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PULSE IT 

AUSTRALIA’S FIRST AND ONLY HEALTH IT MAGAZINE

ISSUE 7: FEBRUARY 2008

SPECIALIST COMPUTING


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Publisher Pulse Magazine PO Box 7194 Yarralumla ACT 2600 ABN 19 923 710 562 www.pulsemagazine.com.au Editor Simon James 0402 149 859 simon.james@pulsemagazine.com.au

COVER STORY: SPECIALIST COMPUTING PAGE 30

Sub-Editor Erica McLellan Editorial Enquiries editor@pulsemagazine.com.au Advertising Enquiries ads@pulsemagazine.com.au About Pulse+IT (ISSN: 1835-1522) Pulse+IT is produced by Pulse Magazine, the most innovative publisher in health. With a total circulation exceeding 23,000, Pulse+IT is not only the largest Health IT publication in Australia, but one of the highest circulating health publications of any kind. 15,000 copies of Pulse+IT are distributed to GPs, specialists, practice managers and the IT professionals that support them. In addition, over 8,100 copies of Pulse+IT are distributed to key IT decision makers in hospitals, day surgeries and aged care facilities. Contributors Matthew Antcliff, Dr Paul Cooper, Andy David, Heather Hunt, Simon James, Dr Ronald McCoy, Dr David More, Chris Paine, Glenn Stephens and John Stewart. Non-Commercial Supporting Organisations Australian General Practice Network (AGPN), National E-Health Transition Authority (NEHTA), The Royal Australian College of General Practitioners (RACGP). Disclaimer The views contained herein are not necessarily the views of Pulse 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 Magazine has no affiliation with any organisation, including, but not limited to Health Services Australia, Sony, CMP Medica or the Kimberley Aboriginal Medical Services Council, all who produce publications under the title “Pulse”. Copyright 2008 Pulse Magazine 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.

PAGE 10 BITS & BYTES Pulse+IT’s expanded eHealth news section, delivering the latest developments from Australia and around the globe.

PAGE 26 EVENTS CALENDAR Up and coming Australian and international Health, IT, and Health IT events.

PAGE 40 EMR and CLINICAL TRIALS Andy David highlights the benefits of linking Clinical Trials with Electronic Medical Records.


CCeH and AHML PAGE 34

RECRUITING PAGE 36

SUSTAINABLE IT PAGE 38

DECISION SUPPORT PAGE 44

REGULARS PAGE 06 STARTUP Editor Simon James introduces the seventh edition of Pulse+IT. PAGE 08 GUEST EDITORIAL Dr David More reports on the BCG review into NEHTA, and NEHTA’s response to its recommendations. PAGE 10 BITS & BYTES Pulse+IT’s expanded eHealth news section, delivering the latest developments from Australia and around the globe.

PAGE 22 AGPN Matthew Antcliff outlines the Top End Division of General Practice’s eHealth initiatives.

PAGE 26 EVENTS CALENDAR Up and coming Australian and international Health, IT, and Health IT events.

PAGE 23 NEHTA Heather Hunt overviews the National eHealth Transition Authority’s program for 2008.

PAGE 28 INTERVIEW: ZEDMED Pulse+IT checks in with Zedmed’s Clinical Director, Dr Andrew Pascoe.

PAGE 24 RACGP Dr Ronald McCoy discusses the importance of General Practice IT research and education.

PAGE 48 MARKET PLACE Australia’s most innovative and influential eHealth organisations.

FEATURES PAGE 30 SPECIALIST COMPUTING Simon James presents the first article in a series dealing with IT issues relevant to Specialists and their staff.

PAGE 36 HEALTH IT RECRUITING Chris Paine suggests organisations looking for staff should take a closer look in their backyard before looking abroad.

PAGE 34 CCeH and AHML Simon James checks in with the Collaborative Centre for eHealth and the Australian Healthcare Messaging Laboratory.

PAGE 38 SUSTAINABLE HEALTH IT Dr Paul Cooper encourages healthcare organisations to consider the positive benefits of going green with their IT.

PAGE 40 EMR and CLINICAL TRIALS Andy David highlights the benefits of linking Clinical Trials with Electronic Medical Records. PAGE 44 DECISION SUPPORT Glenn Stephens outlines a modern decision support framework.

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STARTUP Simon James BIT, BComm Editor, Pulse+IT simon.james@pulsemagazine.com.au

Pulse+IT: 2008.1 Welcome to the seventh edition of Pulse+IT, Australia’s first and only Health IT magazine. Regular readers will note that the magazine has received a design overhaul since our November edition. While we hope our readership will find this new look more aesthetically pleasing, the primary motivation for the style change was to provide us with a more versatile layout capable of accommodating articles of a variety of shapes, sizes and technical complexities. The best example of this new style direction can be seen towards the front of the magazine in our revamped and significantly expanded Bits&Bytes news section. More in-depth technical articles will still be a major feature of Pulse+IT going forward and constitute most of the second half of this edition.

PULSE+IT ONLINE RAMPS UP Not to be outdone by its printed sibling, the Pulse+IT website has also been redesigned to improve both the appearance and functionality of the site. As part of this refresh, an online events calendar has been added, and the site’s banner advertisement positions have been brought in-line with the Interactive Advertising Bureau (IAB) standards. As has always been the case, all content from all printed editions of Pulse+IT is available at our website. After a tentative start last year, the Pulse+IT eNewsletter service is now in full swing. Each Tuesday, a collection of original Health IT articles and links to relevant third party content will be distributed to our eNewsletter subscriber list, with a view to keeping our readership up-to-date on Australian Health IT developments between releases of our quarterly magazine. The Pulse+IT eNewsletter service is free and we encourage all readers of our magazine to sign up via our website.

PARTNERSHIPS FORGED The past few months have been a busy time for Pulse+IT behind the scenes, with several important partnerships being established. Firstly, the Australian Association of Practice Managers (AAPM) has committed to circulating this and all future editions of Pulse+IT to their entire membership base, a welcome

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THIS EDITION In addition to a significant news section, this edition contains organisational contributions from the Australian General Practice Network (AGPN), the National eHealth Transition Authority (NEHTA), and the Royal Australian College of General Practitioners (RACGP). An interview with Dr Andrew Pascoe, Zedmed’s Clinical Director, is also included, as are feature articles covering Decision Support, IT Sustainability, Health IT Recruiting, Clinical Trials and Electronic Medical Records, the Collaborative Centre for eHealth and the Australian Healthcare Messaging Laboratory. Our cover story on specialist computing, the first article in a four part series, rounds out this edition. I would like to thank all editorial contributors to this edition, namely Matthew Antcliff, Dr Paul Cooper, Andy David, Heather Hunt, Dr Ronald McCoy, Dr David More, Chris Paine, Glenn Stephens and John Stewart. Their collective contribution to this edition has allowed us to compile what is undoubtedly the most diverse edition of Pulse+IT to date. The next edition of Pulse+IT will be sent to subscribers in early May. As always, in the run up to this edition, I look forward to your suggestions and feedback. Simon James, Editor simon.james@pulsemagazine.com.au

Subscription packages to Pulse+IT start at just $99.

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initiative that will ensure that one of private practice’s key IT decision making groups has ongoing access to timely and relevant IT information. The Health Informatics Society of Australia (HISA) has appointed Pulse+IT as its official media partner for its 2008 Health Informatics Conference (HIC), which will commence in late August in Melbourne. As the largest informatics and Health IT conference on Australia’s calendar, this event is one we are very proud to be associated with. Pulse+IT has also been awarded media partner duties for IQPC Event’s forthcoming Electronic Health Record and Data Management Conference to be held in Sydney in April. For more information about each of these conferences, please refer to the events calendar on page 26 of this edition of Pulse+IT, or visit the events calendar on our website.

For more information about Pulse+IT and our special iPod subscription offer, turn to page 25.

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GUEST EDITORIAL Dr David More MB, PhD, FACHI, is an independent Health Information Technology consultant and blogger who has been working in the e-Health domain for over twenty years. He is concerned with the lack of clinician and patient focus in much of what is happening in e-Health in Australia. davidgm@optusnet.com.au

Where to next for NEHTA? Very late December, 2007 the National E-Health Transition Authority (NEHTA) released a report developed by the Boston Consulting Group (BCG) reviewing NEHTA’s performance since establishment. A response to the BCG report, prepared by NEHTA, was released on the same day. The ‘BCG NEHTA Review’ had been finalised in October 2007 and the NEHTA response on December 6, 2007. If it was not for reasons of media management in immediate proximity to the Christmas holiday period, the reason for the delayed release of the two documents remains unclear. That there was a long congratulatory piece1 published in association with the document’s release would lend some support to that view. Delayed release aside, it is the purpose of this article to critically review each document in turn.

THE BCG NEHTA REVIEW The review document is the outcome of a consultative process (with a call for public submissions) that ran from July to late October 2007. The review involved interviews with over sixty stakeholders and consideration of some nineteen written submissions. The major findings of the review were: 1. NEHTA has raised the profile of e-Health in Australia. 2. NEHTA has largely focused its efforts in the right areas to facilitate the emergence of an appropriate e-Health infrastructure in Australia. 3. NEHTA’s initial work plan was overly ambitious – why NEHTA lacked the insight to recognise that is not explained – but a revised, less ambitious plan is now only a few months behind its reframed target dates. 4. NEHTA has put in place recommendations for terminology and secure messaging standards, but is yet to have reference implementations available. Additionally there is no certification process in place to assess interoperability. 5. NEHTA has been unable to recruit an adequately skilled workforce to deliver on many of its plans. While a lot of documentation has been developed, the implementation of much of this documentation is yet to be achieved meaning it is unclear how well some of the major projects will be delivered. 6. The delay in staff recruitment has meant many initiatives are very substantially underspent. 7. NEHTA has dealt with virtually all stakeholders, other than its jurisdictional masters, with a lack of transparency and virtually no effective communication leading to very considerable annoyance and frustration on the part of many stakeholders. 8. While NEHTA has delivered much documentation, actual ‘proof on concept’ implementations are yet to happen. 9. As far as Shared Electronic Health Records (EHR) are concerned, NEHTA won’t be delivering in the 2009 timeframe and so should focus on building support for the concept and ensuring issues such as privacy are properly addressed. The

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BCG report says NEHTA has done a lot of high-quality work in this area but has not let anyone external to the organisation assess it – so there is really no agreed status of all this. It should be noted that the BCG report suggests that by mid 2009 there is a good chance terminology, secure messaging, supply chain improvements and identifiers will be in place but that the Shared EHR is unlikely to make much progress. The essential recommendations of the review were: 1. Start communicating sensibly and openly with stakeholders. 2. Move from the theoretical to more practically focused ‘proof of concept’ implementations and re-organise around project delivery. 3. Fix staff shortages – possibly by recruiting overseas or outsourcing. 4. Put in place accreditation and implementation / interoperation functions. 5. Create a much more representative Board to guide the organisation and build stakeholder trust. In summary what the report says is that NEHTA has not recognised ‘Lesson 101’ of working in the health sector – i.e. you must communicate, listen and engage – and have thus essentially “fallen at the first hurdle”. Unless this is rapidly changed it is likely success will elude them in the long term is the very clear subtext of the BCG Report.

NEHTA’S RESPONSE In response to the BCG report, NEHTA developed a 10 page document titled ‘Action Plan for Adoption Success’. In this document, NEHTA responded to each of the formal recommendations and agreed to each of them – however I am still wondering what the title of the document actually means – it is hardly an action plan and there is much more at stake than adoption. Recommendation 1: Create a more outwardly-focused culture. NEHTA says it recognises the need for this and has developed a plan to achieve it. Recommendation 2: Reorient the workplan to deliver tried and tested outputs through practical ‘domains’. In an important shift, NEHTA now says it will work with partner organisations to make deliverables that actually meet a need – e.g. pathology messaging, referrals and e-prescription – while continuing to deliver identification, authentication and terminologies. Recommendation 3: Raise the level of proactive engagement through clinical and technical leads. NEHTA plans to recognise the importance of the various clinical groups. Unfortunately it did not list nurses, allied health or specialists as targets – but we can wait and hope.


In a worrying example of ‘non-openness’, NEHTA reveals it has finalised a submission for the Council of Australian Governments for a Personal e-Health Record (PHR) and the first the public will really know anything about it is when it is approved. To quote: “NEHTA will increase its engagement with healthcare consumer audiences. The focus of this program is on raising awareness of the proposed personal e-health record, and will establish a basis for a significant increase in engagement once the business case for the personal e-health record is approved.” I must note it is by no means clear if the proposed Personal e-Health Record is the same thing as the Shared EHR of the recent past. If ever there was a candidate for full and open stakeholder review and discussion, this is it! Recommendation 4: Accelerate resourcing through outsourcing, offshore recruiting and more creative contractual arrangements. NEHTA admits there is a problem – but seems hesitant to go overseas. It does however seem keen to outsource some key operations. Recommendation 5: Reshape the organisation structure to address revised priorities. This response actually reveals some interesting elements. First there are now three (not two) National Infrastructure Programs: • Unique Healthcare Identifiers Services • The National Authentication Service for Health • Clinical Terminologies As far as I am aware, this was the first mention of an authentication service. It was apparently approved in October 2007 by the NEHTA board and it seems to be intended to replace – in a year or three – HESA, Medicare and other private authenticators. Second, we discover there is to be a NEHTA Conformance, Compliance and Accreditation program whose scope is yet to be fully revealed. Third, we discover – very belatedly – that NEHTA will also examine requirements for clinical registries, GP desktop systems, e-consulting, and decision support techniques and tools to determine the scope of any future involvement by NEHTA. Frankly, if NEHTA is not involved deeply in each of these domains, the organisation is a waste of time in my view! Recommendation 6: Add a number of independent directors to the NEHTA board to be broader advocates of e-health, and to counter stakeholder perceptions of conflict of interest. While it is great the recommendation has been accepted (if not yet actioned at the time of writing), it would have been good to see some admission that the present board structure was unsatisfactory and worked very poorly. NEHTA have clearly ignored primary care and the private sector, and it is excellent the BCG has pointed this out.

THE NEED FOR A PLAN The main question is “what is missing here”. Given all the apparent agreement between the reviewer and reviewed, a number of major things concern me about all this. My first major issue is that the last paragraph of the executive summary, identifying the need for a national Health IT Strategy, has simply been ignored by the NEHTA Board. “In parallel, planning for the next phase of eHealth

coordination and implementation needs to commence now or momentum could be lost. An eHealth strategy and eHealth policies need to be developed. Further analysis and debate by NEHTA and its members on the future vision for eHealth and the role of a central agency (as described above) is needed now to generate a plan by mid 2008. Regardless of the funding scenario and any future role of NEHTA II, we believe that the ‘transition’ NEHTA is tasked to support has at least another five to ten years to run.” I welcome all the recommendations, cited above, as far as they go - but feel they do not point to where the real work is needed - i.e. a National e-Health Strategy. This analysis needs to be in-depth and fundamentally assess where e-Health is up to now, what has worked and what has not and then design a practical and pragmatic route to an e-Health enabled future for the Health Sector. My second major concern is that while it is clear there have been a very large number of issues with the way NEHTA has operated - there is no apparent accountability for the mis-steps being accepted by the Board and Staff of NEHTA. That said, the BCG report’s findings seem to me to accurately reflect the view of external stakeholders (Health IT experts, Health Providers and IT experts) but the impact is diluted by continual use throughout the report of the views of the NEHTA staff on the quality of the job they are doing. The staff and Board are hardly likely to be objective regarding their own performance! It is clear from the BCG report that NEHTA has received a ‘fail’ from its customers, while the staff are so disconnected from reality they cannot even grasp why they are seen as having done such an indifferent job. My third major concern is that we now seem to have NEHTA recommending a business case for a National Shared EHR (or Personal e-Health Record or whatever) to the Council of Australian Government – and the public has had no apparent input – other than via a discredited NEHTA Board and a few bureaucrats. This is hardly the new open, engaging and consultative NEHTA! This is frankly unacceptable in my view. My fourth concern is that with this review completed, it is not clear that there will be any assessment of NEHTA’s success in getting back on the rails. I, for one, think a reassessment in 12 to 18 months is vital. My fifth major concern is that to date, there is no evidence that NEHTA (or the BCG) really understands that its client is the entire Health Sector and that its efforts need to be shaped in a way that addresses the needs of all the sector’s components and treats the health sector as an integrated whole. In summary, the BCG report addresses some of the operational, cultural and engagement failures of NEHTA, while failing to firmly recommend the development of a national e-Health plan to achieve value from NEHTA’s work. Without this, NEHTA will remain an unguided missile operating without strategic context and at risk of continuing to underperform. For the BCG to let NEHTA escape from this review without a clear articulation of the need for a National E-Health Plan and a strong recommendation for the work to be done is really very poor indeed.

REFERENCES 1. Hewett J. Healing Australia via broadband. Available at http://www.australianit.news.com.au/ story/0,24897,22935859-24169,00.html [Accessed on 7/2/2008].

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BITS & BYTES BLU-RAY TRIUMPHANT Blu-ray has officially won the next generation DVD war with Toshiba officially withdrawing support for rival format, HD-DVD. The company will no longer develop or market HD-DVD, however they will undertake to support hardware currently in the channel. Toshiba recently slashed the price of their HD-DVD products in an effort to accelerate market adoption of the technology, however the results were underwhelming according to Toshiba’s Australia General Manager, Mark Whittard. “We did recover our share to about 30 per cent, but it was below our expectations.” It is expected Toshiba will fall in line with its competitors and begin releasing Blu-ray in the coming months.

SUN SNAPS UP MYSQL Sun Microsystems, has agreed to purchase MySQL AB, developers of the worlds most popular open source database solution,, for $US1 billion. Sun, an active supporter of several open source software initiatives including Solaris and Open Office, will pay approximately $800 million in cash and $200 million in options in exchange for all MySQL stock. The transaction is expected to be completed by the end of 2008.

HISA calls for national eHealth plan, workforce reform, support for IHE On 18th of January, the Health Informatics Society of Australia (HISA) responded to Treasurer Wayne Swann’s call for pre-budget submissions. HISA’s submission makes three key recommendations that the peak health informatics group believes will lead to a more efficient health system. ”Australia faces unprecedented pressure on its health system and needs to have a plan and the resources necessary to transform the way healthcare is provided using modern information systems and technology,” said HISA President Dr Michael Legg. To guide this transformation, the submission calls for funding from the Government for the development of an “agreed vision and plan for eHealth in Australia”. Pointing to the BCG Review position that it has not been NEHTA’s role to set the vision and plan, and that the Australian Health Information Council (AHIC) has not as yet succeeded in doing so, and citing an unlikeliehood that based on their record either group would attract the necessary stakeholder buy-in for a consensus plan, the submission recommends that this plan be developed by a diverse stakeholder group independent of both NEHTA and AHIC. ”There is consistent concern in feedback from surveys of the membership of HISA

that there is no agreed plan in the eHealth space nor the kind of long term planning process and commitment required to get the job done. This is a perfect candidate for consideration at the 20/20 summit being organised by Mr Kevin Rudd,” said Dr Legg. To address the chronic lack of health IT expertise in Australia, the second HISA recommendation calls for additional funding to be allocated to relevant undergraduate and post graduate education programs, as well as the implementation of professional development programs to up-skill IT and health professionals with specialised health informatics expertise. In addition to taking these measures to bolster the health IT workforce in Australia, the submission calls for the establishment of a Health informatics accreditation program to quantify expertise and simplify the recruiting process. In its final recommendation, HISA have called for the Government to support the establishment of an Australian branch of the Integrating the Healthcare Enterprise (IHE) organisation. Dr Peter MacIsaac, a former informatics advisor to the Department of Health’s information strategy area and now independent consultant, heads up the IHE initiative which is sponsored by HISA, HL7, MSIA and the Royal Australian and New Zealand College of Radiologists. Dr MacIsaac expands on the IHE vision:

A scene from the 2007 Interoperability Demonstration held at the MedInfo conference in Brisbane last year.

AAPP MESSAGING DECISION IMMINENT The Australian Association of Pathology Practices (AAPP) are understood to have completed a long running process to select a preferred secure clinical messaging solution. While the successful vendor has not been announced by the AAPP, ArgusConnect have publicly stated that the peak pathology organisation did not select Argus as the solution to be recommended to their membership.

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BITS & BYTES “IHE is a decade old healthcare system implementation program which bridges the gap between standards and solving real world health communication problems. IHE activities are designed to bring vendors together in an environment where their technical experts are charged with the task of taking existing sets of standards and making them work in specific, practical health care scenarios across a broad range of systems. IHE is being engaged by major national IT programs in several countries and regions, most notably Canada, USA, Europe, Japan and China. IHE works on solving interoperability problems, a few per year, limiting the potential for failure due to over enthusiasm, yet steadily building up an array of reusable component solutions. All of these are based on the intelligent

stitching together of existing standards and engagement with professional associations as well as the IT community.” “The public face of IHE is their interoperability showcases, showing real systems creating the virtual healthcare systems that current initiatives have failed to deliver. The less well known face is the ‘connectathons’ — international engineering events that are both proving grounds for the secure communication solutions as well as a process for testing conformance to the IHE profiles and their underpinning standards.” The plan to run a connectathon and IHE showcase this year in Australia is seen as a logical evolution of the HISA co-ordinated interoperability demonstrations that have been held annually at HISA’s Health Informatics Conferences (HIC) since 2005.

Thunderbird Software donates oncology software CONTRO, a software package that captures data relating to the diagnosis and treatment of cancers has recently been donated to the Cancer Council Victoria (CCV) in a gesture of goodwill by Thunderbird Software, the developers of the application. CONTRO includes multiple tumor staging methodologies, incorporates ICD-10 coding regimes, and can be configured to target specific oncology specialties including gynaecology and breast. GeMMA, the gynaecological implementation of CONTRO, was originally developed for use at the Royal Woman’s Hospital (RWH) in Melbourne. The software was first installed at RWH in 2000 and has been used to report on a clinical cancer data capture trial, which has been running for 18 months at RWH. GeMMA will also be used by the CCV Gynaecology Oncology Project (GOP), an expanded clinical cancer data capture trial. GeMMA will be installed at a further three metropolitan gynaecological cancer treatment centres, namely Monash Medical Centre, Freemasons and Mercy Hospitals. Clinical cancer data capture will occur at these centres via the GOP, with selected data elements to be transferred to the population based cancer registry for aggregated analysis. The centres will have the capacity to use GeMMA beyond the data requirements as specified within the GOP, with clinicians

German police officials have admitted to being unsuccessful in their attempts to breach the encryption protocol used by Skype, a popular Internet telephony solution. Faced with rising surveillance challenges, the German authorities are reported to be developing spyware‑like technology to intercept Internet communications before encryption and transmission can take place. German law currently prevents such solutions from being deployed.

TELSTRA TO CLOSE CDMA

also able to use the clinical management features of CONTRO/GeMMA also. With gynaecological cancer diagnosed in over 1000 Victorian women per year, there is a need to improve data collection and analysis for this population. Ms Helen Farrugia, Director of Information Systems at the Cancer Council Victoria, said the software has the flexibility to be adapted for all streams of cancer, with another version for breast cancer – RUTH – currently in development. “This will result in better data management. As a result, our yearly statistics will be more detailed than previous years,” said Ms Farrugia. Ms Farrugia said that with over 24,000 Victorians being diagnosed with cancer each year, there is a desperate need for a useful patient management tool that allows and encourages data to be entered as events occur. “Currently, there are no databases in place at hospitals that can track this type of information. CONTRO allows oncologists, pharmacists, nurses and social workers to record patient information from the time of diagnosis and then track their treatment regime, outcomes and reviews,” said Ms Farrugia. The Cancer Council Victoria has committed to provide full training and support to any hospital that wishes to install CONTRO software.

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SKYPE ENCRYPTION HOLDS FIRM

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Having been thwarted in their efforts to close the CDMA network in January by Communications Minister Stephen Conroy, Telstra are again preparing to close the legacy mobile phone and data network. Under conditions imposed on Telstra by the Government, the telecommunications company is required to demonstrate that their new Next G network provides equivalent or better coverage to that provided by their CDMA service before it can be closed down. In an effort to allay Minister Conroy’s reservations and win support from disgruntled rural customers who are concerned about the closure of the CDMA network, Telstra has committed to provide “Blue Tick” certified phones, reception boosters and free external antennas to new Next G customers who suffer a reduction in coverage as a result of migrating from the CDMA network. Telstra are preparing a submission to Minister Conroy detailing recent improvements in Next G coverage. Assuming Telstra’s report is accepted following its submission in late March, the CDMA network will be closed on 28th April.


BITS & BYTES MD3 UPDATE RELEASED HCN has released an update to its flagship clinical software for medical practice, Medical Director 3 (MD3). Now at version 3.7, HCN have added an integrated secure messaging solution dubbed MDExchange. Users of the service can send letters to other registered MDExchange users from within MD3. There are no per message charges or setup costs for existing MD3 subscribers who wish to use MDExchange. The new version of MD3 also allows patient photos to be stored in the clinical record. Photos are displayed in the corner of the patient window, providing clinicians with a visual aid to ensure they have the correct patient file open. To comply with legislative requirements in some states, photos can also be printed on medication sheets. PracSoft, HCN’s GP practice management system, has also been refreshed. The latest version now interfaces with Tyro EFTPOS terminals to provide “Integrated EFTPOS” functionality. Promising to streamline EFTPOS transactions at practice reception counters, the solution negates the need for transaction information to be entered directly into the EFTPOS terminal by the receptionists. Integrated Easyclaim functionality for PracSoft and Blue Chip, HCN’s specialist practice management solution is slated for the middle of 2008.

Divisions map Australia’s health care facilities online General Practice Victoria (GPV), the peak body for Victorian Divisions, has released an application that allows Divisions to map the locations of their member practices and other local health care organisations online. Leveraging the power of Google Maps, the application is designed to assist patients to locate medical practices and other health care organisations in their local area. In addition to the physical location of the health care facility, other information can be displayed on the map, including contact details and practice opening hours. Health care organisations included on the maps can be categorised and colour coded by type or speciality to allow the desired type of facility to be easily identified. Route planning functionality is built into the system, making it easy for patients to navigate to their intended destination from their current location. The service is designed to be made publicly accessible via Division web sites, as well as any hospitals interested in deploying the solution. Having commissioned and funded the project internally, GPV has undertaken to provide the software to these organisations free of charge.

ANZ TO OFFER EASYCLAIM In late December, Minister for Human Services, Senator Joe Ludwig, announced that the ANZ bank had signed on to deliver Medicare Easyclaim. ANZ joins the CBA, NAB and Tyro as the fourth bank signed up to offer the system. Once all four banks have successfully deployed their solutions, it is estimated that over 70 per cent of doctors will have the opportunity to adopt Easyclaim.

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Brendon Wickham, eHealth Support Officer at GPV said “The application is one example of how the information contained within the CRMS (Customer Relationship Management System) of Divisions can be value-added for the benefits of their members and healthcare consumers.” The mapping service can be embedded within the body of a web page or displayed independently to maximise the map viewing area. The solution has modest system requirements, and has been designed so that non-technical staff can administer it once installed. “As an interactive web application it is a fairly sophisticated IT resource - yet it has been designed to be as easy as possible for divisions to install and maintain. All 3 Divisions who put their hands up to test it while it was being developed were able to get it on their website with minimal effort,” Mr Wickham said. Since the Division mapping initiative was launched at the Australian General Practice Network (AGPN) national conference in Hobart late last year, more than 25 Divisions have expressed interest in adopting the solution.


What we could help you develop a better practice all round? Pioneering Change

Expressions of interest open in March 08 iF you could improve patient outcomes, develop a stronger practice team, and solve problems by sharing ideas with other practices, wouldn’t it be worth finding out more about The Australian Primary Care Collaboratives Program? The first phase of the program achieved excellent outcomes for practices and patients, and over the next 4 years we look forward to working with the Divisions network to initiate quality improvement across primary care, all over Australia. iF your practice or Division is interested in participating, expressions of interest will be called soon, starting with NSW in March ’08. To find out more about the exciting APCC Program and the state, local, and virtual waves, visit www.apcc.org.au Delivered by the Improvement Foundation Australia

The Collaboratives Program is funded by the Australian Government Department of Health and Ageing


BITS & BYTES APPLE TIME CAPSULE Apple have released a SOHO backup solution designed to compliment the “Time Machine” backup software built into MacOS X 10.5 Leopard. The “Apple Time Capsule”, is an integrated device featuring a large hard drive (500GB or 1TB), 802.11n Wi-Fi networking, a USB port for printer sharing, and three Gigabit LAN ports. The solution allows multiple computers on a wireless or Ethernet LAN to backup important data to the device, providing users with rollback options in the event of data corruption. While the device is compatible with Windows, the data recovery process for MacOS X 10.5 Leopard has been animated with healthy doses of eye candy, presenting the user with the notion that they are travelling back in time to retrieve their data.

ACS SEEKS GROWTH The Australian Computer Society (ACS) has announced plans to aggressively expand its membership base. Currently standing at around 16,500, President of the ACS, Kumar Prakala, intends to build the membership base to 40,000 during his two-year term as president. While Mr Prakala estimates there are over 190,000 IT professionals in Australia that he believes would benefit from ACS membership, the president of Australia’s peak computing body is also reported to be interested in attracting a large contingent of international members, mostly from Asia. The ACS currently boasts over 1000 international members. In a related development, the ACS is in negotiations with the international computing societies of Britain and Canada with a view to establishing a common accreditation process for their memberships.

Royal Prince Alfred ICU deploys automated SNOMED-CT system On 31st October, representatives from the Royal Prince Alfred Hospital (RPAH) Intensive Care Service (ICS) and the School of Information Technologies from the University of Sydney demonstrated the ICS’s recently implemented SNOMED-CT functionality to an audience of clinicians, Health IT professionals and representatives from the media. The event showcased the results of two years worth of collaborative effort between the hospital and the university, namely two inter-related clinical software prototypes that deliver SNOMED-CT functionality to the ICS. According to the International Health Terminology Standards Development Organisation (IHTSDO), SNOMED-CT is the most comprehensive multilingual clinical healthcare terminology in the world. It was created through a joint development between the National Health Service (NHS) in the UK and the College of American Pathologists, representing the convergence of SNOMED-RT and the UK Read Codes. The intellectual property for SNOMED-CT has been transferred by these bodies to the IHTSDO for future development. SNOMED-CT has been nominated by the National e-Health Transitional Authority as the preferred clinical terminology for Australia. NEHTA have negotiated licensing arrangements with IHTSDO that allow Australian software developers to implement SNOMED-CT functionality in their products without having to pay any licence fees. The Government funded body has also been tasked with the role of setting up the necessary infrastructure to produce localised SNOMED-CT terms for Australia, however this process is yet to yield deployable local terms. The RPAH ICS is the largest critical care service in Australia. It provides 45 operational critical care beds and accepts over 3440 admissions per year. The ICS has been using clinical information systems (CIS) since 1984. CareVue Classic, the current CIS was first implemented in 1999 and functions as a near complete Electronic Health Record (EHR). The first application developed as part of the partnership between the hospital and the university is dubbed the Ward Rounds Information System (WRIS). This application has been designed to convert the unstructured clinical notes entered into the ICS’s clinical information system into SNOMED-CT codes, thus enabling more

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consistent descriptions of patient conditions and, in turn, dramatically improving the capacity of the ICS to retrieve and analyse the information in the EHR. During a clinician’s ward round, the WRIS creates a summary of the progress notes stored in the CIS and presents these to the clinician. Additional progress notes are entered into the WRIS, which analyses them and returns SNOMED-CT codes for the clinician to verify. Once verified, the codes are transferred to the CIS for storage. Compared to the process of retrospective clinical coding of progress notes by staff, the WRIS can deliver time savings of up to 10 minutes per patient encounter. Within the context of the RPAH ICS, this amounts to a potential time saving of four hours worth of clinical coder time per ward round. As well as being used for real time SNOMED-CT conversion, the WRIS can also be used to retrospectively code the seven years worth of historical data stored in the CIS. In the absence of real time clinician verification however, the retrospective process is prone to error. According to Professor Jon Patrick, Chair of Language Technologies at the University of Sydney, “The error rate is currently about 30%. Reducing this is part of our ongoing research and has become the basis of a collaborative project with the Health Informatics group at the University of Manchester.” To complement the WRIS, a Clinical Data Analytics Language (CDAL) system has been deployed in the ICS. This system allows clinicians to interrogate the data in the CIS using restricted natural language queries, negating the need for them to understand SQL or other computer centric languages. According to Professor Patrick, the CDAL system also has the ability to ask for statistical comparisons to be made between patient groups. For example, “Do patients with blood sugar levels between 4.4 - 6.1 mmol/l have shorter lengths of stay compared with those patients with blood sugar levels outside of this range?” The CDAL system utilises the SNOMED-CT codes generated by the WRIS to maximise the accuracy of the retrieved information. Both the WRIS and CDAL system went live in October 2007. According to Angela Ryan, CIS Manager for the Intensive Care


BITS & BYTES Service, “The WRIS automates a previously manual task so training needs have not been significant, with the bulk of training focused on the process of verification of SNOMEDCT terms. This has been conducted in small groups of medical staff as part of their normal ward round. Furthermore, SNOMEDCT was an unknown entity prior to this project so one of the most significant achievements to date has been the introduction to clinicians of the concept of medical terminologies”. The system’s initial lack of interactive spell checking functionality has been flagged as an area for future improvement, with a sophisticated spell checking module currently being prepared for beta testing. The already complex task of interpreting unstructured English sentences and converting them to SNOMED-CT codes is made significantly more difficult if grammatical and spelling errors are presented to the system. By ensuring these errors are eliminated prior to the running of the conversion routines, the developers expect an immediate improvement in the accuracy of the system. Both the WRIS and CDAL systems have been designed using a modular approach to allow them to be installed as enhancements

to any other clinical information system. This modularity has already been tested to some extent; the deployment of the WRIS required two data mappings to be written as the CareVue system used in the RPAH ICU utilises two separate databases to store its clinical information. These databases are not only structurally different, but are hosted on two different database management systems which increased the complexity of interfacing the WRIS with CareVue. According to Professor Patrick, “The long term aim of the research is to understand the processes of creating enhancement technologies that can be attached readily to any clinical information system. We are investigating how the WRIS can be viewed as a special example of a Handover System and create a more general system that could be used to support Handovers in any department within a hospital, attached to any local CIS.” Outside of the RPAH, the WRIS and CDAL system are being ported to the clinical information systems at the Paediatric ICU in the Children’s Hospital at Westmead. Negotiations to bring the SNOMED-CT systems to other hospitals are underway, however at the time of writing, no formal agreements have been reached.

Prof Jon Patrick (L) and Dr Robert Herkes (R) demonstrating the recently deployed Snomed-CT enabled Ward Rounds Information System (WRIS) at the Royal Price Alfred Hospital Intensive Care Unit.

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NEHTA CALLS FOR CLINICIAN INPUT Australia’s expert clinicians have been asked to play a part in health reform by providing input into the development of a national e-health system. The National E-Health Transition Authority (NEHTA) will appoint a team of senior clinicians and form an online clinical network to increase engagement with clinical communities and ensure that the clinician’s perspective is embedded in all aspects of NEHTA’s work. NEHTA Chief Executive Dr Ian Reinecke said the clinical perspective of experienced professionals was vital to the reform agenda. “We are appointing a team of senior clinicians to provide advice on NEHTA’s development programs as well as support engagement and consultation within the healthcare sector. Former AMA President Dr Mukesh Haikerwal is already on board with us and will lead the new team in this important work,” he said. He said NEHTA would consult widely with leading clinician organisations and establish a broader clinical network to be developed through an online community. This engagement would enable NEHTA to have access to a breadth of knowledge essential for the quality development and implementation of e-health programs. Dr Reinecke said clinical leaders would be assigned to NEHTA development programs and national infrastructure projects to provide input and guide the development teams on likely clinical issues and appropriate mechanisms for engaging with clinical stakeholders. He said interested clinicians are invited to access a full role description and make their expression of interest at the NEHTA website.


BITS & BYTES IPODS HEART SAFE The US Food and Drug Administration (FDA) has concluded that iPods are safe for people with pacemakers. In a recent report published in the BioMedical Engineering Online journal, the FDA found that the electromagnetic field produced by an iPod was not strong enough to interfere with pacemakers. The study tested four different iPod models and measured the electromagnetic field produced by each device. No other brands of portable media players were tested in the study.

MOBILE PHONE BANKING Major banks are adding mobile phone banking services to their product lines, a development that, according to Juniper Research, is set to have as large an impact on the banking sector as the introduction of ATMs, EFTPOS and Internet banking. ANZ is the first major financial institution in Australia to offer mobile phone banking service. Under their system, customers have the ability to access account details, pay bills, and transfer funds using a phone centric Java platform. A text message based banking service is also available for customers that don’t have a modern phone, however this service has a more limited feature set. Other banks, including the NAB and Bank of Queensland, are reported to be readying similar mobile banking services.

GOOGLE ENTERS PHR RACE Google has announced it is trialling a new Personal Health Record (PHR) system at the Cleveland Clinic in the US. Up to 10,000 Cleveland Clinic patients who opt into the technology trial will have their medical history, allergies and current medications uploaded into the system.

Stat Health delivers online claiming for IBA Classic Practice software developer Stat Health has released a Medicare and DVA online claiming solution for IBA Classic. Known as Medical Spectrum Classic prior to acquisition by IBA Health in 2004, the now-legacy product does not contain this functionality and relies on the X400 based Medclaims system to submit claims electronically Introduced in 1992 by the then Health Insurance Comission (now Medicare Australia), Medclaims was the first claiming system to allow practitioners to submit bulk bill claims electronically. The Stat Online Claiming Solution (SOCS) has been released in preparation for the impending closure of the Medclaims system. Superseded by the increasingly popular Medicare Online claiming service, the Medclaims system is scheduled to be discontinued from 1st July 2008. For users of practice management solutions that don’t contain Medicare Online functionality, the closure of the Medclaims system means that practices will need to upgrade or change their practice software to continue submitting claims electronically, or instead utilise the stand alone EFTPOSbased Medicare Easyclaim system. SOCS has been designed to interface with the Medclaims functionality of IBA Classic. The software works by intercepting Medclaims transactions generated in IBA

Classic, converts these claims to Medicare Online transactions, then sends them to Medicare for processing. SOCS then receives subsequent banking and exception messages from Medicare and exports them back to IBA Classic. Practice staff use IBA Classic in the usual way to handle these banking and exception reports. SOCS works seamlessly alongside the existing Medclaims functionality in IBA Classic and does not require practice staff to change their existing workflow to operate the new claiming system. Both bulk bill and DVA claims can be transmitted using the system. Once installed, practices will be eligible for the recently introduced Medicare online claiming incentive of 18c per transaction, in addition to the $750 grant ($1000 for rural practices) for commencing Medicare Online claiming. SOCS is Stat Health’s second major offering to the market. Stat Services, a premium IT support service for medical practices was launched last year. For a monthly fee, practices who sign up to Stat Services receive 24 hour phone support, remote access support, an instant messaging account and access to a dedicated support person. SOCS is being made available exclusively to Stat Services clients and the application is free.

Chicago to host “SOA in Healthcare Workshop” in April From April 15-17, 2008, healthcare experts from Australia, the US and the UK will gather in Chicago to discuss the role that Service Oriented Architecture (SOA) plays in Healthcare. The “SOA in Healthcare: Realizing Quality of Care, Business Value and Delivery on IT’s Promise” event is targeted at a Health IT savvy audience and focuses on SOA’s role in meeting healthcare’s challenges. The event commences with an executive summit on day one, followed by business and technical tracks on days two and three. Case studies will be the basis for several sessions.

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The workshop will feature presenters from several organisations including the Rural & Regional Health & Aged Care Services Division (Department of Human Services, Victoria, Australia), BlueCross BlueShield Excellus, Kaiser-Permanente, and NHS Connecting for Health (NPFIT, UK). Among others, themes to be covered at the workshop include “The Role of SOA in Improving Health Quality”, “SOA and Health Informatics”, “Integrating Standards to Achieve Semantically Interoperable Healthcare IT Solutions” and “Transforming Health Care, Current and Future Impact on Patient Safety, Culture, and Process”.


BITS & BYTES

AGPN calls for roll out of Argus secure messaging In a wide-ranging budget submission to Treasurer, Mr Wayne Swann, the Australian General Practice Network (AGPN) has called for the national roll out of secure electronic messaging, in addition to $25 million for the establishment of a small grants program to enable 15,000 primary healthcare professionals to purchase computers and clinical management software. Kate Carnell, CEO of the AGPN, has indicated that the grants program is designed to improve the ability of allied health professionals to communicate with their GP colleagues. “Over 90% of GPs now have a computer on their desk, and supporting clinical information management in general practice is core business for Divisions. The submission extends to the rest of primary health care, which we understand to have limited computerisation. This is necessary to enable sharing of clinical information between professionals engaged in team based care, and are already included in a range of Division eHealth programs.” In addition to grant funding for computers and clinical software, the AGPN has requested $3.6 million ($30K per Division) be allocated to Divisions to rollout and support the Argus secure messaging suite. Argus, developed by ArgusConnect, is an open source secure messaging product that enhances traditional email systems by adding encryption and provider directory services. ArgusConnect CEO, Mr Ross Davey welcomed the endorsement, highlighting the importance of secure clinical messaging to General Practice. “Although ArgusConnect have not been involved in the preparation of the AGPN submission, we welcome the realisation by the AGPN board that General Practice has a significant stake in the improvement of clinical communication across most of healthcare. In particular, General Practice is being adversely affected by their inability to communicate easily and seamlessly with any other healthcare provider regardless of type of provider, where they are located or what messaging technology they use. GPs have a lot of power as a combined voice to have this problem fixed.” The backing of a specific solution by the

PREMION INSTALLS IMAGE GUIDED RADIATION THERAPY

AGPN has led to concerns being raised by other secure messaging vendors. Tom Bowden, CEO of Healthlink, said “To be successful a communications system needs to be well integrated into the GPs’ practice management systems and supported throughout an end-to-end process. Our view, and we believe the view of a number of other commentators is that an enhanced email system without true system-system integration and support falls well short of delivering the desired level of robustness and reliability needed to support a primary-care led healthcare model. There are a range of solutions that do meet the needs of a primary-care led health system and it would probably be helpful to all concerned if AGPN took a wider look at what might best underpin a Primary-care led health system.” When asked how the AGPN came to select Argus over its competitors, Ms Carnell said, “The initial development of Argus was funded by the Divisions Network. It is the only secure messaging product in use in the Network available whose intellectual property is available to the Commonwealth, and is also the only available Open Source product in use in the Network. With over 40% of Divisions having committed to implement Argus, it is a solution that we are highly committed to as a Network. With the current lack of interoperability between other secure messaging systems, extension of a universal free messaging client will provide a common communications platform within primary health care. It is also supported by a large portion of hospital systems.” Ms Carnell went on to indicate that the naming of Argus in the submission did not preclude other secure messaging vendors from participating in the market, or from being supported by the Division network. “The AGPN proposal included with the 2007/08 budget Submission sought resources for Divisions to install a universal client however does not preclude the use of any other system. Should the program be funded, AGPN would clearly need to do some work to address Divisions or States that have committed to implementing other products. If the products were able to interoperate with Argus there could be a strong argument to suggest that they would be equivalent in this regard.”

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Premion, Queenslands largest private radiation therapy provider, has announced the implementation of the BrainLAB ExacTrac X-Ray 6D ImageGuided Radiation Therapy (IGRT) system. The system will allow Premion’s Radiation Oncologists to deliver radiation treatment doses to a tumour with millimetre accuracy. Traditionally, inaccuracies in patient positioning or radiation beam alignment have been compensated for by larger treatment margins. This has resulted in higher irradiation of healthy tissue. For more precise patient positioning, ExacTrac X-Ray 6D uses high-resolution x-rays to locate the position of the tumour seconds before each treatment. It automatically corrects the patient set-up and tracks patient movement throughout the procedure. The new system is suitable for the treatment of patients with tumours in the lung, liver, prostate, spine or brain. “With the implementation of the BrainLAB ExacTrac X-Ray 6D, we are able to put cutting-edge treatment technology into the hands of our cancer specialists – providing patients with highly advanced care,” said Dr David Schlect, Senior Radiation Oncologist at Premion. With 15 Radiation Oncologists, Premion employs over 150 full time, part time and casual staff and offers a comprehensive range of clinical services across its three treatment centres at The Wesley Hospital in Brisbane, John Flynn Private Hospital at Tugun on the Gold Coast, and at Nambour on the Sunshine Coast. Premion is the first radiation therapy practice in Australia to implement the BrainLAB Image Guided Radiology Therapy solution.


BITS & BYTES AXA EXPANDS E-SECURITY IN MELBOURNE The Victorian Minister for Information and Communication Technology, Mr Theo Theophanous, has announced that Melbourne will be home to AXA Technology Services’ new global ICT activity hub. The hub will provide support to AXA clients via a data centre facility, technical support and eSecurity Regional Centre. “The new AXA operation will also provide a range of technical support in the areas of infrastructure and management process, operations, change management and networking – all of which means more technology jobs for people in Victoria,” said Mr Theophanous. The ICT industry in Victoria employs 83,900 people, which represents around 34% of national ICT employment. Victoria’s ICT industry has been growing strongly both domestically and internationally over the past year, with the sector generating $24.4 billion in annual revenue, a figure that represents a quarter of the national ICT revenue.

APPLE COMMENCES MOVIE RENTALS Apple have extended the usefulness of their Apple TV product with a free software upgrade that allows customers to rent movies directly from their TV. The service is only available in the US at this time, however Apple intends to expand the service internationally by year’s end. Customers get the choice of standard or high definition video for $US4.99 or $US5.99 respectively. Movies can also be rented directly from the iTunes store and viewed on a computer, iPod or iPhone. Under Apple’s movie rental model, customers have 30 days to commence watching rented movies, and 24 hours to finish the viewing after the movie has begun.

SingHealth deploys integrated digital neurosurgery facility In what Singapore Health Services (SingHealth) are claiming as a world first, the Singapore General Hospital (SGH) has opened a cutting-edge brain and spine surgical facility. Established in 1821, SGH is Singapore’s largest acute tertiary hospital and national referral centre. The installation of the facility was made possible by a significant donation by the estate of Tan Sri Khoo Teck Puat, Singapore’s wealthiest man at the time of his death in 2004. In reflection of the donation, the facility was launched under the name of Khoo Teck Puat Integrated Neuroscience Centre. Taking over a year of planning and construction to complete, the new facility comprises five separate operating theatres, three of which include intra-operative imaging capabilities. While most invasive surgical procedures utilise pre-operative imagery taken using MRI devices and CT scanners, the intra-operative capabilities allow clinicians to generate timely images during the surgical procedures, dramatically improving the quality of the information available to the surgeons. As explained by a surgeon at SGH, this capability is particularly beneficial for brain surgery. “The brain adjusts position in response to the removal of tumours, diminishing the accuracy of pre-operative images as the surgical procedure progresses. The longer the procedure takes, the less relevant and useful the pre-operative image becomes.” The intra-operative image capability is achieved by the inclusion of MRI, CT and C-arm X-ray devices in the operating theatres. In the case of the CT operating room, the CT scanner simply slides over the patient’s operating table, however due to the immovable nature of MRI machines, the MRI operating theatre relies on an operating table that can be repositioned to slide into the device. Due to the strong magnetic field created by an MRI machine when in use, designing a fully featured digital operating theatre around an MRI machine posed significant technical challenges for BrainLAB, the supplier of the technology selected for the facility. According to Stefan Vilsmeier, BrainLAB’s CEO, “The MRI disturbs every other device in the OR, and every other device

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in the OR disturbs the MRI. To eliminate the interference between the devices in a practical way is really very complex.” In addition to the invasive surgical based operating theatres, the SGH have installed a “Novalis” radiotherapy facility. Also developed and implemented by BrainLAB, this facility is designed to treat tumours that would otherwise be inoperable. The Novalis system employs technology that allows the shape of the radiation beam to be tailored to the shape of the tumour, facilitating faster, more accurate treatments. By limiting the amount of healthy tissue exposed to radiation, adverse side effects from radiation therapy can be dramatically reduced. Associate Professor Ivan Ng, Head of the Neurosurgery Department at the SGH said, “The new treatment reduces side effects from very high - 20 or 30 percent - down to one or two per cent now.” Since the Novalis facility opened in May 2007, over 100 patients have been treated using the radiotherapy system. Patients do not need to be anaethatised, and treatments can be performed in as little as 5 minutes. Treatment régimes vary widely between patients — at the time of writing, the most treatment sessions prescribed for a patient was 28. Suffering from a tumour located in his ear canal, this patient attended these sessions on consecutive business days. SGH have also deployed BrainLAB’s sophisticated surgical instrument tracking system. Using GPS-like concepts, the system utilises special cameras placed in elevated positions around the operating theatre. These cameras monitor special “tracking balls” affixed to all surgical instruments. This information is collated by a computer which constructs and displays a 3 dimensional image of the position of the surgeon’s tools relative to the patient’s brain. The position of the tool can be superimposed on a recent scan to allow the surgeon to operate using a virtual image for scenarios where the surgeon’s vision is impaired. Associate Professor Ng stated that the combination of intra-operative imaging and instrument tracking technology will make complex, 24 hour long surgery sessions a thing of the past, slashing the time required for such procedures to as little as two hours.


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BITS & BYTES BATTERY TECHNOLOGY BOOSTED Stanford University researchers have developed a technique that they hope will lead to significantly improved battery performance. Led by assistant professor Yi Cue, the researchers have found a way to use silicon nanowires to give rechargeable Lithium-ion batteries used in laptops, iPods, video cameras and mobile phones as much as 10 times more charge. The increased Lithium-Ion battery capacity was made possible through the use of silicon nanowires to construct the battery anodes. Traditionally, graphite has been used for this purpose. Silicon anodes have the “the highest theoretical charge capacity” according to Ciu, however battery charging cycles cause silicon to fracture and degrade due to expansion and contraction processes. Cui’s new anode design, stores lithium in a forest of tiny silicon nanowires, each with a diameter one-thousandth the thickness of a sheet of paper. The nanowires inflate to four times their normal size as they soak up lithium, but, unlike previous silicon anodes, they do not fracture. If the technology can be successfully commercialised, Cui expects that batteries featuring this silicon technology will be available within “several years”.

GOOGLE TO BUILD UNDERSEA CABLE Google has partnered up with five telecommunications companies to roll out a high capacity fibre optic data cable between the US and Japan. Estimated to cost in excess of $US300 million, the 10,000km cable will provide a much needed increase in bandwidth capacity between the two countries. The cable is expected to be operational by early 2010.

Apple releases world’s thinnest laptop Apple has released an ultra-thin laptop dubbed the MacBook Air. In the pursuit of a light weight design and sleek appearance, the laptop jettisons many features found in Apple’s MacBook and MacBook Pro ranges. Several common features found in competing ultra portable computing devices have also been left out of the MacBook Air’s arsenal. Sporting a single USB port for expansion, the laptop omits a dial-up modem, contains no Ethernet port or optical drive, and lacks the Express Card slot found in many modern laptops. It also lacks FireWire and Serial ATA ports, limiting its suitability for video editing and other computational tasks that require high capacity, high-speed storage options. Using optional USB dongles supplied by Apple, Ethernet and dial-up modem functionality can be restored, as can the ability to read and write to optical medial via an external DVD burner. This drive is designed to draws its power through the MacBook Air’s USB port, negating the need for a separate power adapter to be used. With the MacBook Air’s minimal core feature set, Apple has emphasised the flexibility of modern wireless technologies. The laptop sports the latest iterations of both Wi-Fi and Bluetooth technology to allow for connection to both networks and peripherals. Perhaps the most innovative application of the wireless capabilities in the MacBook Air is Apple’s new “Remote Disk”. By installing a software driver on any near-by Mac or PC, MacBook Air users can wirelessly access CDs or DVDs inserted into the optical drive of the remote computer as if the disk was inserted into the MacBook Air directly (albeit at transfer rates determined by the speed of the wireless network). Beyond being able to simply access files on the remote disk, it is possible to boot the MacBook Air from a MacOS X system disk and perform low level system tasks such as hard drive erasure and operating system installation. The laptop tapers in thickness from 19.4mm under the screen hinge, down to an impressive 4mm at the front of the device. Weighing just 1.36 kilograms and measuring 32.4cm across and 22.7cm deep, the foot print of

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the laptop is only slightly larger than an A4 piece of paper. Despite minimising the thickness of the device, Apple has distanced itself from its competitors by not compromising on the size of the laptop’s screen or keyboard. The MacBook Air features a 13.3-inch wide screen display with a 1280x800 pixel resolution. Like the more feature laden 15-inch MacBook Pro, the MacBook Air utilises LED backlight technology to illuminate the monitor. Compared to the Cold Cathode Fluorescent (CCFL) technology found in most flat panels on the market, LED backlit monitors draw less power resulting in better battery life. It is claimed that this technology is also more environmentally friendly as LED panels do not contain mercury. The laptops keyboard is described as “full size” and can be illuminated in low-light conditions using LEDs placed under each button on the keyboard. The MacBook Air borrows Apple’s patented “Multitouch” technology from the iPhone and iPod Touch product lines. Built into the laptop’s trackpad, this technology allows the user to perform common tasks using a combination of finger gestures, minimising the need for the user to switch back and forth between their keyboard and the trackpad. As is found across Apple’s entire laptop range, the MacBook Air includes a web camera and microphone to facilitate video conferencing. Sound output is facilitated by a solitary internal speaker - a sound output port can be used to achieve stereo sound through either headphones or external speakers. The MacBook Air ships with a single platter 80GB disk. The laptop is Apple’s first laptop to use a 1.8 inch hard disk, the diminutive storage form factor popularised by the iPod and currently favoured by manufacturers of other ultra-portable devices. Heralding a sign of things to come for the broader laptop industry, Apple allows cashed up consumers to


BITS & BYTES purchase a MacBook Air with a 64 GB NAND flash storage module in place of a hard drive. Internal flash storage uses less power and generally performs better than hard disk based technology, however it is currently much more expensive than the entrenched alternative. Upgrading to a flash drive equipped MacBook Air costs a staggering $1409! Apple have built the MacBook Air around a custom designed Intel Core 2 Duo processor running at clock speeds of either 1.6 or 1.8 GHz. While certainly not the fastest

processors on the market, the chip is both smaller and draws less power than other laptop processors. Like Apple’s consumer oriented MacBook range, the MacBook Air utilises an Intel Graphics Media Accelerator X3100 to drive its monitor. Sporting a MicroDVI port and bundled with VGA and full sized DVI adaptors, the laptop can be attached to projectors or monitors capable of resolutions of up to 1920x1200 pixels. First announced at Apple’s Macworld Expo in mid-January, the MacBook Air ships with a starting price of $2499.

Improvement Foundation Australia awarded National Primary Care Collaboratives The Department of Health and Ageing has awarded the National Primary Care Collaboratives tender to Improvement Foundation Australia (IFA). The next phase of the program, to be known as the Australian Primary Care Collaboratives (APCC), will commence in 2008 with the first of 7 state based waves. The name of the program has been changed to APCC (Australian Primary Care Collaboratives), to better differentiate the program from similar work now being done in other countries. The state based waves will be followed by local workshops delivered at the Divisional level to increase the program’s capacity. “We look forward to working with the AGPN and the broader network to build capacity and embed key elements of quality improvement within primary care organisations”, Colin Frick, IFA Chief Operating Officer said. According to Mr Frick, Divisions will be offered quality improvement skills and program related training for practice support staff. “It’s our intention to introduce improvements to the APCC program, such as more flexible options for Divisions to participate and a wider emphasis on training divisional staff in quality improvement techniques”, said Mr Frick. When asked about the ongoing goals of the APCC, Dr Tony Lembke, APCC Clinical Director said, “The main aims of this ground-breaking program, which has already achieved outstanding results

for practices all over Australia, are the improvement of patient health outcomes and the development of a culture of quality improvement within primary care. The focus for this next phase will continue to be on three key areas: Diabetes, Cardiovascular Disease, and Better Access.” Reflecting on the successes of the NPCC to date, Dr Lembke, who was introduced to the Collaboratives program as a participant in Wave 1, said, “The Collaborative Program has been described as one of the most positive innovations in Australian primary care and I have to agree. As a participant in Wave 1, then the Clinical Chair of the Program for Waves 2 and 3, I was amazed to see the improvements being made by practices (including my own) simply by implementing small changes in their systems and measuring the results. Practices involved have greatly improved the management of their patients with diabetes and coronary heart disease, freed up the time of doctors and increased practice income as a result of this program. Participants gain confidence, motivation and a framework to make a real difference in how their practice runs and the level of care they provide for their patients.” With Phase 2 of the APCC program kicking off in NSW in March, it is planned that 1000 practices nationally will participate, in addition to the 560 practices that were part of Phase 1. The IFA team expect to work with the Divisions Network through to at least 2011, by which time up to 20% of Australian practices are expected to participating in the APCC program.

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MICROSOFT EYES YAHOO In an effort to counter Google’s growing online dominance, Microsoft have made an unsolicited offer to buy Yahoo for $US44.6 billion. The offer of $31 a share represented a 62 percent premium over Yahoo’s pre-offer closing stock price of $19.18. If the bid is accepted, the acquisition will be Microsoft’s largest ever, fundamentally reshaping the online search and advertising markets.

IBM UPDATES MAINFRAME IBM has released a new mainframe dubbed “System z10”. Standing 80 inches high and weighing in at 5,000 pounds, the system including a 4.4GHz quad-core processor, significantly more powerful than the 1.7GHz single-core processor used in the superseded and now three year old z9. The z10 supports up to 1.5TB of available memory per system, several times larger than the hard drive capacity of many currently shipping PCs. With these impressive specifications, the the z10 is designed to run up to 50% faster than the z9 in overall performance and can deliver as much as twice the performance when performing CPU-intensive applications. The z10 starts at below US$1 million, however a fully configured model with 64 discrete processors will cost the purchaser several million dollars. IBM is touting the combined benefits of virtualisation and modern mainframes in the face of increasingly overcrowded data centres. “We are about to hit a wall,” said Rod Adkins, senior vice president of development and manufacturing in IBM’s systems and technology group. “Companies will either have the opportunity to expand their data centres or innovate within an existing data centre envelope.”


AGPN Matthew Antcliff Matthew is the eHealth Program Manager for the Top End Division of General Practice

Division eHealth initiatives Delivering local health solutions Established in November 1994, the Top End Division of General Practice (TEDGP) covers 509,900 square kilometres. This vast area includes urban and rural areas of Darwin and Katherine as well as remote areas within the Northern Territory including Wadeye, Timber Creek, Melville Island, Groote Eylandt, Borroloola, East Arnhem Land, Jabiru, Oenpelli and Nhulunbuy. TEDGP identified the need to develop the capabilities of eHealth initiatives to support and strengthen general practice, saving time and money as well as improving the quality and safety of care provided to patients. Two of these initiatives, the Secure Electronic Messaging Service (SEMS) and the Electronic Transfer of Prescriptions (ETP) projects have been trialled successfully and are currently being progressively implemented throughout the Northern Territory.

SECURE ELECTRONIC MESSAGING SERVICE (SEMS) SEMS provides an easy, fast and secure way of communicating with health providers and hospitals on the SEMS network using an Argus based secure messaging solution. The aim of SEMS is to have all health providers in the Northern Territory communicating in a secure encrypted electronic environment. Integration with clinical software packages enables referrals, pathology and radiology results, discharge summaries and notifications to be directly imported into the health provider’s patient notes of their clinical software package. The messaging service also provides the transport mechanism for data being fed into the NT Shared Electronic Health Record. Since commencing in 2005 there has been significant expansion of the SEMS network to Central Australian sites, in conjunction with the Central Australia Division of Primary Health Care. In addition, the health service providers for the indigenous communities across the borders in SA and WA have also been invited and soon will be participating in SEMS. Achievements to date include completion of development work and testing to integrate Aboriginal Controlled Community Health Organisations that use Communicare and the inclusion of all NT Public Hospitals. SEMS users in the NT are now able to receive electronic referrals, notifications and discharge

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summaries from NT public hospitals. GP’s, specialists and allied health providers are also able to send electronic referrals directly to the appropriate hospital department and receive electronic notifications of appointments made and whether patients attend or not. The SEMS Service continues to grow in both numbers of participants and types of messages being sent.

ELECTRONIC TRANSFER OF PRESCRIPTIONS (ETP) The ETP project integrates models of care through linking GP’s clinical information systems to pharmacy dispensing systems. ETP is unique to the Northern Territory and last year was the first of its kind anywhere in Australia to implement the digital signing and dispensing of electronically created prescriptions. A Darwin Residential Aged Care Facility (RACF) was selected for the first ETP trial to improve enhanced primary care patient outcomes, particularly for the chronically ill and the aged on multiple medications and to improve the quality and safety of care for all RACF patients. The first digitally signed and encrypted prescriptions and medication charts were sent directly from GP’s laptops using clinical information software via an internet connection to the RACF and the Pharmacy to dispense medications in December 2006 and have been running successfully since. The implementation of Phase 2 will commence shortly and introduce ETP into the broader community-prescribing sector, providing patients with freedom of choice when it comes to selecting the pharmacy they wish to use. Software vendors Genie, Minfos and ArgusConnect have developed a software solution to accommodate ETP processing. The ETP solution will be fully integrated into Genie’s practice management software & Minfos’ pharmacy dispensing software. A central prescription server will be developed for storing digitally signed and encrypted prescriptions until the patient presents at their choice of pharmacy to have the prescription filled. It is hoped future development will enable ETP to eventually include all pharmacies and GPs within the Northern Territory, and provide a successful model for a national implementation.


NEHTA Heather Hunt Head of Public Affairs, NEHTA heather.hunt@nehta.gov.au

Shaping the future of Australian healthcare In December 2007, NEHTA announced an action plan to move towards implementation and adoption of e-health. “After working to build foundations for electronic health since the organisation was established in 2005, we are now in a position to begin to deliver some concrete applications of our work,” NEHTA’s Chair Dr Tony Sherbon said. “The new Federal Government has signaled health reform and improvements in state and federal relations as major policy objectives,” said Dr Sherbon. “Given also the government’s emphasis on the provision and use of broadband communications, NEHTA is well-positioned to play its role in advancing e-health as part of this new agenda,” he said. NEHTA announced the action plan focused on four key areas for electronic communications in 2008: pathology, medication management, discharge and referral. In addition, NEHTA will continue to focus on the delivery of: • National infrastructure programs including the Unique Healthcare Identifiers Services, National Authentication Service for Health and Clinical Terminologies; and • Compliance, Conformance and Accreditation program, with a view to establishing a software integration testing and accreditation function.

THE NEHTA PROGRAM 2008 Every day, in every site of healthcare delivery in Australia, healthcare providers are collecting, communicating and exchanging information, of sometimes critical importance to their patients and the quality of care they can deliver. Clinical communications between doctors and hospitals, clinics and laboratories, GPs and pharmacies are standard procedure in the workplace of every health provider. While some healthcare communications are electronic, the vast majority remain paper-based – a system with real and present flaws that can limit the speed, flow and accuracy of vital health information. NEHTA is working on a national platform to provide everyone with access to the right technology. The following principles underpin our approach to e-health: Identification: A national system to reliably identify the parties involved is important to improving the quality and safety of healthcare. Health identifiers will be given to patients, healthcare providers and professionals so that there will be no misunderstandings. Providers will also have secure and simple authentication processes to allow them to access the systems that contain the electronic healthcare information. Clinical terminologies: Computer systems used by healthcare providers will have software to interpret the clinical information

(or terminology) being input by the provider or organisation about a patient. This is another way to ensure that the communication is accurate and can be easily understood by the recipient. Message security: When a healthcare provider sends a message or a lab sends a test result, it is critical to know that the message will be transmitted to the recipient without interference or access during transmission. E-health ensures the safest and best method of delivering healthcare information. Privacy: As with all healthcare communications we want to ensure that our information is safe and protected. E-health systems have secure measures in place to protect information and provide audits on who has accessed the information. Choice: Finally, choice is a critical element in the delivery of healthcare. Patients are empowered to choose to participate in e-health.

THE MOST COMMON HEALTHCARE COMMUNICATIONS - FIRST OFF THE MARK The following common healthcare communications will be the first to be developed: Receiving pathology results seamlessly: E-pathology ensures a pathology test is accurately identified so there are no mistakes and quality of care is improved. Results can be delivered electronically, saving time and streamlining the process of patient testing. Prompt accurate patient reports: With e-discharge summaries, hospitals will be able to send a patient’s hospital record directly to the patient’s healthcare provider in a comprehensive report that again contains the ID of the patient and providers of care, so it is clear who received the hospital care and exactly what was provided. Comprehensive patient referrals: E-referrals are sent safely by electronic means by the referring healthcare provider. Again referrals will be tagged with the IDs of healthcare consumers and providers and the information contained in the referral will be clear and comprehensive because it has been transmitted through e-health. Instant, accurate prescriptions: Through e-medication management, prescriptions would be accurately and securely transmitted from the desktop to the pharmacy.

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RACGP Dr Ronald McCoy Dr McCoy is a GP and senior medical educator at the RACGP

General practice IT research GENERAL PRACTICE AND RESEARCH The need for scientific research in general practice is a largely untold story. Around 83% of the Australian community visit a general practitioner each year. How patients are treated in general practice must be based on sound research, often called evidence based medicine. Much of the evidence we require as general practitioners can only be obtained from general practice research that involves general practitioners and patients. Common problems faced daily in general practice include: • diagnosing conditions as early as possible where potential treatment benefits are maximal • whether a patient will receive the best treatment in the community setting or in hospital • managing treatments, including medications and lifestyle changes, and • balancing the treatments of multiple conditions. In general practice these decisions are serious, as many common conditions require lifelong treatment, such as for high blood pressure, asthma, depression, diabetes and arthritis. Evidence based health care must cross professional and organisational boundaries and this includes general practice.

GENERAL PRACTICE AND IT Information technology within the general practice setting seeks to improve both the delivery of care and the quality of care. This is done by reducing consultation time, strengthening allied and tertiary health networks and improving practice business models that will afford GPs higher levels of remuneration. While computer use has not been a traditional part of medical training, incorporating computer skills into medical training is the shape of things to come. As part of defining this shape, the RACGP curriculum1 now includes a statement on informatics. “General practitioners require modern skills for the increasing pace and change in clinical practice. The Internet is increasingly used to manage information in general practice. The RACGP Research Foundation attracts and distributes funds to support research and researchers in general practice through the provision of scholarships, fellowships, grants and awards. In addition, the RACGP Research Foundation encourages and supports all general practitioners to develop research competencies, especially targeting scholarships and grants for new and emerging researchers who are RACGP members or Fellows. The new round for grants is open now.

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Online tools can enhance the uptake of evidence based practice. As the profession faces information overload, general practitioners must equip themselves with the skill of information mastery,” said Dr Justin Tse, a Melbourne GP and Clinical SubDean, at the Royal Melbourne Hospital Clinical School.

GENERAL PRACTICE AND IT RESEARCH Over time, the perceived importance of IT in the general practice setting is changing. However, it is still often seen as a driver from a business sense and not necessarily an important part of ‘medicine’. “I’m a doctor,” someone said to me on the phone when talking about GPCG issues, “what the hell do computers have to do with me?!” This is where the role of general practice and IT research need to further merge in order to help the paradigm shift. Dr Tse received the RACGP Chris Silagy Research Scholarship and looked at online learning tools. “I really wanted to study two areas. One was general practice registrars’ attitudes and beliefs toward the internet and online tools for medical practice, and the impact of training on registrars – our future general practitioners – to see if there was an increase in the use of online tools in the general practice setting after specifically tailored intervention. “Using a combination of qualitative and quantitative methods, the study demonstrated that registrars participating in training for the use of online tools found that the internet was a useful and reliable resource.” Unfortunately Dr Tse noted that barriers included infrastructure, skills and acceptance. Hopefully future directions for general practice research involve further investigation of how to improve uptake, acceptance and harness IT. Change in general practice IT needs to be driven by those using the technology. After all, doctors have a hell of a lot to do with computers!

FOR MORE INFORMATION Should you wish to access further information on potential funding for general practice IT research, please contact Gabrielle Douglas at gabrielle.douglas@racgp.org.au or visit the RACGP website at http://www.racgp.org.au/ researchfoundation Should you wish to access further information on Dr Tse’s research go to: Tse J. Evaluation of online and computer learning as tools for enhancing evidenced based practice. Available at http://www.racgp.org.au/researchfoundation/ reports/8667

REFERENCES 1. Curriculum for Australian general practice. Available at http://www.racgp.org.au/curriculum [Accessed on 1/2/2008].


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EVENTS CALENDAR

Featured Event: Electronic Health Record and Data Management 2008 This event will show you how to: Improve the accuracy of your data and facilitate decision making; Address data storage, access, security and privacy issues; Achieve greater communication and facilitate health data transfer and remote access; Benefit from the latest digital imaging, network and other emerging technologies and more! Keynote Speakers: Prof Katherine McGrath, Fiona Wilson, Marc Probst, Gary Morgan, Chris Lynton-Moll, Prof Richard Madden, Angela Ryan, Dr John Lambert, Barry Lollo, Josephine Holman, George Bodilsen, Dr Craig Barnett, Jodie Pycroft, Evi Giameos 31st March - 3rd April • Bayview Boulevard, Sydney • Phone: 02 9223 2600 • Fax: 02 9223 2622 • www.iqpc.com/au/ehealth

HIMSS 2008 25th-28th February Orlando, USA P: 02 4365 7500 W: www.himss08.org 17th Annual Medico Legal Congress 2008 27th-29th February Sydney, NSW P: 02 9080 4000 W: www.iir.com.au 10th Annual AFR Health Congress 27th-29th February Dockside, Sydney, NSW P: 02 9080 4307 W: www.informa.com.au/ healthcongress 17th Annual HISA NSW Health Informatics Conference 14th March Coogee, Sydney, NSW P: 02 8907 1405 W: www.hisansw.org.au

19th Australian Software Engineering Conference 26th-28th March Perth, WA P: 08 9266 1835 W: www.aswec2008.curtin.edu.au

4th International Conference in Primary Health Care 17th-19th April Melbourne, VIC P: 1300 362 111 W: www.qip.com.au/conference.asp

Electronic Health Record and Data Management 2008 31st March - 3rd April Sydney, NSW P: 02 9223 2600 W: www.iqpc.com/au/ehealth

Hospital Bed Management Conference 7th-8th May Sydney, NSW P: 02 9080 4000 W: www.iir.com.au

Chronic Disease Management Australia 2008 1st-3rd April Sydney, NSW P: 02 9021 8851 W: www.terrapinn.com/2008/cdm SOA In Healthcare Workshop 15th-17th April Chicago, USA P: +1 781 444 0404 W: www.omg.org

7th Australian Wound Management Association Conference Darwin, NT 7th-10th May P: 02 6281 6624 W: www.awma.com.au Redesigning Healthcare for the Ageing Population 2008 20th-21st May Brisbane, QLD P: 02 9223 2600 W: www.iqpc.com.au Health Informatics Conference - The Person in the Centre 31st August - 2nd September Melbourne, VIC P: 03 9388 0555 W: www.hisa.org.au Health-e-Nation 2008 3rd September Melbourne, VIC P: 03 9388 0555 W: www.health-e-nation.com.au To view more Health, IT, and Health IT events, please visit the Pulse+IT website. Events can be submitted for consideration via the calendar on the website, or via email to: editor@pulsemagazine.com.au

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INTERVIEW: ZEDMED

In our first interview for 2008, Pulse+IT checks in with Dr Andrew Pascoe, Clinical Director of Zedmed and CIO/ Executive Director of Medical One Pulse+IT: What products does Zedmed have available to GPs and Specialists? Zedmed offers a full featured and fully integrated Practice Management and Clinical Solution. We have a single solution which is very customisable to both GP’s and Specialists and includes specific features for both, like our Billing Wizard and Chronic Disease Management Module for GP’s and our Batch Letter Writing Function for Specialists. Pulse+IT: What Zedmed features are new users attracted to? When we were evaluating software for our Medical One practices a few years ago, we chose Zedmed, or Medipak as it was known back then, for its ease of use, stability and security. We were also very impressed with the data conversion and the support that we received after the installation. Over the next couple of years we were so impressed with the software that we decided to buy the company. One of the key features that is generating a lot of interest in the market place is our Chronic Disease Management Module. This module has been designed to assist doctors and practices in the management of patients care plans, reviews and assessments, including Mental, 45+ and 75+. Prompts to remind doctors that the patients may be eligible for a plan, review or assessment, connect straight into templates and recalls and some very flexible reporting tools all assist the doctors and practices in providing excellence in patient care and benefiting from those Medicare rebates. A really handy feature in this module is the inclusion of the date and item number that the patient has last been charged for – stopping the doctors from performing unnecessary care plans, reviews or assessments that are not within the allocated Medicare date range.

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I also believe that it is the staff at Zedmed that new users are attracted to. We have always had an exceptional reputation through the industry for our support team and we see this as a key strength to the company. Pulse+IT: Which competing programs can you import data from? Having been in the industry for so long, Zedmed has seen just about all the software packages come and go from the market place. We have data conversions from almost all current and legacy programs - Pracsoft, MD2 & MD3, Medtech, Genie, IBA Classic, Plexus and Practix, Best Practice, RX, Medwin, Locum, Profile, and Mediflex to name a few. We also provide conversions from multiple solutions and merge them into a single Zedmed database. We offer free trail data conversions to all our interested clients. It is so much easier to evaluate software when you can see your patient information on the screen and have the assurance that all the information is there. Pulse+IT: How is the data conversion performed? Our staff perform the data conversion at the clients’ site, generally the night before they start using the software. With a trial data conversion done several weeks prior to installation, we can also tell how long the conversion is going to take, and provide the client with a full schedule for the roll out of the software. Pulse+IT: In addition to your own clinical product, do you allow other solutions to interface with your practice management product? Yes, Zedmed has the ability to separate our integrated solution into two modules – Zedmed Office and Zedmed Clinical. This allows us the flexibility to provide a practice with a practice management solution (Zedmed Office) where Doctors

are happy with their current clinical solution ie MD2/3. Usually over-time given the support and stability they see in Zedmed Office, we upgrade them to our integrated solution. Pulse+IT: Which secure messaging products does Zedmed integrate with? Currently, Zedmed integrates with a number of third party messaging products including Argus, Healthlink, Promedicus and Medical Objects. We continue to monitor and work with 3rd parties, in what we see as a critical component for the healthcare industry. Pulse+IT: How is training and support provided? We believe that comprehensive training is very important to the smooth transition to new software. Our training is done on site with the practice divided into Office and Clinical. The day that the practice start using our software (‘Go-Live’) we have trainers on site to assist with any questions and provide additional training to the practice management. Once the doctors are really using the software and preferably within a month, we like to go back in for an advanced training session. Customers support calls are answered by a “real” person, with over 97% calls resolved by the person answering the phone. This high level of staff product knowledge and expertise sets us apart in the market. All our support calls are logged into our internal helpdesk solution, which allows us to track each and every call and ensure that our customers are responded to in a timely fashion. We can then run reports on the types of calls logged and by whom, which provides us with information on who may need additional training and on what, as well as what areas in the software need some attention by development.


Pulse+IT: How many people make up the Zedmed team? The Zedmed team consists of 18 staff, 17 of which are based at our Head Office in South Melbourne and 1 in Adelaide. We have 5 full-time developers and a team of 6 support staff sitting next to each other, sharing information. To support our rapidly expanding NSW Market we will be opening an office in Sydney this year. In addition to this, we have partners providing local support in WA (Heron Consulting), SA and Queensland. This allows us to provide on the ground sales and support assistance across Australia.

database (approx. $230 for a single doctor) and ICPC for problem coding (approx $210 upfront then $110 per doctor). These costs are pro-rated based on a sliding scale dependent on users’ numbers.

Pulse+IT: Overview your pricing structure. Zedmed pricing consists of an upfront fee for the software licenses, installation, training and, if required, a data conversion. Our only ongoing fee is for our support subscription, which provides unlimited telephone, email and internet support as well as all the upgrades to our software and the MBS / private health fund fee’s. For example an average 8 workstation practice has a software license cost of $7900 and an annual support fee of $2370. Data conversion, installation and training costs are customised depending on requirements and number of staff.

Pulse+IT: How frequently does Zedmed release program updates? For our major software enhancements, we have a formal development cycle of 6 months. This includes a testing period both internally and at selected Beta sites reducing the number of errors and ensuring a smooth upgrade of our software. These releases fall in time with the MBS schedule of May and November. Having a development team here in Australia also means that we are very responsive to any updates that are required immediately such as changes in Medicare, MIM’s etc. New updates are posted onto our web site when required.

Pulse+IT: In addition to the Zedmed licences, what other costs may practices have to meet? Thirdpage.180x80.pdf 10/10/2007 Zedmed uses MIMS as our drug

Pulse+IT: How frequently does Zedmed release drug updates? MIMs updates are available for download monthly from the Zedmed website. If at any time there are other updates, for example the Streamline Authority Scripts, we endeavour to have it on our website and available to our customers as quickly as possible.

Pulse+IT: Is professional IT assistance required to perform these updates? No, updates are very simple, they can 7:49:32 AM be downloaded from our web site or

we send out CD’s. Once installed on the server by a practice staff member, they automatically copy to the workstations on launching the application. If any practices are concerned about doing their upgrades they are more then welcome to call our support line for assistance Pulse+IT: How many practices are currently running Zedmed? Over 700 practices are currently running Zedmed and these numbers are increasing rapidly. In particular Zedmed is well suited to large sites and/ or multiple branches running on a single database so at last count we had over 4,500 users. Pulse+IT: What new features are you working on that Zedmed users should look forward to? We are currently working on some small enhancements that our customers have requested, to make the software more intuitive for doctors. Larger projects in the development cycle include integration with Medicare Easyclaim and upgrading to Medicare v6.8 which includes the DVA changes. We are looking to provide simple integration to numerous 3rd party clinical audit tools as more doctors require flexible reporting capabilities to manage and provide superior patient care. Zedmed www.zedmed.com.au

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FEATURE Simon James BIT, BComm Editor, Pulse+IT simon.james@pulsemagazine.com.au

An introduction to specialist computing INTRODUCTION This article is the first in a series that will seek to draw attention to the importance and potential of specialist computing. This instalment serves to map out the themes that will be canvassed throughout the series by highlighting some of the unique computing challenges and opportunities specialists face in their private practice setting. For the purposes of this introductory article, no attempt has been made to differentiate between the needs and nuances of the various specialties i.e. all participants in the secondary care market have been treated as a homogenous collective. Future articles in this series will highlight the different IT requirements of procedural and non-procedural specialists, and indeed, draw attention to some of the unique requirements of individual specialties.

capacity many specialists enjoy would limit the effectiveness of IT related Practice Incentive Program (PIP) style incentives for specialists, the author is of the belief that this should not preclude the secondary care market from receiving resources and training to assist with the adoption of information technology. That said, with information technology permeating into all aspects of modern society, it may be that the motivation for some specialists to computerise may come from entirely nonmedical influences. Indeed, specialists who have previously had little exposure or interest in computers may be attracted to increasingly accessible main-stream technology applications such as online banking and share trading, digital photography, online music and movie downloads, Internet telephony, and even computer games.

INCENTIVES TO COMPUTERISE

UNIQUE NEEDS

While there has been a long running push to improve levels of computerisation in private practice, to date, much of this attention has been directed at general practice. As a consequence, general practice is now relatively well computerised, however adoption of information technology by private specialist practice has been less impressive. The recent Australian General Practice Network (AGPN) budget submission has highlighted the importance of improving the level of information technology uptake by non-GP health professionals. Focussing on the purported need for more effective team based primary care, the AGPN has requested that $25 million funds be directed to allied health professionals to assist with the purchase of hardware and clinical software. While the AGPN is not jurisdictionally bound or resourced to drive the adoption of information technology in the secondary care space, the justification presented by the AGPN in its pitch to the Treasurer to support the rollout of information technology in the allied health sector applies equally well to specialist practice. That is, improving the level of computerisation in the secondary care sector will benefit both the clinicians who adopt information technology, as well as their colleagues with whom they routinely correspond. Unlike general practice, specialist practice has not enjoyed any significant direct financial subsidies from Government to computerise, nor have they enjoyed technical support and assistance from an over arching Government funded Divisionlike network. While it may be successfully argued that the high earning

From a computing perspective, there are several similarities between the needs of specialists and GPs. Indeed, many of the software packages originally pitched at general practice are now also sold in configurations for specialist practice. In addition, most hardware and associated peripherals are equally suited to both specialist and general practice. Despite the commonality in their software and hardware options, the fundamental differences between the way that GPs and specialists practice medicine dictates that the way GPs and specialists interact with their information technology will also be different. Following is an introductory overview of some of the IT related aspects of specialist practice that will be discussed in detail during the course of this series.

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Referrals and Scanning Referrals, and letters back to referrers, drive the IT workflow in specialist practice. Because of the importance of these documents, practice software designed for specialists tends to have a strong focus on document generation, storage and management. High capacity document scanners suitable for general and specialist practice have fallen in price, and have greatly improved in quality in recent years. Perhaps more importantly, the software that drives these devices has also improved, as have the clinical document storage options available to specialist practice. Suitable document scanners and the scanning and


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document management functionality of various practice software solutions will be reviewed in the May 2008 edition of Pulse+IT. Typing and Dictation Stemming from the predominantly ‘letter-based” patient record system used by specialists, the combination of dictaphones and medical typists (either in-house, or outsourced) is often found in specialist practice. This clinical note-taking and document generation workflow can be contrasted with that of GPs — while a regrettably high number of GPs still record their clinical notes on paper, GPs that do keep electronic health records tend to input their notes directly into their clinical system themselves. The various medical typing services, and the way popular specialist clinical software integrates with these services, will be discussed in the November 2008 edition of Pulse+IT.

(IHE). The activities of this group and the potential impact of their work on the secondary care sector will be highlighted in the August 2008 edition of Pulse+IT. This edition will also include coverage of the various digital clinical imaging distribution solutions available on the market.

Voice Recognition On the back of ever increasing computer processing power, voice recognition technology has matured rapidly in the past few years. While it is certainly not a flawless technology, it is being used successfully as an effective primary input technology by specialists interested in generating their own reports without the assistance of a typist or typing service. Suitable microphone options and voice recognition software, for both Windows and MacOS X, will be previewed in the November 2008 edition of Pulse+IT.

Mobility Specialists typically spend less time tethered to a single location than their GP colleagues. As a result, IT systems designed for specialists need to be able to function seamlessly from multiple, geographically dispersed locations. Access to both clinical and billing data can be facilitated using either remote access solutions, or by physically transporting practice data to the various sites of service. Largely driven by improvements in software technology and Internet bandwidth, the establishment of a secure connection from a remote location to a specialist’s base practice is now a relatively straight forward undertaking. The dramatic improvements in mobile wireless broadband technology, and the burgeoning ultra-portable laptop and slate tablet markets provide specialists with a wide variety of portable computing options. A comparison of the various remote access software solutions will be featured in the May 2008 edition of Pulse+IT. This edition will also feature a comparative review of various mobile broadband solutions, in addition to a separate discussion about the rising popularity of ultra-portable laptops and slate tablet devices.

Secure Electronic Messaging The entire health sector is rapidly becoming aware of the burden placed on recipients of paper documents. While scanning can overcome physical storage issues, it is unavoidably a labour intensive process that consumes hundreds of hours worth of time per year in a typical “paperless” practice. While many specialists place great emphasis on the physical presentation of their letters, the GP sector is becoming more vocal about the benefits that the electronic receipt of clinical documents delivers. In addition to providing their referrers with a valued service, secure clinical messaging allows specialist practices to benefit from reduced paper handling and postage costs. Further, as more GPs adopt secure messaging solutions and electronic referral rates begin to rise, specialist practice also stands to benefit from a reduction in incoming clinical paper correspondence. While significant coverage of secure messaging was presented in all editions of Pulse+IT throughout 2007, an article focussing on secure messaging from the perspective of specialist practice will be included in the August 2008 edition of Pulse+IT.

Appointment Systems Stemming from the fact that many specialists work from multiple locations, sometimes under complex cyclical arrangements, specialist practice’s usually have more specific requirements for their electronic appointment systems than their GP colleagues. Given the limited availability of doctors within many specialties, it is not uncommon for appointments to be booked months in advance of the scheduled encounter. Due to the high commercial value placed on specialist’s time, the importance of patients presenting for their scheduled appointments with a valid referral cannot be overstated. While a busy GP may relish the occasional “no-show”, the failure of a patient to present for a scheduled procedure is likely to impose a significant opportunity cost on a specialist. Technological solutions such as SMS and email can help to minimise patient “no shows” without placing additional burden on administrative staff. The August 2008 edition of Pulse+IT will feature an in-depth comparison of the various appointment systems available to specialist practice, including a discussion of how these appointment systems interact with SMS and email reminder functions.

Clinical Imaging Recent improvements in the bandwidth of both cabled and wireless broadband solutions means that specialists now have access to technology that provides the ability for them to view and transmit clinical images over the Internet. In the wider digital clinical imaging context, the importance of standards are being promoted by the recently formed Australian chapter of Integrating the Healthcare Enterprise

CONCLUSION

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This article has presented an overview of a forthcoming series on specialist computing aimed at demonstrating some of the practical benefits information technology can deliver to specialist practice. Throughout the course of the research and construction of this series, input from specialists, their practice managers and their support staff will be warmly received by the author.


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Australia’s Leading e-Health Conference HIC’08 brings together a broad community of those involved in health care, the information sciences and industry to explore the critical issues that sit at the interface between health care and information technology.

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The Person in the Centre This year HIC’08 will look at the changing role of consumers and providers in health care and the systems that support them.

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FEATURE Simon James BIT, BComm Editor, Pulse+IT simon.james@pulsemagazine.com.au

The Collaborative Centre for eHealth and the Australian Healthcare Messaging Laboratory INTRODUCTION Opened in 2000 by the Vice Chancellor of Ballarat University, the Collaborative Centre for eHealth (CCeH) was established to advance the quality of healthcare information systems integration in both Australia and around the globe. The CCeH is located in the University of Ballarat’s Technology Park, a modern university campus hosting offices for several IT companies servicing the health sector, including IBM and GE Healthcare Technologies.

THE AUSTRALIAN HEALTHCARE MESSAGING LABORATORY CCeH is best known as the organisation behind the establishment of the Australian Healthcare Messaging Laboratory (AHML). Secure clinical messaging is a complex area that presents a wide array of regulatory, privacy and technical issues. The inability for the creators of transportable electronic health data to harmonise the formatting of such data remains one of the biggest impediments to widespread secure electronic messaging in Australia. The AHML seeks to assist software developers to address these technical issues through its message testing and software certification services, each of which are discussed in more detail below: HL7 Message Testing Facility The facility allows clinical and messaging software vendors to test the quality of their Health Level 7 (HL7) messages against various international and Australian iterations of the HL7 version 2 standard. Endorsed by the National e-Health Transition Authority (NEHTA) for the short to medium term, HL7 v2 is widely used in Australia for secure clinical messaging. The AHML service is virtual in nature and is accessed via the Internet, either via a graphical web user interface or using HTTP commands. After registering, users are able to select a HL7 profile and upload a HL7 message to the system for testing against this profile. Within a matter of seconds, a report on the quality of the message is generated and displayed for the consideration of the user. The report highlights areas of non-conformance, errors, warnings and alerts, referencing the relevant part of the HL7 standard that has been breached to assist the user to

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address any issues. The AHML does not charge setup or per message charges, and access to the testing facility is available to both Australian and international users. To date, the facility boasts over 380 registered users hailing from over 30 different countries. Unique globally, the AHML message testing engine has proven particularly popular in the United States, Britain, Europe and India. For reasons of merit or otherwise, there is an increasing global interest in the XML based HL7 version 3 family of formats. While AHML does not currently provide testing routines for HL7 v3 messages, this significant undertaking is currently under consideration. Software Certification Services Beyond its online message testing facility, AHML also provides software certification for products that generate or manipulate HL7 messages. After testing a product’s HL7 capabilities, a certification officer works with the software vendor to address any non-conformance issues. AHML certification services can be used by individuals and organisations involved in the development and implementation of software within the healthcare arena who wish to guarantee that their HL7 messages are compliant with the HL7 standards. Among others, AHML certification clients can include those from the following sectors: • Software industry developers requiring certification of conformance to recognised standards of messaging functionality in their products. • Government Departments and Agencies developing software systems that communicate with other parties in the healthcare system. • Private and public healthcare organisations requiring certification that messaging implementations conform to specified standards. According to Chris Lynton-Moll, Manager and Executive Director of AHML, certification can deliver significant benefits for organisations that complete the process. “Certification is for those organisations wishing to pass on the extra assurance to their customers that the messages generated or manipulated by their software can be


relied upon. Your business partners will know that you can communicate with one another according to Standards and you competitors will be aware that you are serious about healthcare messaging.”

NATA ACCREDITATION The AHML is accredited by the National Association of Testing Authorities (NATA), an Australian Government endorsed provider of accreditation services for laboratories and testing facilities. Every three years, independent assessors from NATA conduct a 2 day accreditation visit to ensure compliance with both ISO 17025 and NATA standards. Because of the AHML’s accreditation by NATA, software vendors who obtain AHML certification can display both the AHML logo and the mark of the International Laboratory Accreditation Cooperation / Multilateral Recognition Agreement (ILAC MRA). The ILAC MRA mark affords global recognition to organisations that attain the qualification, allowing organisations to be compared to their international peers.

OTHER CCeH SERVICES CCeH is largely self-funded, receiving proceeds from consulting, tenders and research grants. CCeH also offers training courses in HL7 messaging, and has recently been engaged by HL7 Australia to run a series of HL7 training courses and workshops around the country. Sessions have already been held in Melbourne and Brisbane, with the CCeH staff scheduled to visit Sydney, Adelaide, Perth and Hobart later in the year.

Currently, CCeH is commencing a project with the Royal Australian and New Zealand College of Radiologists (RANZCR) to develop Best Practice Report Templates, as well as some further work for DHS Victoria on their SCTT referral project. CCeH has also entered into a partnership with CAL2CAL Corporation in Los Angeles, California, to establish, develop and promote healthcare applications to the Australian and United States healthcare systems.

THE CCeH TEAM CCeH is staffed by a core team of four, with contractors engaged on short term contracts when expanded work programs require additional staffing capacity. The running of CCeH is overseen by Chris Lynton-Moll, Manager and Executive Director of AHML. Prior to assuming his current role in 2002, Chris worked as a Chief Scientist for a pathology group, and more recently as the CIO of the Royal Hobart Hospital. Programming duties are undertaken by Senior Software Engineer, Jane Gilbert, and Programmer, Evan Dekker. In her roles as a Project Officer and Quality Manager, Priscilla Clark is primarily responsible for maintaining the preparedness of AHML for accreditation by NATA.

REFERENCES ISO 17025 (General requirements for the competence of testing and calibration laboratories). Available at http://www. iso.org/iso/catalogue_detail?csnumber=39883 [Accessed on 1/2/2008].

Introducing HealthLink’s Partner Systems

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Tel 1800 125 036 enquiries@healthlink.net

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FEATURE Chris Paine and John Stewart Senior Consultants, National Recruitment Healthcare chrisp@natrec.com.au johns@natrec.com.au

Health IT recruiting DIG deeper or look overseas?

Many organisations struggle to find adequate numbers of suitably qualified staff within the broader Health IT domain. This brief commentary makes some suggestions that organisations may wish to consider when developing Health IT recruitment strategies. The shortage of qualified staff is endemic through all industry groups in Australia - we are not alone in Health IT. With the national unemployment rate registering at a 30 year low of just 4.3% in January 2008, it should come as no surprise that there is a high demand for workers in the business, legal, science, engineering, technology and health sectors. The latest Australian Medical Workforce Advisory Committee report1 into General Practice pointed to a shortage of between 800-1300 GPs nationally, recommending that as many as 1200 GP workforce entrants will be required annually between 2007 and 2013 to address the shortfall. Nurses are also in short supply, with pre-election promises from the Rudd Labor Government committing to bring an additional 9,250 nurses into the Hospital system to reduce the chronic shortage. Over and above the general workforce gaps faced by the health sector, the Australian Health IT industry faces some of its own issues. As a discipline, Health IT is relatively new; many of the roles currently available did not exist 10 - 15 years ago. As the sector continues to evolve we anticipate that many new roles will be created into the future. Furthermore, recruitment in this space can be difficult for both the employer and employee, especially when the candidate is attempting to transition from a purely clinical role, or has experience in IT but little exposure to the health sector. Experience tells us that there is not a simple solution to these workforce issues — effective strategies will include re-visiting Australia’s current capabilities and possibly looking abroad. Indeed, the recently released review1 of NEHTA’s operations prepared by The Boston Consulting Group (BCG) urged the organisation to engage in offshore recruiting activities to address its inability to hire sufficient numbers of suitably qualified Australian Health IT professionals. “Where feasible, short-term international secondments of experts from the UK, Canada or the US could also be beneficial where there are suitable local staff to learn from them.” We routinely discuss international recruitment with clients ranging from Health IT suppliers to public hospitals, and feel that while offshore recruitment may be part of the solution, it is an expensive and hazardous proposition. In the first instance therefore, we encourage all organisations to have a closer look at our own back yard and do a bit more digging.

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DIG DEEPER The vast majority of the Health IT roles we recruit for are for consultants and implementors - very few are for IT developers. Often candidates for these roles are clinically trained individuals who are IT savvy with a desire to further their careers. DIG-IT is a methodology we and our more successful clients utilise to find the right people for roles in Health IT: D - Define your needs The first question to ask is: Does Health come before IT or does IT come before Health? This seems like a crude question yet we find it particularly useful. A lot of our clients find it a lot easier to train people in IT skills than it is to teach IT specialist the workflows and intricacies of the HealthCare environment. Also, be very specific about the exact clinical requirements for a role and which attributes are necessary and which are desirable. I - Identify your audience If you are looking for IT savvy clinical staff then your efforts should be focused on talking with clinically trained people. In these instances we focus our efforts on clinically trained individuals who can demonstrate a competency with IT and a willingness and aptitude to learn. G - Grow your base and communicate Many candidates are unsure of Health IT and sometimes intimidated by the concept. Why? - Because they may associate IT with programmers, technicians and developers thereby overstating and misunderstanding the actual skills required to be successful. Also, they may be uncertain of the role IT now plays in improving patient management and care, and unaware of career development opportunities Health IT offers. Take time to educate potential candidates and grow your recruiting pool. I - Interview creatively The interview process can be difficult for all parties. During the course of a working day, an ICU Nurse thinks, speaks and behaves differently to a Radiographer, Accountant, Doctor, Pathologist and IT Professional. Recognise this and afford candidates the opportunity to speak freely about what is


important to the role from their perspective. A focus on what a candidate can do will also identify areas for further training, lead to improved understanding of the roles and often uncover relevant information that the candidate might not otherwise express. T - Tailor the transition For a candidate to make the transition from a clinical position into a Health IT role there is often emotional and intellectual stress. The reason is that the candidate is effectively making a career change and will be moving away from what is known and comfortable. Assist them. Take time to explain the nature of the roles and their importance within the healthcare sector. Provide the necessary training and continuing mentorship and support. In our experience, we have found that both age and sex are not good predictors of the suitability of candidates. We have assisted several candidates with a variety of backgrounds transition from pure clinical roles across to Health IT positions. These include a Pathologist with 4 years clinical experience, a Director of Nursing with over 18 years experience in emergency wards and intensive care units, a Radiographer, and a Psychiatric Nurse.

LOOK FURTHER AFIELD International recruitment may be advantageous. However, as our industry is part of a global shift in the provision of healthcare, our impression is that a focus on7:46:33 Canada, UK Halfpage.180x120.pdf 10/10/2007 AM

and the USA may not be beneficial. Sure, there are language advantages and the Canadian and British health systems demonstrate some similarities with Australia’s health system, however if we look at nursing as an example, we observe that the trafficking of staff between these countries is reciprocated and does not lead to net workforce gains. Europe is a potential source; however we feel that there are many more opportunities within Asia. This is due to Australia’s changed demography, government and business initiatives into Asia and our increasing national interdependence with the broader Asian region. Importantly there are a number of countries in our region that are doing excellent, and at times unseen work in this domain. Importantly, many of the people doing the work have studied overseas, speak English, have a wider cultural awareness and exhibit high levels of adaptability. Notable in their efforts of adopting IT in health include South Korea, Thailand, India, Singapore, China and Hong Kong.

REFERENCES 1. Australian Medical Workforce Advisory Committee. The General Practice Workforce In Australia: Supply and Requirements to 2013. Available at http://www.health.nsw.gov. au/amwac/pdf/gp_summary.pdf [Accessed at 1/2/2008]. 2. The Boston Consulting Group. NEHTA Review. Available at http://www.nehta.gov.au/index.php?option=com_ docman&task=doc_download&gid=421&Itemid=139 [Accessed at 1/2/2008].

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FEATURE Dr Paul Cooper Ph.D (Biochemistry) Industry Director, Health and Human Service, SMS Management & Technology Member AICD, Dep Chair Australian Information Industry Association (Vic) pcooper@smsmt.com

Leaning towards sustainability INTRODUCTION It’s now clear that in an effort to appear green, many organisations are trying to paint over poor business processes – a practice known as “green-washing”. This is a shame because it’s increasingly clear that true sustainability-oriented practices provide tangible long-term benefits for organisations as well as being good for the environment. To help give some dimensions to one aspect – let’s look firstly just at waste management in healthcare. A recent Victorian Government finding1 estimated that waste management costs in the Victorian healthcare setting are around $90M per annum. The report also stated that ”senior management levels at some sites were not aware of the high costs of general and clinical waste management and the financial savings that can be made from ensuring correct waste separation, increased recycling and waste reduction; environmental successes made by reducing waste and increasing recycling are not widely acknowledged and or promoted; and up to 40 different departments are responsible for waste management.” This conclusion is undoubtedly true of other jurisdictions. In a healthcare setting there is also the potential benefit of improved health outcomes for people in an optimum environmental setting. Putting all these improved sustainability practices together can provide tangible benefits such as cost savings, improved well-being and reduced environmental impact. In the USA there is at least one index2 attempting to measure hospitals by a Green Index of 12 criteria including physical site location, waste reduction, energy and air pollution, materials and resources. But given that many of our healthcare practices and hospitals have been in place for many years, what benefits might realistically be achievable for the healthcare sector in Australia today? This was the question put to a forum of our consultants recently. In response, our consultants recommended that the improvement practices developed in other sectors including the corporate sector could be usefully applied to the health sector. A key approach that originated in the manufacturing sector is known as Lean/Six Sigma. Lean was developed by the car-maker Toyota in an effort to reduce waste in seven major categories. In more recent times, Lean has been combined with Six Sigma process improvement which concentrates on reducing process variance. Combined together, Lean/Six Sigma is becoming widely accepted as an effective process improvement and waste reduction management approach – well beyond the manufacturing sector where it began.

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HOW CAN LEAN/SIX SIGMA WORK TO IMPROVE SUSTAINABILITY PRACTICES? In fact, it is pleasing that the health sector has embraced the Lean/Six Sigma process improvement practices with a noteworthy degree of interest. This adoption of Lean/Six Sigma suggests that building upon this approach in a holistic manner to further incorporate improvements in waste and energy management in addition to the patient flow improvements that are a frequent target, could be helpful in building a sustainable healthcare approach. The use of Lean/Six Sigma might thereby help achieve the twin benefits of greener hospitals that also have reduced running costs and better health outcomes (e.g. through improved patient flow and lower error rates.) It is our belief that many organisations, and most particularly the health and human services sector would benefit from any sustainability initiatives being considered in the context of overall process improvement approaches. After all, the Lean approach considers process improvement from the point of view of waste elimination – primarily from the perspective of wasted time and effort to be sure – but it is not a large leap from that thinking to the more direct and tangible waste aspects associated with supply chains, and actual physical waste disposal processes and carbon and energy footprint reduction. Efforts to improve work processes that result in better business practices also have a resultant flow-through of reduced consumption of supplies and reduced waste.

ENGAGE GREEN TECHNOLOGY TO ASSIST Some practical ideas that help in sustainability include the use of low-energy lighting (with proximity sensors), and better environmental management systems using advanced heating, cooling and air recirculation systems for buildings. However, consider enlisting the Information Technology department as well: they can also assist in the drive to improved sustainability. With manufacturers creating low energy servers and desktops, there is an emerging opportunity to change over some or all of your computers towards more energy efficient devices. There’s also a technology called virtualisation that is proving helpful: virtualisation is where today’s powerful hardware is enabled to run several instances of software so that its utilisation is increased and made considerably more efficient. Virtualisation of servers also has the benefit of enabling easier migration of servers from one physical location to another. This is a key requirement in relocating an IT environment in the event of a physical issue (power failure, fire, flood, etc).


Computer processor manufacturers have recently made the task of virtualisation even more efficient by enabling the processors themselves to do some of this complex work thereby further improving the efficiency of this approach. While figures vary, medium-sized organisations are finding some energy savings and benefits through virtualisation approaches. We believe virtualisation will become mainstream in 2008 and beyond. Going further than changing the desktop environment, some organisations are deploying approaches that enable whole departments or specifically nominated sets of desktops to be put to sleep or powered off by centralised commands. In this manner power can be saved. Some green sites are even advocating the use of software to change the default screen colour of older CRT monitors to black in order to reduce power consumption in monitors! While we are not fully convinced yet about some of these claims, we do know that paper printing is a major cost in all industries including healthcare, and that much printing is wasted or unnecessary. One partial solution is to employ a software application that acts as a final layer before a print is generated. Such software can show the user what the printed document will look like and also provide the option to eliminate unnecessary pages (for example that wasted column from a spreadsheet, or unwanted graphics from a print of web pages.) Try Googling the term “greenprint” to see one example of this approach that looks interesting although we haven’t yet seen it deployed in a healthcare setting. Other efforts include eliminating duplicated information entry – so implementing efficient Patient Administration System, and finance systems can provide major benefits here – as can developing an overall information management plan to ensure that an efficient information flow is occurring in the service as a whole. In more clinical areas, companies such as Intel and Microsoft with specific health practices are heavily investing in technologies that enable mobile healthcare at the point of care. These systems (built on replicable processes and practices) are often less affected by the interrupted workflows experienced by clinicians than contemporary approaches. A key goal of sustainability efforts is to reduce car or air travel by both staff and patients, and in certain specialised cases of telemedicine (remote diagnosis, and even remote robotic surgery) has some potential travel savings benefits as well. Now is also the time to start planning for how to take advantage of the eHealth initiatives (electronic referrals, electronic shared

health records, electronic booking, electronic prescriptions etc). eHealth also has the potential to decrease unnecessary travel and increase efficiency. In fact, many trials are underway both here and overseas that demonstrate improvement to organisational efficiency and effectiveness, but it is also clear that electronic health records provide an additional benefit of data security (as seen during Hurricane Katrina where USA military patient records that were electronic were preserved where many paper records in public hospitals were lost.) Other useful technologies to consider include scanning software, advanced document management systems, and digital transcription/ voice recognition systems to reduce the need for additional work effort. Measuring the benefits to be achieved will require some up-front thinking from a Benefits Management approach which will help to identify the contribution expected from each of the identified benefits prior to the initiative being implemented. A Benefits Management approach relies on appropriate measures being regularly reviewed to ensure the expected benefits are achieved. In the end, all savings in work-effort ultimately reduce environmental impact and thereby help achieve long-term sustainability goals.

WHERE CAN YOU START? Our advice is: 1. Begin from a Lean/Six Sigma process improvement perspective with one of the process areas required to identify how sustainability objectives might be included, and to put appropriate benefits measure in place. 2. Make sure you have the needed buy-in from the executive team – ideally they should be the direct sponsors of the improvement program. 3. Conduct a sustainability audit that will identify the most significant areas of waste and cost – and then target those areas in which Lean/Six Sigma process improvements might best be focussed 4. Don’t forget your IT Department – apart from improving their own efficiency of operation, they may be the key to your overall organisation achieving some very significant efficiency, quality and sustainability objectives In summary, to “go-green”, “think-lean”!

REFERENCES 1. Waste Minimisation in Health Care. Available at http://www.sustainability.vic.gov.au/www/ html/2375-health-care.asp [Accessed on 18/02/2008]. 2. Kweller K. The Top 10 Green Hospitals in the US: 2006. Available at http://www. thegreenguide.com/doc/113/top10hospitals [Accessed on 18/02/2008].

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FEATURE Andy David Asia Pacific Healthcare Director for Oracle andy.david@oracle.com

Electronic health data holds potential to transform clinical trial recruitment and hasten new drug releases Electronic Medical Records (EMR), software that allows the creation, storage, editing and retrieval of a patient’s data on a computer, and to a lesser extent Electronic/Personal Health Records (EHR/PHR) have been making strides around the world. Many hospitals or hospital clusters have to some extent either implemented EMRs or are in the process of doing so. Many countries around the region are also looking at putting in place the infrastructure that would support EHR/PHR as well. Countries like Singapore, Australia, Taiwan, Malaysia and Hong Kong have made significant progress in both these areas and there will be more to come. As exciting, but often less reported, are the potential benefits such initiatives can deliver to the life sciences and biomedical industry. There are significant crossover benefits that take aim at some of the industry’s most vexing challenges – more effective and efficient identification and recruitment of clinical trial participants and the ability to simultaneously capture clinical trial data from the electronic health record to decrease the costs of clinical trials, resulting in faster time-tomarket for new drugs.

WANTED: FASTER, MORE COST-EFFECTIVE CLINICAL TRIAL RECRUITMENT With the average cost of developing a new prescription drug creeping toward US$1 billion and the process often spanning more than a decade, pharmaceutical manufacturers are continually searching for ways to extend efficiencies at all stages of the development continuum, allowing them to bring safe products to market faster and at a lower cost. Clinical trials – which average US$124 million per drug candidate after accounting for drug failure rates1 and whose costs are rising faster than pre-clinical research and development activities – are a prime target for scrutiny. Rising clinical trial costs can be attributed to several factors, including new challenges related to trial candidate identification and recruitment2. Clinical trial patient recruitment is also an increasingly timeconsuming process. One study, which looked at 4,000 clinical trials over five years, discovered that nearly half of the time spent on the trial process involved patient, site and investigator recruitment2. On average, difficulties in patient enrolment delay 81 percent of all clinical trials from one to six months, costing

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pharmaceutical companies as much as US$8 million dollars each day3. This figure does not take into account the human costs of such delays in terms of the inevitable morbidity and mortality when promising new drugs are delayed in reaching the market.

CONNECTING EMR AND CLINICAL TRIALS Today, initiatives at individual investigation sites in the United States, Europe and Asia are revealing glimpses into the potential of patient’s EMR data to transform clinical trial recruitment. This will require biomedical and life sciences to work together in terms of information exchange. The pharmaceutical company will provide physicians, in both the public and the private sector, with information on the clinical trials currently being conducted, as well as the selection criteria for the trials. The physicians, on the other hand, could reference a patient’s EMR during a routine examination to determine if the patient meets eligibility requirement for a particular clinical trial based on the record and the trial requirements. If a patient matches the criteria for any study, the physician could immediately collect the additional information required for the trial from the patient, record the data in the EMR and send an electronic notification to the relevant party. At that point, screening for the trial is completed – within a matter of minutes. By combining electronic health records with data mining tools, pharmaceutical companies can also have the potential to quickly query the EMR database to determine the number of potential candidates for a specific study and to assess the viability of candidates for a specific trial. They can also potentially and quickly screen large numbers of anonymised electronic records for potential trial candidates using any number of factors, including age, sex, co-morbidities, lab results etc. In this way, pharmaceutical companies could efficiently approach physician groups that they know treat significant numbers of patients matching a specific trial candidate profile. This method could be particularly useful when recruiting for trials for drugs intended to treat rare conditions, as the trial sponsor from the pharmaceutical or biomedical company could efficiently search for specific criteria. The end result could be faster and more cost-effective trial participant identification and recruitment – ultimately accelerating time-to-market.


While the approach outlined above would enable more effective targeting of physician practices that treat viable candidates, another approach being advanced would take information on clinical trials directly to the potential candidates. It would involve the creation of a patient opt-in mechanism, in which individuals would grant permission to have life sciences organizations access their health information via the EMR and when launching a clinical trial, to contact them directly. This approach could go a long way toward empowering patients to take charge of key health decisions, as well as streamlining the participant recruitment process. To optimise the success of this approach, physicians would also need to be notified, in tandem, when trial sponsor contacts their patients. Once a patient is enrolled in a trial, researchers could then incorporate data captured from a specific study as part of the EMR and routine clinical care by physicians. Automating these processes can help accelerate clinical trials by streamlining patient enrolment and documentation. If all the relevant trial and medical information is available to the doctor in the form of EMR, the physicians are able to make accurate and correct diagnosis 80% of the time.

ELECTRONIC RECORDS AN IMPERATIVE; NEED TO OVERCOME HURDLES The conversion from paper records to electronic records in the healthcare system will be a complex one. Issues such as data privacy, data protection, regulation and audit have to be addressed. Having said that, the healthcare and life sciences industries are optimistic about the potential of electronic health data to transform the delivery of healthcare as well as the drug development process, including spurring advances in the quest for personalized and translational treatments and therapies. The critical technology components needed to enable meaningful exchange of information between the healthcare and life sciences industry exist today – as do the data mining and analytical tools needed to interpret data and drive incisive action. By combining these core technologies with proper planning and vision, electronic health records offer one of the brightest hopes for the future of the healthcare and life sciences industries and their quest to save and enhance the quality of lives.

Critical information when you need it For free downloads of health informatics Australian Standards, handbooks and implementation guidelines visit www.e-health.standards.org.au Messaging

Electronic health records Health supply chain

Security for health information

Health concept representation

Telehealth

Standards Australia develops consensus-based e-health Standards and related document that meet Australian requirements for secure health system interoperability. Standards Australia is recognised nationally and internationally as a leader in the development of standardisation solutions, allowing Australian businesses to compete globally.

REFERENCES 1. Di Masi, J.A., Hansen, R.W., Grabowski, H.G. “The Price of Innovation: New Estimates of Drug Development Costs,” Journal of Health Economics, 2003. 2. CMR International R&D Briefing: Benchmarking for Efficient Drug Development (2000). 3. CenterWatch

STANDARDS


FEATURE Glenn Stephens B. Comp. Sci, MBA (ebusiness) CEO, Medical-Objects glenn.stephens@medical-objects.com.au

Implementing effective clinical decision support OVERVIEW The goal of decision support is often touted as one of the key drivers for Health IT, in that it will result in improvements in patient outcomes, cost savings and other benefits. According to AMIA’s Clinical Decision Roadmap, “decision support has the capability to reduce adverse effects, improve health maintenance and chronic disease management, improve efficiency of health care and reduce costs”. NEHTA’s response to the Boston Consulting Group Report also flagged decision support as an area of interest to examine over the coming year. Decision support systems are not simple endeavours. While decision support is seen as the end game, many health informatics standards need to be in place before effective decision support can work. This includes atomic data in messages, good use of terminology, structured data collection, and an engine to run decision support rules. Medical-Objects have always had a plan to implement decision support in our systems — this plan has led us to embrace technologies such as SNOMED-CT, Archetypes in HL7 2.3.1 and to implement the world’s first GELLO Compiler. Some of these concepts may be new to the readers, but in essence, the combination of these tools allows you to capture data in a structured way, make suggestions and in some cases automate decisions based on the existing EHR data.

DECISION SUPPORT FOR LYMPHOMA In 2006-07, the Haematology Society of Australia and New Zealand, the Leukaemia Foundation, Sullivan Nicolaides Pathology, Queensland Medical Laboratories and MedicalObjects all participated in the development of a tool called the Lymphoma Wizard. The purpose of this tool was to implement an executable version of the clinical practice guidelines for the diagnosis and management of lymphoma available from the Cancer Council’s web site. Starting Small Like most projects, especially IT systems, adoption of a decision support system needs to start small to create small victories. Initially we created the archetypes that would be needed to capture the data and created an editor to represent the workflow and present static guideline information. These steps alone would constitute a decision support system that still would provide benefits. It can demonstrate the flow of actions that are recommended for the clinician, and the clinician would not have to refer to paper guideline documents that may already be out of date. When updates to a clinical guideline occur, these updates would automatically be pushed

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from the author to the clinician’s desktop. This is important as it allows for updates in best practice to be distributed automatically. In the case of the Lymphoma Wizard, updates could potentially incorporate new treatments relating to new drugs that help patients or give them a list of updated clinical trials that may benefit the patient. Enhancing the Decision Support At this point, we then had a working version of the decision support tool that was practical to use. Once this was in place, we could complement the system by incorporating decision support rules in the form of GELLO. GELLO is an object orientated expression language (it is an ANSI standard programming language managed by the HL7 organisation) designed specifically to represent the logic in clinical guidelines. GELLO’s object orientated nature allows it to extract data in more powerful ways including queries, sorting, statistical analysis and much more. GELLO is based on the Objects Management Groups’ OCL (Object Constraint Language). Many software developers would be familiar with OCL as it is used in UML and in many tools that can support Model Driven Architecture (MDA). What makes GELLO so effective for clinical decision support is that it is designed to work against the clinical record Figure 1 - Example of Clinical Guideline that allows step through the process of treating a condition


of a patient or patients using something known as a virtual Electronic Medical Record (vEMR). The vEMR is based on HL7 version 3 Reference Implementation Model (RIM) to model the patient information. As Australia predominantly uses HL7 version 2 as its messaging standard of choice, we have created an implementation of the HL7 v3 model that uses HL7 v2 as its data model. This allows for the results that are received from Pathology Labs, Specialists and other clinicians to be incorporated into the solution, and provides a pathway to HL7 v3 and CDA. While both HL7 v3 and CDA may be many years away from widespread Australian usage, the investment in the decision support logic will not be wasted. The following snippet of Gello code demonstrates how to determine if a patient is allergic to Penicillin by examining the associated names with code or determining if there is a SNOMED-CT equivalence of Penicillin: let PA = Model.Allergies->select((code. code=”6369005”) or (code.name=”Penicillin”) or code.asType(SD).implies(“6369005”)) if PA.is_empty() then false else true endif GELLO can be used for a variety of purposes. It can be used for screening of pathology results for notifiable conditions, perform preliminary checking on the patient to determine possible risks for surgery or contraindications for medications based on the patients past history. Archetypes, which we will look at next, define the structure of clinical data collection. Medical-Objects implementation of Archetypes also includes support for GELLO as a way of calculating data about the patient, determining what information is valid and also what information should be visible or hidden based on the information known about the patient. We have combines Archetypes and GELLO to automate the calculation of clinical scores, such as the Crohn’s Disease Activity Index (CDAI), which can be used to monitor a patients progress. GELLO can read the results of recent blood tests automatically, removing the drudgery involved in calculating these scores manually. A slightly more complex example using the patients past surgical history to screen for past open surgery: //Try and determine if any open abdominal surgery //setup a dummy surgical history let Chole:SD = Factory.SnomedUtterance(“60228 007|Cholecystectomy, exploration of duct and cholangiogram|”) let Appendix: SD = Factory.SnomedUtterance(“6025 007|Laparoscopic Appendectomy|”) let KneeArthroscopy: SD = Factory. Snomedutterance(“38964008|Knee Arthroscopy and Meniscectomy|”) let PastSurgery: set(SD) = set{Chole, Appendix, KneeArthroscopy} <continues in next column>

//We use this as the test for a laparoscopic procedure let Laparoscopic: SD = Factory.SnomedUtterance(“ 73632009|Laparoscopic Procedure|”) let AbdoSurgery: SD = Factory.SnomedUtterance(“3 86671008|Abdominal Cavity Surgery|”) //Iterate over past history, seeing if any laparoscopic surgery let OpenSurgeryCount: Integer = PastSurgery->iterate(SX, i:integer = 0 | if (SX.implies(AbdoSurgery) and (not SX.implies(Laparoscopic))) then i+1 else i endif) //see if there has been any open abdo surgery if OpenSurgeryCount > 0 then true else false endif

Archetypes Many in the health industry are aware of Archetypes, primarily as a result of their promotion through openEHR. Archetypes themselves are a concept not tied to openEHR and can be applied elsewhere, including HL7 v2. Structuring information appropriately for data entry is essential to capture information particular to a clinical workflow. Many of those filling in the details of a clinical observation or incident are not concerned with the coding as such, however this coded information is essential to ensure that a computable level of information is provided in the data. The archetypes can map concepts to SNOMED‑CT and reduce the complexity of data entry by dynamically hiding and showing sections of the data entry form at run time. This eliminates text such as “If negative, go to section seven”. Section seven only appears when it is needed. The data entry forms are constructed automatically from the archetype and are dynamic. The archetype fragment for the lymph node shown in Figure 2. The data entry form is created automatically. You would not realise by filling in the form that you are entering coded information that will then become part of the patients computable medical record. By consistently using data entry methods which enrich our knowledge of the patient that we are able to use the information gathered in ways that are not only available to use for our immediate use, but for data mining for public health, for determining what pathway the patient should take through a guideline, or by eliminating the need to order unnecessary tests. The Lymphoma wizard includes electronic ordering and the content of the orders is dynamic and based on the patients path through the guideline. It is these features that can improve patient outcomes and reduce clinician workload and will allow us to move to a more pro-active mode of monitoring and also save costs and man-hours in unnecessary tests. Using Archetypes in HL7, the collected data can also be then on sent to applications that support HL7 from an enterprise hospital system, a disease registry or through to a practice management system.

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GLIF - Workflow for Clinicians The Guideline Interchange Format (GLIF) is designed to implement an executable clinical guideline in a single file that can be easily distributed to many groups. Since 2004, GLIF has used GELLO as a way of expressing decisions and eligibility criteria. In a practical sense, GLIF is used to obtain clinical findings and provide information in the form of diadatics. By providing information at the point of the decision and the ability to access patient data through GELLO, GLIF can provide one of the most sophisticated decision support environments possible. The reality is that the Lymphoma Wizard is not a single application, but instead, it is a GLIF file that not only contains the information about the guideline and workflow steps, but also the Archetypes required for the guideline, in addition to the GELLO rules that evaluate the patient information based on what has been selected and what is available in the patient EHR. The GLIF file is structured in XML and can be downloaded and updated easily. Making modifications to the guideline is an extremely easy process that can be done by clinicians with some training in the GELLO syntax and our GLIF editor. The advantage of a system that supports GELLO is that it can be enhanced and extended by clinicians, and customised for an institution without recompiling the application. This allows domain experts to capture knowledge and logic that can examine the individual patients history, medications and lab results and make recommendations that are specifically customised to the patient sitting in front of the clinician. This eliminates noise by filtering and refining the recommendations to make them highly relevant and useful. It also opens the door for agent like processes to interrogate the EHR, constantly checking on a patients progress in the background, while the clinician is at home asleep.

Rector’s Model of Models Many in the health informatics space will be familiar with Rectors model of models which analyses the interfaces between information, terminology and inference. Figure 4 presents Rector’s model in the context of the Medical-Objects’ solution, highlighting the links between the information, terminology and inference. The interfaces between the models are a critical part of the solution. Between both the information model/inference model and the inference and concept model, GELLO is used. For the interface for the between the information and concept models. This interface can vary depending on how much semantic richness is to be found in either model, so sometimes SNOMED-CT has clinically relevant modelling richness, sometimes its the EHR model or the archetype that is rich. If the former situation obtains then we can make use of the richness of the SNOMED CT concept model. If the later, then SNOMEDCT can be dumbed down to simply supply attribute values.

SUMMARY The ability to build rich decision support capabilities is available today, and like the Lymphoma Wizard it needs to be built on the best knowledge available and in an easily updatable standards based format. By combining Electronic Health Records, HL7 based Archetypes, Clinical Terminologies, GLIF and GELLO the end game of decision support becomes possible. Standards are used at every level to ensure that the solution can be implemented by anyone.

REFERENCES 1. Greenes, Robert A. Clinical Decision Support - The Road Ahead. 2. Rector’s Model of Models - http://cmbi.bjmu.edu.cn/ news/report/2001/medinfo_2001/Papers/Ch4/253_Rector.pdf [Accessed on 2/2/2008].

Figure 2 - Defining an Archetype Fragment for a Lymph Node Finding.

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Figure 3 (Above) - Data Entry screen for the Lymph Node Archetype fragment shown in Figure 2. Figure 4 (Below) - Medical-Objects’ decision support interfaces shown over “Rector’s model of models”.

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