A fortnight ago, Sydney's St Vincent's Hospital became the first hospital in Australia to upload a clinical document to a patient's PCEHR. It is also the first to allow clinicians to view patients' PCEHRs through its clinical information system, and it moved into production status last week to alert clinicians that the patient has a functional eHealth record.
Clinicians at St Vincent's will now be notified that a patient has a PCEHR via a simple green tick icon on the screen of the hospital's clinical information system, Emerging Systems' EHS, known in-house as deLacy.
Other hospitals might decide to do it differently, but at St Vincent's, admissions staff will ask patients if they have a PCEHR during the pre-admission or booking process, when they will also search for the patient's Individual Healthcare Identifier (IHI) through the Healthcare Identifiers Service, if it is not already known to the hospital.
In the recent patient's case, clinicians were able to see an up-to-date summary of his healthcare information uploaded by his GP, along with his recent Medicare history. The hospital was also able to transmit a full electronic discharge summary to the system.
Getting eDischarge summaries flowing between hospital, GP and the patients themselves has been a big part of the work St Vincent's and Emerging Systems have been doing with the Eastern Sydney Connect Wave 2 project. Eighty-two per cent of patients are now receiving an electronically generated discharge summary, which includes a full list of prescribed medications sourced through the hospital's MedChart medications management system.
The discharge summaries are also being sent straight to the patient's GP, if that GP is known to the hospital and has the capability to receive eDischarge summaries in his or her practice management system. Through deLacy, they can also be loaded directly to the patient's PCEHR, Emerging Systems' managing director, Russel Duncan, said.
“When clinicians first turn on the screen there is a little icon that comes on to show whether the patient has a [PCEHR],” Mr Duncan said. “We do a search on the PCEHR at booking or pre-admission – depending on when we capture the patient for the first time – and a little icon is presented on the patient list screen to say they have one or not.”
A 'lock' icon has been designed to show that the patient has elected to restrict access to certain parts of their PCEHR. Allowing access to St Vincent's clinicians through a provider access code (PAC) will also be managed at pre-admission, Mr Duncan said.
St Vincent's CIO, David Roffe, said the idea was to make it as easy for the clinicians as possible and to integrate it with their workflow.
“The question is, will the clinician actually go and look [for a PCEHR]? The answer is probably no,” he said. “But if there is a screen that says there is one there they will probably go and have a look. We don't want our clinicians to have to search the system – it does it in the background so you know when there is a PCEHR.”
St Vincent's has had eDischarge summary capability for some time, with junior medical officers curating the summary and sending it to the GP's desktop system. That practice is not yet widespread, however. Mr Roffe said project technical staff had been working with five different practice management system vendors to test the templates for eDischarge summaries and this proved to be a laborious exercise.
“We got a copy of each of them, we stuck them on PCs and hammered them with different combinations of HL7 streams and we hand-crafted them.
“That took us two and a half months. Why did we do that? To get a good user experience for the GP. Otherwise it would just be plain text. It was a big piece of work to be done but once we tweaked it, it was easy to replicate.”
However, while most patients receive an electronic discharge summary, nowhere near that amount is able to be delivered to the GP. “It depends on whether the GP has an EDI account,” Mr Roffe said. “When the patient comes into the hospital we ask them for their GP. If the GP is known to us and we know their EDI address, it is matched up and that's how it gets to the GP. If we don't know the GP, it doesn't go anywhere so we just give it to the patient.
“If we know the general practice but it does not have an EDI address, then we fax. The issue here is that not all GPs have an EDI address and another problem is that if they have an EDI address with a secure messaging vendor that we don't currently support, then we can't send it at this point in time.”
Mr Roffe said that as soon as the various GP desktop systems become compliant with the Secure Message Delivery (SMD) standard, the problem with intermediaries will disappear.
“But while there are intermediaries there is a bit of a problem because they are not interoperable. Even though HealthLink and Argus have announced that they are working towards it, it is still not in production yet. To do it hand-crafted is one thing, but to get it into production where it just works every time is another.”
Another issue to be faced is the reconciliation of medications on shared health summaries. Part of the Wave 2 funding was to investigate electronic medications management, and terminology is proving to be difficult.
GPs tend to use brand names when prescribing drugs, while hospitals use generic descriptors and are dose-based, Mr Roffe said. In the absence of the complete Australian Medicines Terminology (AMT), this is still proving a problem when reconciling medications prescribed by the GP and then by the hospital.
“AMT will help and MIMS mapping will help, but we are not there yet,” Mr Roffe said. “There is still lots of work to get there. The way we do it is we have pharmacists employed in the project to actually do the moderation from the GP's inbound summary. On the way out we still have a bit of a problem but we can send meds out. That's a clear learning that this can be done but there are still some major bits to do.
“Some of our colleagues have been saying why are we getting all of this money to do point-to-point communications when it is all about the PCEHR and point-to-share. The answer to that is you need to entrench business process flows. It is all about workflow, it is all about making things easier. It is all about trying to fit into the normal practice flow of a public hospital, a busy GP practice or a specialist practice.”
St Vincent's has also been working on eReferrals through the Eastern Sydney Connect project. Emerging Systems created an eReferral template that practice management systems can transmit to the hospital's specialist clinics.
Again, there are a few barriers that need to be overcome before this becomes part of normal workflows, Mr Roffe said. The PCEHR is not yet able to accept eReferrals, but St Vincent's system now is.
“We wanted to try and get eReferrals in from GPs and to get them into our specialist clinics. It enhances the experience of the GP – he doesn't want to have this process work with a public hospital and this process to work with a private hospital and this process to work with a specialist and five different specialists do it five different ways.
“The proposition we went with to our GPs in our catchment – we said if you refer electronically to us, we'll make sure it gets to the other end. That is a very challenging thing to do and failed quite a number of times. But we also told them it was a learning process and a journey. We wanted to entrench the care value chain and that is a team effort.”
St Vincent's has also streamlined the sending of specialist letters from outpatients, which in the past could take up to six weeks. The hospital has been able to reduce this to an average of 14 hours, with all letters stored in a central repository, accessible through deLacy. Emerging Systems also developed the specialist letters component.
That is not to say that enabling private specialists is easy either, Mr Roffe said. Specialists are private businesspeople who have honed workflows and are often not interested in changing those workflows merely for a few patients or referring GPs who would like to do things differently.
“The private specialists are still an issue but I think the tipping point will come as more GPs and more vendors of practice management systems become e-enabled,” he said. “They will start talking to specialists and say unless you accept my electronic referral I will refer to someone else. That will be the tipping point.”
Mr Roffe said improving electronic communication was a long-term, ongoing process, but St Vincent's had committed to making it work. The Darlinghurst-based hospital is now working with the Prince of Wales at Randwick to include it in some of these eHealth initiatives, as the Prince of Wales is within the same Medicare Local and area health service.
“We currently have connected eReferrals into their outpatients department and we are constantly looking at ways to engage them better,” Mr Roffe said.
“At the end of the day, what we are passionate about is the mission focus part of it. Clearly people fall between the cracks in our healthcare systems – that's why we put our hands up for the PCEHR. We believe that being able to share clinical information will allow us to provide better care wherever they are.
“St Vincent's wants this to be sustainable because it is good medicine – people won't fall between the cracks of care. That is what St Vincent's is all about.
“We have to mainstream everybody. When somebody comes to the hospital, we have to ask that question – would you like to have your PCEHR created? Until you get enough body of documents up in the PCEHR, a GP or specialist will go to the PCEHR and say there's nothing there.
“This is a long journey – it is only the start of it. That is what we are telling our GPs and that is why the point-to-point is also important: continue to get the value chain up to the GPs in our particular Medicare Local and keep them engaged while we get the PCEHR loaded.”
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