providing better quality of care. Electronic medications management was identified in the original PCEHR business case as the source of approximately 60 per cent of the financial benefits from the PCEHR. These benefits come primarily from the reduction of hospitalisations and deaths due to medications misadventure. A 2010 study by Booz & Co, titled Optimising eHealth Value, came up with this startling finding: in Australia, 138,000 hospital admissions every year are a result of adverse drug events and it has been
estimated that up to 18,000 die as a direct result. eMM can be a major part of delivering enormous social, clinical and financial benefits to the health system and the community and whilst this certainly isn’t an instant fix, great progress has been made and will continue in the future. ETP has achieved great results and continues to gather momentum. This success will help to enable the journey towards paperless prescriptions and effective electronic medications management, further cementing medications at the centre of Australia’s eHealth future.
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IMPLEMENTING SNOMED CT ISSUES AND OPPORTUNITIES
SNOMED Clinical Terms (SNOMED CT) is a clinical terminology that has been endorsed as the preferred national terminology for Australia. The Australian extension, SNOMED CT-AU, is slowly being implemented in Australian clinical IT systems, but it is a complex exercise that is still in its early stages.
ASSOCIATE PROFESSOR HEATHER GRAIN A.Dip MRA, RMRA, GDIS, MHI, FACHI Director and chief development officer, eHealth Education firstname.lastname@example.org
SNOMED CT: is it just another code system, a nuisance to implement, a challenge for mapping to and from my system? Well, yes, it is these things, but also much, much more. It is the key to achieving the benefits of eHealth systems. Getting the benefits of SNOMED CT in our systems is more than simply using SNOMED CT codes; it requires more sophistication than this to gain major benefits and to accurately use SNOMED CT in our EHRs. Some facts: computers are able to do magical things but they are only as good as the instructions they are given. Computers need three things to support clinical decision systems: • Computer interpretable representation of meaning, provided by SNOMED CT • Knowledge-based rules represented using SNOMED CT • Computer systems which can interpret and query the meanings in SNOMED CT.
About the author Heather Grain is an internationally recognised consultant in eHealth and electronic health records. She is vice chair of the IHTSDO education special interest group, convenor of ISO WG3 semantic content, and vocabulary co-chair of HL7.
SNOMED CT provides interpretable meaning as each ‘code’ used is defined by relationships to other ‘codes’. For example, ‘196609006 – Barrett’s ulcer of oesophagus’ is defined by the following concepts (each of which a computer can query):
It is a: • Barrett’s oesophagus • Ulcer of oesophagus Has associated morphology of: • Metaplasia Has finding site of: • Oesophageal mucous membrane structure Has associated morphology of: • Ulcer Has binding site of: • Oesophageal structure There is no other clinical condition that has this definition (unless that condition is a sub-type of Barrett’s ulcer of oesophagus). This definitional structure supports computer queries such as: • Find all ulcers • Find all conditions of the oesophageal mucous membrane • Find all conditions with metaplasia morphology • Or combinations of these. SNOMED CT also identifies ‘children/ parent’ relationships between terms. For example, a computer can develop a rule which is to apply to all conditions of
“SNOMED CT relationships and structures can be used to build rules to trigger action and decision support.” A/Prof Heather Grain
oesophageal ulcer. This would include a wide range of conditions such as: • • • •
Barrett’s ulcer of oesophagus Bleeding ulcer of oesophagus Gastro-oesophageal erosion Gastro-oesophageal reflux disease with ulceration • Infective ulcer of oesophagus (and many more conditions).
Codes and meanings Electronic health record systems which record SNOMED CT need to indicate the version of SNOMED CT used and to bind the concept to the information model in order to ensure meaning is retained over time. For example, if the SNOMED CT concept ‘hearing difficulty’ (162340000) is recorded in a person’s diagnosis field, the meaning is that at that time, the individual was diagnosed as having a hearing difficulty. If recorded in the field Family History, the meaning intended is quite different. SNOMED CT relationships and structures can be used to build rules to trigger action and decision support. This use case has computer software applying queries to the health record and SNOMED CT databases to apply knowledge inherent in SNOMED CT definitions. For example, the ability to build a rule using SNOMED CT has the advantage that the rule can indicate all concepts which
are children of (include the definitional component) ulcer of the oesophagus without having to list every possible code which meets this criteria. The result of this functionality is the ability to build rules with confidence and less effort, and rules that are maintainable. If a new condition is determined to be an ulcer of the oesophagus in SNOMED CT, the rule does not have to be re-written as the new condition automatically still meets the rule requirement. The knowledge inherent in SNOMED CT allows a properly structured and implemented SNOMED CT-enabled query to apply the rule without ongoing maintenance efforts.
Levels of implementation These are simple examples of SNOMED CT’s quite extensive functionality, which is much more complex than can be described here. However, most implementations of SNOMED CT in Australia are still emerging and are not able to leverage this functionality.
to query them in any way. This means that these systems are not able to leverage any of the functionality of SNOMED CT at all. Implementation: Level 1 Includes SNOMED CT codes but does not have query facilities to establish equivalence or subsumption (the functionality required to deliver the most commonly required benefits of implementing SNOMED CT). These systems may have limited subsumption testing, or the ability to store postcoordinated expressions. This is usually the first step to implementation. Implementation: Level 2 Includes full equivalence, and subsumption queries as well as the ability to manage SNOMED CT release files, implement and manage reference sets, maps, navigation and other special functions of SNOMED CT. The most common approach to achieving this level of implementation around the world is to use a Common Terminology Service (CTS). HL7 has CTS version 2 standards with which software should be compliant if your organisation wishes to build to Level 2 implementation functionality.
Australian implementations Australian implementations are generally at Level 1, though work is being done by some Australian vendors and researchers to develop further into Level 2 functionality.
The International Health Terminology Standards Development Organisation (IHTSDO) has identified levels of implementation based upon the functionality the implementation can deliver. Table 1 outlines a simplified version of these implementation issues.
Examples of SNOMED CT in use in Australia include the Sydney Adventist Hospital’s development of a SNOMEDenabled allergies list that is mapped to brand and generic names for medications through the Australian Medicines Terminology (AMT). The Alfred Hospital and Austin Health are also in the early Level 1 implementation stage.
Implementation: Level 0 Is unable to record SNOMED CT codes or
General practice systems are at the very early implementation stage, generally
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“Australian implementations are generally at [Level 1] of implementation, though work is being done by some Australian vendors and researchers to develop further into Level 2 functionality.” A/Prof Heather Grain
limited to mapping ICPC-2-PLUS codes to SNOMED CT. A mapping project has been undertaken by the Family Medicine Research Centre (FMRC) at the University of Sydney, which developed the ICPC-2PLUS codes. Some that don’t use ICPC2-PLUS codes, such as Best Practice Software, which uses its own coding system, are also mapped to SNOMED CT.
software vendors and healthcare providers of all types, but it is not simple and does require a strategy to obtain the right tools and build understanding in the organisation if implementation is to be safe. Selecting the right ‘code’ to represent meaning is not always easy or straight forward and is a very different skill from ICD coding, for example.
In summary, SNOMED CT is an exciting terminology product which can provide significant long-term advantages to
Health informaticians need to encourage decision-makers to understand that as electronic health records develop, we need
to put quality SNOMED CT content into them or the effect of poor terminological practice can lead to health record errors, which can effect patient care for years into the future. The skills needed to safely implement SNOMED CT in our systems are not well understood. A set of foundation competencies have been developed and skill specifications for technical implementation, and clinical governance are in draft specification.
Table 1: Implementable functions of SNOMED CT Functionality
The ability of a computer system to test to see if one concept is actually the same as another. Concepts change over time, and may be constructed through representation of the information model using two codes: Family History of (57177007) Backache (161891005) is the same as Family history of backache (429976008)
Ability for a computer system to identify that concept A is a type of Concept B
Ability of a computer system to represent and determine the meaning of a concept which is represented by using more than one code
Ability to add additional codes when needed in the organisation. This means that the software product/s must be able to manage a local namespace for SNOMED CT over time as SNOMED CT develops and provides mechanisms to represent concepts initially only local
SNOMED CT content has significant, managed and quality controlled international governance in place
CDA USE IN THE PCEHR: LESSONS LEARNED One of the key foundations of the PCEHR is that the Clinical Document Architecture (CDA), an XML-based mark-up standard developed as part of HL7 v3, is used for all the clinical documents used in the PCEHR. This article does not purport to evaluate the PCEHR program itself, nor even how the PCEHR program used CDA, but to simply describe the lessons learned from using CDA for the PCEHR.
GRAHAME GRIEVE FACHI Consultant, Health Intersections firstname.lastname@example.org
Why did the PCEHR program use CDA? In May 2007, NEHTA published a document called Standards for E-Health Interoperability: An E-Health Transition Strategy. The purpose of this document was to recommend a standards approach for a broad range of eHealth information interchange requirements, with a particular focus on a national approach to shared electronic health records. This document rated the advantages and disadvantages of the following four approaches: extending existing use of HL7 v2 as far as possible; a document/ services-centric HL7 v3, based on CDA plus services defined by HL7 (HSSP); CEN 13606; and openEHR. It was a summary of a much larger document that assigned scores for each of these based on a series of criteria. The second option â€“ CDA plus web services â€“ got the highest score (although all the scores were close), and was therefore selected as the preference.
About the author Grahame Grieve is an internationally recognised expert in healthcare standards and interoperability. He consults to NEHTA, HL7 and the ISO, and is the CDA expert for the PCEHR. In 2011, he developed the Fast Healthcare Interoperability Resources (FHIR) framework, now a draft standard.
When the PCEHR project was initiated, this preference became the basis for the general architecture. The HSSP part was replaced by IHE XDS because by then, IHE had published XDS.b, which was based on a web services architecture. CDA was a late comer to the NEHTA work program. For several years prior to the
adoption of the CDA strategy, NEHTA had been working with stakeholders, including jurisdictions, professional colleges, and vendors, to describe a set of information exchanges (information models, and the services that supported them) that had been identified as providing the key opportunities for improving healthcare through better exchange. These identified packages had their own rich consultation and analysis history, and an existing methodology was used for describing and publishing these analyses. Today, these are published by NEHTA as the Core Information Components and the Structured Content Specifications. These specifications describe the logical contents of the document in a form that is independent of CDA, and therefore reusable in other formats and contexts. Within the PCEHR program, then, CDA is seen as a technical vehicle for exchanging/ persisting a logical package of data that conforms to pre-existing stakeholder agreements.
Lessons learned Now that the first round of the PCEHR implementation is nearly complete, there are a few lessons that we can learn about CDA.
1. Document challenges Because of the way that the specifications are produced, the documentation stack that accompanies the CDA specifications is large. Not only does it include the CDA specification stack published by HL7, which already has multiple layers, but there are also the parallel stacks and layers through which the exchange packages are described (see table). In addition to these, there are conformance specifications to read. In practice this meant that implementers needed to read many thousands of pages of documentation in order to implement the CDA documents correctly. Further, the information they needed was spread across the various specifications, and it was not obvious where to look. Later, FAQs were published in response to implementation experience, adding even more documentation. Given the tight timelines of the PCEHR program in practice, this meant the CDA documents were prepared by implementers who were drowning in the documentation and significant rework was often required. Also, the sheer size of the documentation and the relationships between the layers means that the full stack is not completely aligned – there are a few small and subtle but important differences between the many layers, and the possibility and existence of these added to the size of the problem.
Lesson: When using CDA (or anything else), make the documentation easy to read and navigate. Do not assume prior knowledge, and make it as short and flat as possible. 2. Complexity and resilience The underlying CDA documents are based on an abstract grammar (the HL7 RIM) which presented an ongoing challenge through the project. CDA uses a simplified subset of the full grammar, which presented challenges during the specification development process; apparently simple clinical perspectives often turned into complex grammatical statements. This same simplified grammar proved to be an ongoing challenge in complexity during the implementation phase. Rather than simply stating their meaning directly, implementers would have to figure out how their meaning should be stated in a very unfamiliar language. The CDA implementation guides attempted to resolve this as much as possible, but had only a limited success in this regard. In addition to the CDA implementation guides, the PCEHR program also provided software libraries and a thorough conformance testing regime to assist implementers to create quality implementations, and these are largely responsible for the successful implementation of the CDA side of the project.
Lesson: CDA is both too simple, and too complex. Adoption requires expertise, and policies and tools to leverage that expertise as much as possible. 3. Narrative versus data A central feature of CDA documents is that they contain three parts: • A header that describes what’s in the document, who the patient is, who wrote it, etc • A “narrative” that presents the information to a human (if you aren’t familiar with CDA, you can think of this bit like a Word or PDF document) • Structured “data” that a computer can process (e.g. like a database). This implies that the clinical content in the document is duplicated – once for human readers, and once for computers. An obvious result of this arrangement is that it’s possible that the narrative might say something different to the data – and, in fact, this is common: • The narrative will contain words typed by a human for which there is no data representation • The data will contain extra supporting information that is not included in the narrative because it’s a summary. However, it’s also possible that they might disagree with each other, which would be a problem – a real safety issue, in fact.
Table 1: Clinical Document Specifications Business
Data types (Abstract & XML)
Core Information Components (CIC)
Detailed Clinical Models (DCMs)
Structured Content Specification (SCS)
Vocabulary CDA specification Packaging, Rendering
“In practice, after two years of implementation experience, what we have observed is that some third of the documents first submitted for PCEHR conformance testing have disagreements between the narrative and the data.” Grahame Grieve
A human reading the document would understand things one way, but a human reading a computer extraction of the document would see something else. This concern was raised by Eric Browne before implementation started, but in theory this should not be a problem. If the CDA documents are properly constructed, the information should not disagree. The CDA implementation guides made rules about the relationship between the narrative and the data. In practice, after two years of implementation experience, what we have observed is that some third of the documents first submitted for PCEHR conformance testing have disagreements between the narrative and the data. In all cases, these issues do represent mistakes by implementers (see the previous lesson), and, in fact, the duplication has actually acted as a very useful way to check the quality of the implementations. Lesson: The presence of both narrative and data means that you can do much better checking of the implementations. However, it also means that you need to. Note: this narrative/data pattern is not only found in CDA – it’s also found in the Australian pathology v2 messaging standard – which suggests that additional
quality and safety checking may be merited in this context too. 4. Narrative quality and consistency The NEHTA specifications focused exclusively on the data content of the clinical documents, and the content of the narrative was left to the discretion of the implementers. This happened because the stakeholders were unable to come to agreement about making rules for the narrative, and also because it was not known at the start of the program what the technical constraints on the narrative generation process would be. As the PCEHR unfolded, it became clear that this was a mistake – implementers did not devote sufficient attention to the quality of the narrative, and as the implicit data inconsistencies (see next lesson) became apparent as the project developed, the importance of the narrative became more clear. In the current PCEHR implementation, all of the displayed clinical content comes directly from the document narratives (except for the generated content in the NPDR summary view), but this narrative was never specified by the PCEHR specifications. Once it became clear that this was problematic, some suggested guidance around the narrative was
prepared, but this was published too late to affect most implementations, and was never enforceable. In practice, this meant that conformance testing was able to raise issues about narrative quality, but implementers were not required to fix them, and many chose not to given the timeline-related issues. Problems with the narrative have subsequently been raised in public, and are an ongoing source of issues for the PCEHR program. Lesson: CDA specifications need to be specific about how the clinical narrative should be presented, as this is the most important part of the document. 5. Data inconsistencies The narrative/data pattern had an unexpected consequence for the PCEHR program, and it certainly didn’t appear in the previously referenced NEHTA analysis. The underlying assumption of the PCEHR, as described above, was that all systems would implement the information components as agreed with the stakeholders, and data would flow freely between the different systems. However, in practice, most systems contained content that differed from that agreed with the stakeholders – they had different fields, different terminologies, and different workflows. Given the timeframe of the overall project, few systems were in a position to perform the fundamental re-design needed to align with the specifications in the data fields; instead, they simply produced a CDA document that was as near to the published specification as possible. CDA made this possible, because the basic mode of operation throughout the PCEHR and connected systems is to display the CDA narrative. This means that it mostly doesn’t matter if there isn’t perfect alignment with the specifications.
“CDA specifications need to be specific about how the clinical narrative should be presented, as this is the most important part of the document.” Grahame Grieve
This meant that: • The PCEHR was actually possible within the accelerated time frame of the overall project • Many of the projected benefits did not materialise because the data is not sufficiently aligned. The PCEHR program is still adjusting to this outcome. Lesson: the CDA narrative/data pattern allows for interoperability in the presence of poor agreement about the underlying data (whether this is a good thing depends on your perspective). The existence of the narrative/data pattern means that a thorough conformance testing framework is required to ensure quality. 6. Coding problems The representation of codes from terminologies in the CDA documents has proven one of the more difficult parts of the program. The underlying CDA data representation for coded values has many subtleties, and nearly 100 per cent of all CDA documents first submitted for conformance testing have contained errors in the representation of coded values. (The only documents that haven’t are ones that contained no clinical codes at all). These issues were addressed during the implementation process, but the high error rate shows that it is a difficult problem.
Many implementations found the whole coding process too difficult for a variety of reasons, and ended up submitting documents that simply contain text for some fields instead of a coded value, even though they use coded values internally. It was anticipated that systems would use SNOMED CT and AMT, or at least map their codes to these terminologies, in the interest of providing clinical functionality, but this only happened in a few cases. Lesson: the implementation community in Australia still has a long way to go before we have mastered the exchange of codes from terminologies. 7. CDA versus the alternatives The original decision to use CDA with XDS was a close call. From the beginning, there have been sections of the stakeholder community that wished for a different decision, and some of them have continued to discuss this in public. Had some other approach than CDA plus XDS been chosen, the PCEHR project may have unfolded quite differently. The documentation and syntactical complexity may have been less, but the fundamental problems around the data/narrative pattern and lack of clinical alignment would still have occurred, and the community’s lack of maturity with regard to terminologies would still have been an issue.
Further, the PCEHR program represented a significant increase in the complexity of the information exchanged, and the expectations made from it; a solid conformance testing framework would still have been required irrespective of the approach chosen, and given the time frame, there is no reason to think that the outcomes of the conformance process would have been very much different. Lesson: Syntax is less important than content. Interoperability can only fully meet business goals when there is substantial business alignment.
Conclusion The PCEHR program has given us an opportunity to see CDA in use in this country. It hasn’t always been pretty, but it has worked. The PCEHR program had aggressive timelines, but this is a natural feature of any implementation program Although CDA worked for the project, we’ve learnt that it’s hard work; significant implementation assistance and conformance checking is required. We’ve also learnt that some of the reasons we needed these things were unrelated to the choice of CDA, but reflect inherent difficulties in the problem itself. Finally, although CDA “worked” for the PCEHR, one of the underlying drivers for the original choice of CDA was the clinical value in more precise and welldefined information content. However, the combination of the complexities of CDA and underlying lack of clinical consensus around record keeping mean that the clinical value has not eventuated. CDA may yet prove to be the right vehicle for capturing more precise and well-defined clinical information, but much work remains to be done in many areas before this goal will be achieved. References for this article will be made available online.
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IT’S ALL ABOUT THE DATA Interoperable EHRs are the holy grail of eHealth, but most remain a closed shop. The development of archetypes – discretely defined clinical concepts – and the sharing of them through a Clinical Knowledge Manager (CKM) such as that hosted by NEHTA and used to inform the PCEHR, and in clinical use in the Northern Territory, means real interoperability is possible.
DR HEATHER LESLIE MB BS, Dip.Obs (RACOG), FRACGP, FACHI Director of Clinical Modelling, Ocean Informatics firstname.lastname@example.org
Electronic health records (EHRs) have been around for over 30 years now, but it is still hard to share information between health software programs. Traditionally, we have had vendors develop electronic health record software applications created entirely from scratch ‘in house’. Each one has been proprietary and the result has been a data structure that is unique for each software application. The data within each vendor EHR are effectively silos of health information, with clinical content as simple as blood pressure represented differently in each system. Interoperability – the ability to unambiguously share health information between different EHR systems – has been elusive.
About the author Dr Heather Leslie practiced for 15 years as a GP before taking up full-time work in health informatics. She is the director of clinical modelling at Ocean Informatics, and the clinical program lead at the openEHR Foundation. Heather has advised national eHealth programs in Australia and Europe, and provided training here and overseas.
As a means to bridge the gap between each EHR, for more than a decade there has been a gradual growth in the development of agreed, standardised messages, documents and/or profiles. Each of these have been mapped or transformed from the EHR’s proprietary data patterns to the agreed data pattern, so that they can be sent to other healthcare providers or exchanged with other EHR systems. This solution has enabled some success in simple health information sharing, mostly documents or reports such as discharge summaries or pathology results.
The downside to this approach is that each document or message can take years to reach consensus, so the process is effectively glacial and the amount of information available for sharing is limited to the sole purpose of these documents or messages. The unresolved question is whether this is a scalable approach as we want to share greater amounts of health information in finer granularity, and whether this is sustainable. In order to try to change this paradigm, there has been a slowly emerging international approach to provide clinical leadership for defining the clinical data patterns, rather than leaving it to each vendor to ‘reinvent the wheel’. This has originated from over 20 years of research and development into electronic health records, and has been championed by the openEHR Foundation In the openEHR approach, clinical data patterns are known as archetypes. The development of archetypes is cliniciandriven to ensure that the data patterns represent the clinical data we require for direct patient care, health information exchange, clinical decision support, research data aggregation and analysis and population health. Clinicians are starting to have some control over the data, potentially overturning the traditional, vendor-driven approach.
“An archetype is a computable specification for a single, discrete clinical concept – clinicians are critical in ensuring that the archetype is fit for clinical purpose.” Dr Heather Leslie
Defining clinical concepts An archetype is a computable specification for a single, discrete clinical concept – clinicians are critical in ensuring that the archetype is fit for clinical purpose. Each archetype is a pattern for the clinical data. Examples include pulse, blood pressure, symptom, medication order, and allergy or adverse reaction. Archetypes in combination with terminologies, such as SNOMED CT and LOINC, provide a very powerful approach for us to record, store, exchange and use unambiguous clinical data. Implementers can then use them within their EHR systems – sometimes the native archetype and other times after transformation into other technical formalisms, such as XML. Internationally there is a community of clinicians and other domain experts who are collaborating on the development of a library of archetypes and making them freely available for use by anyone. It is a method to generate the ‘little data’ – the finely granular clinical data that we need to record, store, exchange and use – and ensure it is high quality. The more systems that utilise a single data pattern, as defined by the clinical archetype, the more potential for interoperable health data. The openEHR Clinical Knowledge Manager (CKM) is used
as an online tool that collects a library of the archetypes, supports collaboration of clinicians and other experts to ensure that the archetypes are high quality, and provides a governance process for the archetypes.
CKM in action The international openEHR Clinical Knowledge Manager (CKM) is used as an online tool that collects a library of the archetypes, supports collaboration of clinicians and other experts to ensure that the archetypes are high quality, and provides a governance process for the archetypes. As of early March 2014 there are over 1100 experts registered on the openEHR CKM from 83 countries, with many archetypes translated into multiple languages to enable cross country sharing of health data. There are no barriers to participation, and anyone interested can volunteer to join in archetype reviews or submit a candidate archetype to the community. Trained editors and CKM administrators facilitate the archetype reviews and ensure that archetypes in the CKM work together as a cohesive pool, minimising the gaps between archetype concepts as well as any potential overlaps between archetypes. Australia also has a CKM, hosted by NEHTA. This CKM was initially used
to gather some clinical feedback on archetypes that were then transformed into the CDA messages used by primary care software vendors to send documents to the PCEHR. Many of these archetypes are re-used in an infection control system by Queensland Health and a care planning application in use by Western Sydney Medicare Local. Most recently, the Northern Territory Department of Health (NT DoH) has used the Australian CKM and archetypes as an approach to get clinician consensus on the data patterns required for a number of projects, including shared antenatal care and the hearing health components of the iCareNet project. Archetypes are re-used wherever possible for the two clinical specialties to ensure that the data is collected in a common way. Specialised archetypes have been developed to represent specific antenatal and hearing data and the clinicians who will be entering data into these systems when they are completed have been participating in archetype reviews to make sure the data patterns implemented in the EHRs represent the data they need for patient care, sharing, research and reporting. Kathy Currie, project manager for the Hearing Health Information Management System (HHIMS) for NT DoH, coordinated the team of audiologists, community coordinators, ENT surgeons and nurses to participate in the development of the data patterns for the HHIMS software. Initially, a practising audiologist and a clinical modeller worked together to create first draft versions of the hearing-specific archetypes. The hearing team participated in reviewing the archetypes online – a Hearing Health project was set up within the NEHTA CKM.2 This avoided the need for face-to-face meetings, which is onerous given the nature of their day-to-day work in remote NT locations.
Each clinician was then able to participate in an online review round at a time and location that best suited their work and home commitments. Over a series of rounds, each archetype pattern was refined to the point where clinicians agreed that the data representation of their clinical work was ready to be implemented in the building of their EHR. A similar process was used to develop templates which use groupings of the archetypes to represent the documents and reports that were required in the HHIMS software application “The archetypes were developed collaboratively using our team’s combined clinical expertise,” Ms Currie says. “The end result is high quality data patterns which will underpin better patient
treatment decisions, care coordination and accurate reporting without duplication of data entry. “At the end of the archetype and template review process, it was pleasing to see the sense of ownership of the data by our participating clinicians. They had specified the very data that they needed to collect, they knew the purpose of each data element and how it would be used. Some were even prepared to stand up and defend it when external vendors thought they knew better!”
International interoperability There are similar efforts happening internationally, with national CKM
collaboration occurring in Norway and Slovenia, a number of grassroots projects in the UK, and a vendor consortium in Russia developing an EHR for the City of Moscow. This maximises the ability for these data patterns to be re-used and shared internationally. A donation of an archetype that has been funded by one organisation is offset by being able to feely re-use other donated archetypes. This evolving culture of sharing clinical data patterns has the potential for significant disruption in the eHealth ecosystem. A library of freely available archetypes is the foundation for a clinically led data roadmap that can underpin local, national and international efforts in sharing health data.
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big insights: harnessing the power of health data
ACSS AAPM P: 1800 196 000 / +61 3 9095 8712 F: +61 3 9329 2524 E: email@example.com W: www.aapm.org.au The Australian Association of Practice Managers (AAPM) is a not for profit, national peak association founded in 1979, dedicated to supporting effective practice management in the healthcare sector. The Australian Association of Practice Managers: • Represents practice managers and the profession of practice management throughout the healthcare industry. • Promotes professional development and the code of ethics through leadership and education. • Provides specialised services to support quality practice management including advocacy, education, resources, networking, advice and assistance.
ACIVA E: firstname.lastname@example.org W: www.aciva.org.au The Aged Care IT Vendors Association (ACIVA) was formed in early 2010, a not-for-profit organisation, incorporated in NSW. ACIVA represents the residential aged and community care sectors and vendors at various national forums regarding strategic developments and eHealth. ACIVA members are residential aged and community care software vendors, industry benchmarking software, financial software, call-bell, hardware, networking, infrastructure and industry partners. Members are committed to furthering the interests of residential aged and community care in national forums to ensure eHealth and access to the personally controlled health record (PCEHR) becomes a reality for the aged care industry in the very near future. Contact: Emma Pate email@example.com
P: 1300 788 005 / +61 2 9632 0026 F: +61 2 9632 0096 E: firstname.lastname@example.org W: www.acsshealth.com ACSS provides innovative and customisable patient management software streamlining day-to-day operations for GPs, Allied Health, Specialists, Radiologists, Pathologists, Private and Public Hospitals. eClaims® — Comprehensive and robust appointment and billing system with digital/voice recognition capabilities, electronic reporting transmissions and HL7 PACS system integration. eClaims® Hybrid — A solution tailored to Hospitals and other health service providers including billing agents who lack online capabilities. eClaims® Hybrid is the interface solution for connecting you to Medicare and health funds through ECLIPSE. SimDay® — Proven PAS (Patient Administration System) specifically designed for day surgeries and private hospitals – Now with ECLIPSE integration.
P: +61 3 5335 2220 F: +61 3 5335 2211 E: email@example.com W: www.argusdca.com.au
P: +61 3 9023 0800 F: +61 3 9614 2650 E: firstname.lastname@example.org W: www.precedencehealthcare.com
Argus provides and supports Argus secure messaging software; a popular electronic solution that enables healthcare practitioners to exchange many forms of patient related information securely and reliably and to Australian standards.
cdmNet is the gold standard for managing chronic disease in Australian GP clinics.
Argus interfaces with most clinical software applications sending directly from within your letter writing facility or word processor and runs virtually invisibly in the background. Documents sent using Argus can be automatically added to electronic patient records; thus avoiding the need to scan or manually file them.
cdmNet helps practices take a systematic approach to the management of their chronically ill population. It simplifies collaboration with the care team and ensures regular follow up and review.
Argus is the messaging solution chosen by many Medicare Locals through the ARGUS AFFINITY program delivering eHealth strategies across Australia. With over 17,000 users Argus continues to grow in popularity by delivering highly secure messages, a reliable product, backed by outstanding customer service all at the lowest cost possible.
P: 1300 308 531 F: +61 3 9797 0199 E: email@example.com W: www.advantech.net.au
The medical range extends through: • Point-of-Care Terminals. • Mini-PC and Medical Imaging Displays. • Mobile Medical Tablets. • Computerised Medical Carts. • Patient Infotainment Terminals. Advantech is also an official distributor of Microsoft Windows Embedded software across Australia & New Zealand.
cdmNet eliminates paperwork and makes compliance with Medicare requirements easy. It increases the productivity of the entire practice and allows evidence-based care to be delivered to all chronically ill patients. If you wish to use cdmNet to provide high quality care for all your chronically ill patients while increasing your revenues, contact us now. • See cdm.net.au/evidence
Cerner Corporation Pty Limited
Advantech’s medical computing platforms are designed to enhance the quality and efficiency of healthcare for patients and users alike. All of Advantech’s medical PCs match the performance of commercial PCs but are medically rated to UL/EN 60601-1 third revision, IPX1 drip‑proof enclosures and are designed to suit ward and theatre based applications. Advantech offers long term availability and support plus a proven track record of reliability.
University trials show cdmNet results in improved quality of care and better patient outcomes.*
Best Practice P: +61 7 4155 8888 F: +61 7 4153 2093 E: firstname.lastname@example.org W: www.bpsoftware.com.au Best Practice sets the standard for GP clinical software in Australia offering a flexible suite of products designed for the busy GP practice, including: • Best Practice Clinical (“drop-in” replacement for MD) • Integrated Best Practice (Clinical/ Management) • Best Practice Automatic SMS reminders Visit us at the following conferences throughout the year: • • • • •
BP Summit, 14-16 March GPCE Sydney, 23-25 May RDAQ Brisbane, 6-8 June GPCE Brisbane, 12-14 September RACGP Adelaide, 9-11 October
P: +61 2 9900 4800 F: +61 2 9900 4990 E: AsiaPacific@cerner.com W: www.cerner.com.au Cerner is one of the leading global suppliers of health care information technology solutions. Cerner’s mission is to contribute to the systematic improvement of health care delivery and the health of communities. Our vision of proactive health care management drives innovation in the development of effective solutions for today’s health care challenges, while creating a foundation for tomorrow’s health populations. Working with more than 4000 clients worldwide, Cerner is solving health care’s many challenges making sure the right people have the right information at the right time. Our innovative leadership is allowing us to push boundaries by: • Leveraging clinical and pharmaceutical data in Condition Management and Personalised Medicine • Connecting the community with personal and community health records
CONNECT DIRECT Pty Ltd Clintel Systems P: +61 8 8203 0555 E: email@example.com W: www.clintel.com.au The Specialist: A complete solution for your Appointments, Billing including Online Claiming and Clinical requirements in an intuitive scalable solution. Clintel provides systems to Specialist and Day Surgeries nationally. Powerful, highly configurable and easy to use, our systems mirror the needs and workflow of your practice and individual specialty. Our industry standard SQL database enables a true “paperless” practice. Our leading edge architecture is future proof, it is designed to meet changing requirements and offers first class reporting and analysis of clinical and business data. Standalone or networked multi-site installation which runs on both Mac OSX and Windows operating systems. Our support is first class, our philosophy is “whatever it takes”.
Cutting Edge Software P: 1300 237 638 E: firstname.lastname@example.org W: www.cesoft.com.au Cutting Edge produces affordable, intuitive billing solutions for Mac, Windows, Linux and iPad. Cutting Edge is ideal for practitioners who prefer to maintain control of their own billing from a number of sites. Cutting Edge Software is approved by Medicare Australia to manage your electronic: • Verification of Medicare and Fund membership • Bulk Bill and Medicare claims • DVA paperless claims • Inpatient claims to Health Funds We have solutions tailor-made for: • Anaesthetists • Surgeons/Surgical Assistants • Physicians • GPs • Allied Health The software comes with up-to-date schedules for MBS/Rebate, Gap Cover (all registered health funds), Workers’ Compensation, Transport Accident authorities and DVA.
Cloud9 Software P: 1300 875 297 F: +61 2 9715 6573 E: email@example.com W: www.c9s.com At Cloud9 we understand the complexity of healthcare. We understand the importance of having the right information available when and where it’s needed. So Cloud9 created an eco-system to connect healthcare providers that supports the availability of key information to improve outcomes for the patient, clinician and organisation alike. An information infrastructure with real-time access across primary, community and acute setting benefits Clinicians trying to provide the best care for individuals as well as Researchers looking to improve safety and effectiveness of treatments. Our e-Health infrastructure has been designed to fit in with your current systems, whilst Cloud9’s next generation administrative and clinical applications allow you to upgrade existing systems as your business grows. Cloud9 Solutions: • Cloud9 Spine, Health Information Exchange • Synchronicity, Application Integration Suite. • Clarity for GP’s and Specialists. • Clarity Hospital Information System.
Digital Medical Systems P: 1300 865 977 F: +61 3 9753 3049 E: firstname.lastname@example.org W: www.dgs.com.au EASIER MEDICAL IT is a technology partnership with DMS – we make IT work for you. DIGITAL MEDICAL SYSTEMS has provided ICT solutions and services to medical practice clients across Australia since 1990. We have specialist expertise and experience in the installation and support of all Australian leading medical software applications. DMS is a Business Partner for IBM, LENOVO, HP, CISCO and Microsoft. Other leading ICT brands include Webroot Secure Anywhere, StorageCraft, CA, Toshiba, Canon, Epson, Kyocera, Fujitsu and Brother. Accreditation is easier with the customised DMS IT Systems Policy and Procedures Documentation. This ensures your practice has the best IT policy, security and maintenance program that meets and exceeds the standards guidelines from the RACGP.
Direct CONTROL is the innovative answer to administrative excellence integrating with Microsoft Office, accounting applications, the OOP, clinical applications and Medicare Online. Included are all fee schedules (Medicare, DVA, Work Cover, TAC, CTP, Private Health Insurance) with built in rules relevant to each medical discipline (Allied Health, General Practice, Surgeons, Physicians including Oncology, Anaesthetists, Pathologists, Radiologists, Day Surgeries/Hospitals). Manage Episodes of Care including State, Federal and Health Fund Statistical Reporting for Day Surgeries/ Hospitals. Restructuring work flow with Direct CONTROL guarantees to provide remarkable results, enabling you to grow your business and increase cash flow.
World leading DTech provides 24x7 near Real-Time Monitoring and Management technologies sends alerts and enables our engineers to quickly troubleshoot and remotely solve problems fast of security, network, Internet, server and software on almost any client computer system or device – most are fixed in minutes… Proactive, Flexible, Consistent, Reliable, Audited, and Affordable - for the smallest to the largest practice. Call DMS for: • Systems Analysis, Solutions Design & Consulting • IT Systems Documentation for Accreditation & Compliance • Procurement & supply of leading brand hardware, software, network and peripheral products • Full Installation & Configuration services • On-Site and Remote Technical IT Support • 24x7 IT support Help Desk with extensive medical software expertise • 24x7 DTech Monitoring, Maintenance & Management • Disaster Recovery solutions • Fully managed Online Backup customised for clinical data • Fully managed Internet and Web Security EASIER MEDICAL IT – Call 1300 865 977
P: 1300 557 550 / +61 7 5478 5510 F: +61 7 5478 5520 E: email@example.com W: www.directcontrol.com.au
Doctors Control Panel E: www.pracsoftutilities.com W: PSU_admin@pracsoftutilities.com • Download and trial DCP software for GP’s and health teams. • DCP is your digital PA and guidelines advisor. • DCP facilitates TCA, GPMP and MHCP creation and tracking. • Contains guidelines licenced from RACGP. • Low annual subscription. • The best preventive care add-on software in Australia. • Compatible with MD3 and BP. • Achieve new heights in preventive care performance. • Significant benefit for patients. • Increase your revenues. • Streamline your workflow. • 3000 current users. • Several research projects based on DCP. • Try it today.
Emerging Systems P: +61 2 8853 4700 E: firstname.lastname@example.org W: www.emerging.com.au/ehealth Emerging Systems is a market leader of healthcare information and integration technology solutions. Our eHealth products and services have supported clinicians in leading Australian public and private hospitals for over a decade to deliver safe, quality healthcare. The award-winning EHS Clinical Information System is a modular, patient-centric system providing a wide range of clinical functionality to track, record and monitor patient care from pre-admission to discharge creating a multi-disciplinary EMR - improving clinical communication and patient flow while reducing patient risk. PCEHR Compliant. EHS Clinical Mobility Solution further enhances multi-disciplinary clinical communication. Emerging Systems provide clients with a full range of tailored IT services including Consultation and Managed IT Services.
Extensia P: +61 7 3292 0222 F: +61 7 3292 0221 E: email@example.com W: www.extensia.com.au Extensia links healthcare providers, consumers and their communities for better and more efficient health care. The products used to do this can be custom branded for all Organisations and include: • RecordPoint – a proven Shared Electronic Health Record that links all clinical systems, hospital settings, care plan tools and any other sources of information available. It provides a secure means of sharing critical patient data in a privacy compliant and logical structure. • EPRX – an Electronic Patient Referral Exchange and Directory. It streamlines the process of selecting a provider and completing a referral. Patient information is transferred seamlessly from clinical software. The most relevant providers, services and products are presented instantly and referral documents are generated and sent electronically.
GPA P: 1800 188 088 F: 1800 644 807 E: firstname.lastname@example.org W: www.gpa.net.au GPA ACCREDITATION plus (GPA) is the only independent accreditation program for general practice in Australia. Established in 1998 and run by a team of committed general practitioners, business leaders and experienced administrators, GPA has developed a program that continuously evolves in order to set new standards in general practice accreditation, while offering full support to practices to make accreditation both achievable and rewarding.
P: +61 2 8985 6688 / 1300 799 904 E: email@example.com W: www.episoft.com.au
GPA is committed to providing an accreditation program, which is flexible and understands the needs of busy GPs and practice support staff. Whilst accreditation gives practices access to the Practice Incentive Program (PIP), GPA believes it should offer benefits that go well beyond the PIP. Our program provides practices with a pathway to enhanced patient care, continuous professional satisfaction, improved practice efficiency and superior risk management. GPA ACCREDITATION plus certificates and signage remind patients that their practice has achieved a level of care and service above and beyond essential general practice standards.
EpiSoft’s web based platforms deliver dual purpose systems that work as comprehensive clinical and practice management platforms together with clinical trials software facilitating multi-centre investigator initiated trials. EpiSoft has developed platforms for: • Mental Health • Cancer management & surveillance • Inflammatory Bowel Disease • Hepatitis • Indigenous chronic disease management • Asthma shared care • Specialised surgery • Pre-admissions patient portal
GPA provides a system designed to accommodate busy general practices. Among our services, we offer practices the opportunity to use technologicallyadvanced, environmentally-friendly online programs, allowing staff to upload documentation at their own pace; individually assigned client managers, supporting practices through accreditation from start to success and beyond; highly-trained and sensitive surveyors, with extensive experience in all facets of general practice; and interactive training seminars, bringing practices the latest information in standards and innovation.
Affordable and scalable, EpiSoft is used in health organisations ranging from small clinics to large hospital groups across Australia, New Zealand and Singapore. Create multidisciplinary teams, collaborate effortlessly and streamline workflows with our intuitive cloud software. With the highest level of security, redundancy and reliability your data will be accessible anytime and anywhere.
Genie Solutions P: +61 7 3870 4085 F: +61 7 3870 4462 E: firstname.lastname@example.org W: www.geniesolutions.com.au Genie is a fully integrated appointments, billing and clinical management package for Specialists and GPs. Genie runs on both Windows and Mac OS X, or a combination of both. With over 2800 sites, it is now the number one choice of Australian specialists.
At GPA, we believe that accreditation should be an accomplishment, not a test, and we uphold that belief in our approach and service. For an accreditation program that will offer you assistance, support, information and satisfaction…the choice is yours.
Health Communication Network P: +61 2 9906 6633 F: +61 2 9906 8910 E: email@example.com W: www.hcn.com.au Health Communication Network (HCN) is the leading provider of clinical and practice management software for Australian GPs and Specialists and supplies Australia’s major hospitals with online Knowledge resources. HCN focuses on improving patient outcomes by providing evidence based software tools to health care professionals at the point of care. Market snapshot: • 17,000 medical professionals use Medical Director • 3,600 GP Practices use PracSoft • 800 Specialist Practices use Blue Chip and • 2,100 Specialists use Medical Director • Leading suppliers of Knowledge Resources to Australia’s major hospitals
Health Informatics New Zealand E: firstname.lastname@example.org W: www.hinz.org.nz Health Informatics New Zealand (HINZ) is a national, not-forprofit organisation with a focus on collaboration, education and advocacy for the use of IT in the health sector. HINZ enables professional collaboration through conferences, seminars and an interactive online portal, bringing together clinicians, administrators, allied health professionals and many others with an interest in health IT and the advances it can enable. HINZ provides a platform to share information about the Health Informatics industry - leveraging best practice from New Zealand and overseas, as well as facilitating networking activities to bring industry experts and interested parties together to collaborate. Membership is for anyone with an interest in Health Informatics.
Health Informatics Society of Australia P: +61 3 9326 3311 F: +61 3 8610 0006 E: email@example.com W: www.hisa.org.au HISA is Australia’s health informatics organisation. We have been supporting and representing Australia’s health informatics and e-health community for almost 20 years. HISA aims to improve healthcare through the use of technology and information. We: • Provide a national focus for e-health, health informatics, its practitioners, industry and a broad range of stakeholders • Support, promote and advocate • Provide opportunities for networking, learning and professional development • Are effective champions for the value of health informatics HISA members are part of a national network of people and organisations building a healthcare future enabled by e-health. Join the growing community who are committed to, and passionate about, health reform enabled by e-health.
HealthLink P: 1800 125 036 (AU) P: 0800 288 887 (NZ) E: firstname.lastname@example.org W: www.healthlink.net Transforming healthcare by connecting healthcare providers. Australia and New Zealand’s most effective secure communications service. • NEHTA compliant Secure Messaging Delivery (SMD) services • Fully integrated with leading GP and Specialist clinical systems • Referrals, Reports, Forms, Discharge Summaries, Specialists, Diagnostic Orders and Reporting • Affords all healthcare providers efficiencies in reducing paper based handling • Expert partnerships with Healthcare organisations, State and National Health Services • HL Connect for Allied Health, Telehealth and Aged Care Providers • Working with Medicare Locals Australia-wide for eHealth delivery Join HealthLink and connect with more than 85 % of Australian GPs and 99% of NZ GPs who are already part of the HealthLink community.
InterSystems P: +61 2 9380 7111 F: +61 2 9380 7121 E: anz.query@InterSystems.com W: www.InterSystems.com InterSystems is a global leader in software for connected care, with headquarters in Cambridge, Massachusetts, and offices in 25 countries. InterSystems TrakCare® is an Internet-based unified healthcare information system that rapidly delivers the benefits of an electronic patient record. InterSystems HealthShare® is a strategic platform for healthcare informatics, enabling information exchange and active analytics across a hospital network, community, region or nation. InterSystems CACHÉ® is the world’s most widely used database system in clinical applications. InterSystems Ensemble® is a platform for rapid integration and the development of connectable applications. InterSystems’ products are used by thousands of hospitals and laboratories worldwide, including all of the top 15 hospitals on the Honor Roll of America’s Best Hospitals as rated by U.S. News and World Report. For more information, visit InterSystems.com
MEDITECH Australia P: +61 2 9901 6400 F: +61 2 9439 6331 E: email@example.com W: www.meditech.com.au A Worldwide Leader in Health Care Information Systems MEDITECH today stands at the forefront of the health care information systems industry. Our products serve well over 2,300 health care organisations around the world. Large health care enterprises, multi‑hospital alliances, teaching hospitals, community hospitals, rehabilitation and psychiatric chains, long-term care organisations, physicians’ offices, and home care and hospice agencies all use our Health Care Information System to bring integrated care to the populations they serve. Our experience, along with our financial and product stability, assures our customers of a long-term information systems partner to help them achieve their goals.
Medtech Global Ltd P: 1800 148 165 E: firstname.lastname@example.org W: www.medtechglobal.com
For over 30 years, Medtech Global has been a leading provider of health management solutions to the healthcare industry enabling the comprehensive management of patient information throughout all aspects of the healthcare environment.
P: 1800 420 066 (AU) P: 0800 401 111 (NZ) E: email@example.com W: www.houstonmedical.net
Health Information Management Association of Australia P: +61 2 9887 5001 F: +61 2 9887 5895 E: firstname.lastname@example.org W: www.himaa2.org.au The Health Information Management Association of Australia (HIMAA) is the peak professional body of Health Information Managers in Australia. HIMAA aims to support and promote the profession of health information management. HIMAA is also a Registered Training Organisation conducting, by distance education, “industry standard” training courses in Medical Terminology and ICD-10-AM, ACHI and ACS clinical coding.
“We provide time to health professionals through efficient practice management software” Our multidiscipline software provides interfaces to every major manufacturer, enabling many clinics to save space by becoming completely paperless! We are a progressive medical software company and take pride in working with our health care clients to deliver tailored EMR and PMS packages based on each unique situation and practice requirements. We’re focused on helping to make their businesses more efficient and productive as well as delivering measurable improvements in customer satisfaction and market share. You can arrange a free demonstration of our software by visiting: www.HoustonMedical.net
Leecare Solutions P: +61 3 9339 6888 F: +61 3 9339 6899 E: email@example.com W: www.leecare.com.au Leecare Solutions, with their products Platinum 5 & P5 Exec, are the aged care industry’s leading web browser based clinical and management software system. Since 2000, Leecare has provided relevant, contemporary software solutions for Australian and New Zealand aged care organisations. Leecare’s mission and products provide outstanding clinical decision making support, and management support tools that use any device, can be installed on multiple platform types and in any location. Used in over 30,000 aged care places, it is the solution used by quality providers, proven through thousands of accreditation, validation and other regulatory visits, as it is based on professional clinical and lifestyle provision concepts.
Medtech’s Medtech32 and Evolution solutions improve practice management and ensure best practice for electronic health records management and reporting. Clinical Audit Tool integrates with Medtech32 and Evolution providing fast, efficient and secure analysis of patient data enabling practices to identify and deliver services, which address health care priorities across their population. Medtech’s ManageMyHealth patient and clinical portal enables individuals to access their health information online and engage with their healthcare provider to support healthy lifestyle changes.
MIMS Australia P: +61 2 9902 7700 F: +61 2 9902 7701 E: firstname.lastname@example.org W: www.mims.com.au MIMS Australia is built on a heritage of local expertise, credibility and adaptation to changing healthcare provider needs. Our information gathering, analysis and coding systems are proven and robust. MIMS information is backed by MIMS trusted, rigorous editorial process and constantly updated from a variety of sources including primary research literature. Our database and decision support modules are locally relevant, clinically reviewed and updated monthly and compatible with a host of clinical software packages. Indeed, the majority of Australian prescribing packages and many dispensing applications are supported by the MIMS medicines data base. MIMS is delivered all the ways you need – print to electronic, on the move, to your patient’s bedside or your consulting room desk. Whatever the format, MIMS has the latest information you need.
Orion Health P: +61 2 8096 0000 / +64 9 638 0600 E: email@example.com W: www.orionhealth.com Orion Health is New Zealand’s largest privately owned software exporter and a global leader in eHealth technology. Founded in 1993, by CEO Ian McCrae, Orion Health has grown from a specialist health integration vendor into a company that sells a comprehensive suite of eHealth solutions. Orion Health has extensive experience in the design and installation of complex systems within demanding healthcare environments. Orion Health designers and engineers work right alongside in-house clinicians in order to develop elegant and intuitive products that encourage swift adoption with minimal disruption, allowing your clinicians to focus on patients. Today, our products and solutions are currently implemented in more than 30 countries, used by hundreds of thousands of clinicians, and help facilitate the care for tens of millions of patients.
OzeScribe P: 1300 727 423 F: 1300 300 174 E: firstname.lastname@example.org W: www.ozescribe.com.au
MITS:Health P: 1300 700 300 E: email@example.com W: www.mitshealth.com.au Managed IT Services for the Health Industry MITS:Health provides a full range of IT services specifically tailored for medical centres, GPs and specialists across Melbourne. • • • • • •
Equipment supply and installation Remote monitoring and support Data backups Networking Internet Website Development
OzeScribe is the dictation and transcription solution for most Australian university teaching hospitals and major private clinics. It really does make sound business sense to let OzeScribe worry about managing dictation, transcription and technology. We provide free electronic document delivery – OzePost – to your EMR and your associates’ EMR, saving you thousands of dollars in time, packing and postage. OzeScribe is the provider of the most advanced solutions available. • Run by doctors – for doctors. • Australian trained typists. • Manage dictation and transcription via computers, iPhone, iPad, android or smartphones. • Integrated M*Modal speech recognition technology on demand.
PicSafe Medi P: +61 3 9670 9339 E: firstname.lastname@example.org W: www.picsafe.com Designed by Australian and US Dermatologists and Plastic Surgeons to be used by a wide range of healthcare professionals working in a variety of clinical settings, PicSafe Medi (patented-provisional) is as simple as using the normal camera function on your mobile smart device except... your patient’s PicSafe Medi photo is completely secure and legally compliant in its consent, transmission, and storage. Both iOS and Android compatible, PicSafe Medi simultaneously suffices patient privacy-related government regulatory requirements (including new Federal APP’s (12th March, 2014) surrounding the capture, use, and storage of medical photographs. Using PicSafe Medi, all healthcare professionals can now quickly connect and efficiently document a patient’s status pictorially, facilitating the medical referral process and, ultimately, improving patient outcomes and satisfaction. Stored clinical photographs are fully patientconsented (including authorization for specific usages of their photo), watermarked to assure authenticity, and managed in a highly secure, auditable, private server environment, accessible only to authenticated PicSafe users. From the time you take a patient’s photo with a smart device, to the encrypted transmission and secure storage phases of photo handling, the process is seamless and non-intrusive to both photographer and patient. • Increase your efficiency and improve your patients’ clinical outcomes • Remove the worry surrounding costly patient privacy breaches • Assure quick, efficient pictorial documentation of your patient’s status • Facilitate a streamlined medical referral process • Fully document your patient encounters for billing, auditing, and medical-legal purposes PicSafe-Medi is “the missing link” in compliant mobile clinical photography.
Precision IT P: 1300 964 404 F: +61 2 8078 0257 E: email@example.com W: www.precisionit.com.au • Cloud Computing Specialists. • Onsite Medical IT Support. • VoIP Telephone Systems and Internet Connectivity. • IT Equipment Procurement. • Experience with all clinical & practice management software packages. • Sydney, Brisbane, Gold Coast and Melbourne. Precision IT is a highly competent and impeccably professional IT support firm with a primary focus on working with GPs and Specialists. Working with our clients, we develop reliable, robust and feature rich IT systems to meet the demands of the modern medical practice today and into the future. Our Precision Cloud service is fast becoming the choice for new and established practices and covers all of the standard guidelines from the RACGP and AGPAL and GPA. Talk with us today about the future of your practice!
Professional Transcription Solutions P: 1300 768 476 E: firstname.lastname@example.org W: www.etranscriptions.com.au Australia’s Most Trusted Teaching Hospital and Private Practice Transcription Provider • Web-based - Dictate and receive reports anywhere • Double-edited with over 99.5% accuracy • Fast turn-around within 24 - 48 hours, as required • All medical and surgical specialities covered in Australia’s largest teaching hospitals • Rapid documentation of recorded HR interviews, Research and Expert Reports • Guaranteed cost savings • Data held securely at a State Government owned data centre • Call our friendly staff anytime for your overflow, backlog or all of your typing or data entry requirements • Call us now for a no obligation free trial
Shexie Medical System P: 1300 743 943 F: 1300 792 943 E: email@example.com W: www.shexie.com.au Shexie is an Australian owned business which has been developing software for medical practices for over 15 years. Our industry and technical knowledge allows us to provide the ultimate ‘easy to use’, ‘fully functioned’ and ‘robust’ product on the market. Shexie Medical System clinical and practice management software is ideal for surgical or specialist practices of any size. Many fully integrated features including Paperless Office, SMS, full Paperless Electronic Claiming including Eclipse, MIMS Integrated, statistical analysis, security, synchronize appointments with Outlook/PDAs, transcription interface, diagnostic equipment interface, automated MBS/Fund rates updates. Soon to be released Shexie Platinum version also contains eHealth - Health Identifiers, PCEHR and Secure Messaging.
Sysmex P: +61 3 9013 4445 E: firstname.lastname@example.org W: www.sysmex.com.au Sysmex is dedicated solely to helping your healthcare organisation achieve more in less time, with fewer errors and better patient outcomes. Sysmex leads the way in eDiagnostics: • Providing an essential building block for the electronic medical record with the Eclair Clinical Information System • Enabling sharing of key patient information across regions through the Eclair Clinical Data Repository • Completing the electronic loop with laboratory and radiology order request management (CPOE) • Streamlining all areas of the anatomical pathology laboratory workflow from request to report with Delphic AP • Improving reporting times and reducing costs through an enterprise Delphic LIS, shared across multiple laboratories
Totalcare Stat Health Systems (Aust) P: +61 7 3121 6550 F: +61 7 3398 5064 E: email@example.com W: www.stathealth.com.au Stat Health Systems (Aust) has built a progressive and resilient system that introduces a new level of stability and flexibility to the medical software market. Stat is an integrated clinical and practice management application which has embraced the latest Microsoft technology to build a new generation solution. Fully scalable and the only medical software application to incorporate a multi-functional intuitive interface, Stat is at the forefront of computing technology. Stat incorporates all eHealth requirements as per the NEHTA specification. Stat Health provide a premium support service, clinical data conversion from existing software and tailor made installation and training plans for your practice. Facebook: facebook.com/StatHealth Twitter: @NotifyStat
P: +61 7 3252 2425 F: +61 7 3252 2410 E: firstname.lastname@example.org W: www.totalcare.net.au Totalcare is a fully integrated Clinical, Office and Management software suite designed to suit the particular needs and processes of healthcare providers. Used since 1995 by health care facilities across Australia including General and Specialist practice, Radiology, Day Surgery and Hospitals, Totalcare is stable, scalable, customisable and easy to learn and use. From a small practice to a multisite, multi-disciplinary corporate entity or hospital, Totalcare can provide solutions for your needs. • • • • • • • •
Admissions / Appointments Billing Statutory Reporting Integrated SMS Prescriptions Orders & Reports Clinical Notes Letter/Report Writing, Document and Image Management • Scanning and Barcode recognition • Video and Image Capture • HL7 Interfaces
Therapeutic Guidelines Ltd P: 1800 061 260 E: email@example.com W: www.tg.org.au Therapeutic Guidelines Limited is an independent not-for-profit organisation dedicated to deriving guidelines for therapy from the latest world literature, interpreted and distilled by Australia’s most eminent and respected experts. These experts, with many years of clinical experience, work with skilled medical editors to sift and sort through research data, systematic reviews, local protocols and other sources of information, to ensure that the clear and practical recommendations developed are based on the best available evidence. eTG complete Incorporates all topics from the Therapeutic Guidelines series in a searchable electronic product, and is the ultimate resource for the essence of current available evidence. It provides access to over 3000 clinical topics, relevant PBS, pregnancy and breastfeeding information, key references, and other independent information such as Australian Prescriber (including Medicines Safety Update), NPS Radar, NPS News and Cochrane Reviews. eTG complete is available in a range of convenient formats – online access, online download, CD, and intranet access for hospitals. Multi-user licences, ideal for a practice or clinic, are also available. It is widely used by practitioners and pharmacists in community and hospital settings in all Australian states and territories. The March 2014 release of eTG complete includes updates of further Endocrinology topics, including disorders of bone and calcium homeostasis, and adrenal disorders. miniTG The mobile version of eTG complete is miniTG, (in offline format), offering the convenience of vital information at the point of care for health professionals who practise and consult on the move. It is supported on a wide range of mobile devices, including Apple®, Pocket PC®, and selected Blackberry® devices.
VIRTUAL CONSULTING ROOMS
VConsult P: 1300 82 66 78 F: 1300 66 10 66 E: firstname.lastname@example.org W: www.vconsult.com.au VConsult offers outsourced practice management solutions for medical and allied health practitioners allowing the focus to be on your professional practice and patient care. VConsult provides a seamless “behind the scenes” service by professionally managing your telephone calls, reception, invoicing and medical transcription requirements. VConsult is perfect for your practice if you are: • Setting up, already established or winding down in Private Practice • Working in a public appointment and want to portray a professional image • Looking to minimise your overhead costs • Requiring your patient calls to be answered by a professional and experienced medical receptionist.
Zedmed P: 1300 933 000 F: +61 3 9284 3399 E: email@example.com W: www.zedmed.com.au At Zedmed, we provide general practice, specialist and allied health clinics with turnkey software solutions for their most common practice needs. We’re committed to producing best in class products and services and are consistently striving to provide additional value-added products and services to help practices work more profitably and efficiently, so our customers can focus on delivering patient care. Zedmed - Focused Innovation.
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Quality improvements and clinical risk management Clinical governance and patient identification Education and training Human resources and OH&S Management of health information Business continuity plans Triage
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