Holiday reading: Practice ICT & eHealth

Pulse+IT is taking a break from daily news reporting for the festive season but will return on Monday, January 5.

If you are after some holiday reading, you may like to review our 2014 Practice ICT & eHealth magazine online below. This and other editions of Pulse+IT are available via the ‘Magazines’ menu at the top of this site, and also via the Issuu app for iOS and Android devices.

Guidelines for taking clinical images on personal devices

The Australian Medical Association has released a guide for doctors and medical students in the proper use of personal devices such as smartphones when taking and transmitting clinical images.

The guide, Clinical Images and the Use of Personal Mobile Devices, was developed jointly by the AMA and the Medical Indemnity Insurance Association of Australia (MIIAA).

AMA president Brian Owler said the guide outlines the key ethical and legal issues that doctors need to be aware of before using a personal mobile device to take or transmit clinical images.

“These images form part of a patient’s medical record, so are subject to the same privacy and confidentiality principles as the rest of the record,” Professor Owler said.

“The guide outlines the professionally appropriate processes of informed consent, documentation, capture, secure storage, disclosure, transmission, and deletion of clinical images, including de-identification and privacy legislation.”

In a study published in the open access Journal of Mobile Technology in Medicine recently, a team led by plastic surgeon David Hunter-Smith, co-developer of the PicSafe Medi application, found that 65 per cent of doctors admitted to taking medical images on their smartphones but only a quarter gained the appropriate consent.

The study also found that of those who took medical images, 64 per cent stored them personally and 82 per cent shared them with someone else.

This practice can run counter to many public hospital policies, which state that clinical images must be de-identified if shared, must be added to the medical record and must not remain on personal devices. They must also be securely stored as part of the medical record for a certain number of years.

The study found that 43 per cent of doctors were aware that an institutional policy existed, but only 28 per cent had read the policy.

PicSafe Medi is one of a number of apps that are now available to allow doctors to take and share clinical images on their devices appropriately. PicSafe Medi itself is currently being trialled in a number of Victorian hospitals as it allows an image to be uploaded to a secure cloud where is can be shared, and then removed from the device.

PicSafe Medi is also available for use by specialists and GPs, particularly for sharing dermatological images.

Acute care software specialist Verdi offers V-Photo, which allows clinicians to take a digital image and upload it straight to the patient record, while in the primary care setting, MedicalDirector offers the Image Safe app from Health v2 through its Widget Store.

Image Safe runs on any iOS and Android mobile device and allows users to take a photo of an area of concern. The image is then sent to Image Safe’s server in the cloud and then directly integrated into the patient’s file within MD.

There is also a free app called Figure 1 that has been dubbed “Instagram for doctors”, a popular app in the US and Canada that allows doctors to upload images to the cloud to ask for advice. However, this app does not contain the ability to remove the image from the device automatically or to attach it to a medical record.

The AMA-MIIAA guide to clinical images and the use of personal mobile devices is available from the AMA website.

Private hospitals need to support GP uploads for PCEHR funds

Private hospitals looking to apply for funding from the National E-Health Transition Authority (NEHTA) to assist them in connecting to the PCEHR will be required to outline proposed activities to support eHealth activity by local healthcare providers such as GPs, as well as supporting their own clinicians.

NEHTA has released the details of its Private Hospital PCEHR Rapid Implementation Program (RIP), which will see a $500,000 funding pool on offer to help with some of the technical requirements of connecting to the HI Service and PCEHR, and to allow for uploading and viewing of clinical documents.

NEHTA said the funds are intended to assist private hospital organisations accelerate their eHealth readiness, and are not intended to cover the entirety of eHealth implementation costs.

As part of the statement of requirements for funding, private hospital operators will need to provide an outline of proposed activities by the organisation to encourage clinicians to embed PCEHR viewing in clinical workflows.

Operators will also need to outline proposed activities to support eHealth use by local healthcare providers, such as encouraging the preparation and uploading of shared health summaries by local GPs prior to patients being admitted to hospital.

Applications must be accompanied by letters of support from at least two senior clinicians employed with or credentialed by the facility, indicating their willingness to help with meaningful use of the PCEHR as part of routine clinical workflows.

Operators will also need to show how they intend to encourage registration for the PCEHR by patients, such as providing information on it in pre-admission materials.

NEHTA said it expects the majority of funding offers to be between $50,000 and $100,000. Agreements will be signed with successful organisations in January or February 2015, with all elements of the deployment to be completed by June 30, 2015.

In return, NEHTA will make available free of charge some support packages, including architectural guidance and advice, technical installation and configuration support, and change and adoption support.

It will also provide what it is calling eHealth Integration Sample Code (eHISC), which has been developed as part of the Healthcare Identifier and PCEHR Services (HIPS) middleware that is being used by public hospitals in Queensland, South Australia, Western Australia, Tasmania and the Northern Territory.

“When deployed by an implementer as part of their software solution, the eHISC operates as middleware to connect existing hospital systems to the HI service and the PCEHR service,” NEHTA said.

“In current public hospital deployments, it enables a local clinical information system to gain access to the eHealth record system, retrieve and upload clinical documents, and interact with the Healthcare Identifiers (HI) Service.”

It can also retrieve HI Service information such as the patient’s IHI, retrieve the patient’s PCEHR information, upload documents in CDA format to the PCEHR, help with assisted registration and also provides an integrated view to allow clinicians to view a patient’s PCEHR.

According to NEHTA, the capability of HIPS is currently being expanded to include the ability to put a wrapper around a PDF document so it can be uploaded. This is necessary following the decision to upload pathology and diagnostic imaging reports as immutable PDFs in advance of the technical capability to upload results as atomic data.

HIPS is also being integrated with the National Health Services Directory to support point-to-point communications, NEHTA said.

Prerequisites for hospitals include already using a clinical information system or patient administration system that can be modified to launch a web browser to view the patient’s PCEHR and to configure HL7 admission/discharge/transfer (ADT) messages to other systems.

“Viewing the PCEHR will allow hospital clinicians to directly view a consenting patient’s important health information where available from primary and community care settings – in particular, the patient’s shared health summary, prescriptions and community pharmacy dispense records, public hospital discharge summaries and additional clinical documents as they are added to the PCEHR in the future (e.g. pathology and diagnostic imaging reports),” NEHTA said.

“Knowing that such documents are being viewed within acute settings will further encourage the creation of these documents within the primary and community care settings.

“Additionally, private hospital organisations uploading relevant clinical documents – such as discharge summaries or medication records for example – to the PCEHR system will encourage further meaningful use of the system.”

One sector that is not particularly happy with the development is aged care, with representatives saying this vital sector is missing out.

Patrick Reid, CEO of Leading Age Services Australia (LASA), which represents for-profit aged care providers, said that while the money on offer to private hospitals was welcome, it was essential that aged service providers were also included.

Mr Reid said aged services need to be recognised, considering they come second only to the state health system in volume.

“To date industry integration has not been supported and yet it is crucial to better care and reducing unnecessary costs,” Mr Reid said.

“The PCEHR can have a very positive impact on the needs of the increasing ageing population. It is a revolution for consumers and health care providers, but still age services are being left behind.

“On behalf of the age services industry I call on Health Minister Peter Dutton to take steps to urgently fund aged care providers to integrate their systems with the PCEHR.”

NEHTA is holding a webinar for prospective applicants for private hospital funding on Tuesday, December 2.

Doing away with Skype for remote specialist care

Telstra Health hopes to replace the need to use Skype for specialist telehealth consultations as part of the infrastructure it is building in association with the Northern Territory government.

Telstra Health announced this week it had been chosen by NT Health to build a National Telehealth Connection Service, which has been devised by the state and territory health department CIOs to become a foundation for connecting video consultations around the country.

It involves a cloud-based connection service that can be accessed by clinicians to allow them to make two-way or multiple consultations, as well as sharing patient information in a timely manner.

Telstra and NT Health have already been piloting the new service in Tennant Creek, Katherine and Alice Springs to provide remote communities with access to specialists by video conference. Telstra is currently connecting two Aboriginal Medical Service clinics – the Anyinginyi Health Aboriginal Corporation and Santa Teresa Health Centre, run by the Central Australian Aboriginal Congress – to the NT Health network.

The NT already has a thriving telehealth sector, with the major hospitals hooked up to fibre optic cable and an ongoing project that allows hospital-based specialist and emergency clinicians to video conference with community clinics through ceiling-mounted, high-definition web cameras.

However, providing specialist consultations to very remote clinics has proved harder. The partnership with Telstra aims to initially improve infrastructure to allow two-way or multiple video consultations with patients in their communities.

NT Health Minister Robyn Lambley said the service allows patients to attend their local health centre with a clinician and perhaps with their family, and speak to hospital-based specialists via video link.

“Telehealth also provides the opportunity for smaller hospitals to instantly tap into specialists in larger hospitals for better emergency treatment, as well as doing away with the need to travel for outpatient or pre-treatment appointments,” Ms Lambley said.

The NT has secured funding of $300,000 from the federal government’s Digital Regions initiative to develop the new service. Some of the money will go towards a technology upgrade to allow seamless connections from one end point to another regardless of the equipment and software.

“At the moment there are restrictions with the software and hardware in telehealth and this project is aimed at fixing this,” Ms Lambley said.

Telstra Health managing director Shane Solomon said in its initial stages, the National Telehealth Connection Service would focus on infrastructure, but it would also involve setting up a unified scheduling system to overcome one of the main barriers to wider provision of specialist video consults.

“In the first instance what we’re building is an infrastructure service that is not dependent on specialised equipment,” Mr Solomon said. “It is a cloud-based service, which is obviously the only way to get it into remote communities, but it’s done with all of the health-grade security needed. We see this, and I believe the CIOs of Australia, as a first step.

“To make this really easy and efficient nationally, it needs a scheduling system so that people don’t have to do a point-to-point phone call to try and organise a video conference.”

Telstra Health has a licensing agreement with Canada’s Telus Health for its iScheduler online scheduling platform that also includes store and forward capabilities that allows patient information and records to be created and distributed.

“We are definitely looking for something more like the Ontario Telemedicine Network and the first step, with what we’ve done with the NT, is to get the connection across the state and across government [networks],” Mr Solomon said. “Fundamentally, it will replace the need for Skype with superior quality video conferencing, and it enables the transfer of information.”

NT Health CIO Stephen Moo said this was a project that could transform the delivery of healthcare across Australia.

“That’s why the National Health CIO Forum recognised the importance of achieving a clinical-grade telehealth service based on agreed, national telehealth standards,” Mr Moo said. “This exciting initiative breaks down the technical barriers that currently exist within telehealth networks in Australia today.

“This solution will break down the silos and allow patients and clinicians to connect to multiple health service partners. Telehealth connectivity and interoperability is enabled through a cloud-based connection service, allowing any health service provider to make seamless, quality connections to one or more other health service providers.

“This service has the potential to become a national service that will greatly benefit consumers, health service providers and healthcare organisations, spanning the public, private and aged care sectors.”

Ms Lambley said negotiations were currently underway with SA Health to run clinics with the Alice Springs Hospital, including cancer services, Royal Adelaide Hospital burns clinics, rehabilitation and liver transplant consultations.

Telstra hoses down AMA concerns over continuity of care

Telstra Health has responded to criticisms from the Australian Medical Association (AMA) over its new ReadyCare telehealth service, saying the plan is to offer it to GPs to use with their existing patients.

AMA president Brian Owler criticised Telstra’s plan following its launch this week, telling AAP that it was a “cynical and inappropriate way” for Telstra to be involved in healthcare.

Professor Owler said the AMA supported telemedicine only where a patient already has a relationship with the doctor.

“We want people to maintain a regular contact with their GP, not just ring someone out of the blue,” he said. “They can just ring up a number, and get a doctor on the other end that they have no knowledge of or relationship with, and get scripts and other treatments prescribed.”

Telstra Health managing director Shane Solomon said the new service has been designed in two phases to ensure continuity of care, and the plan was to offer it to GPs, particularly in rural and remote areas, who are already using telehealth.

“How we are phasing it is in fact heading towards where the AMA wants to be,” Mr Solomon said. “Part one is to establish the service as a credible, safe, national service, so people can see that it works, that there is consumer demand for it and it can be done safely.

“Part of that is we have committed to message the person’s regular GP. The AMA said that’s not enough and I understand where they’re coming from, so phase two … is to work with a limited number of GPs, and particularly with [the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine (ACRRM)], to adapt the platform so that GPs in their local practices can do telemedicine safely with their own patients.”

He used the example of prominent rural GP, Bruce Chater, a member of Telstra Health’s medical advisory panel, who practices in the small town of Theodore in central Queensland.

“[Dr Chater] realises that if it’s a repeat prescription or it’s a minor ailment, to get someone to travel an hour or two hours or three hours into Theodore is crazy,” Mr Solomon said.

“The problem is they do it but they don’t get paid for it, so we believe that the contribution we will make ultimately will be to have this form of GP service accepted as a normal part of practice in the national Medicare system.”

In a statement provided to Pulse+IT, a spokesperson for ACRRM has distanced the college from Telstra’s telehealth plans, saying it has not had the opportunity to properly consider the arrangements.

“Telstra has indicated that we will be properly briefed at a workshop which has yet to occur. The ACRRM board has not had the opportunity to consider what Telstra is proposing, let alone provide endorsement.

“Telehealth should enhance the existing primary clinician-patient relationship, not fragment it. Telehealth arrangements should complement existing specialist services (where available), build on rural workforce and referral patterns to avoid further service fragmentation, and address practicalities of coordination, scheduling and support from the patient’s perspective to improve their continuity of care.”

Mr Solomon said the plan was to provide a full end-to-end service, which is why Telstra has chosen to partner with the Swiss company Medgate, which has been operating for 13 years. Proof that the system works in another jurisdiction was essential to its acceptance here, he said.

“We’ll adapt the guidelines for Australian purposes and there are other adaptations, but basically you have to stand up the service as a stand-alone service in the first instance. Our ambition is to introduce this to Australia and give it credibility that would ultimately allow local GPs to use it.

“I would qualify that by saying the Commonwealth has a legitimate concern that people will just ring up Mrs Smith and say how are you today and call that telemedicine, but in Switzerland the way they have handled that is to have an accreditation program.

“We would love to have a vision where the college of GPs and the college of rural and remote medicine offer training in telemedicine so they can be accredited as telemedicine providers.”

He said the plan to offer it to GPs to use in their own practice would address the continuity of care issue that the AMA is concerned about. “We are partly addressing that continuity of care issue in phase one by making sure that that we send back to the regular GP information about a telemedicine service a person might have received.”

While he could not speculate, the establishment of a safe, efficient telehealth service that was accepted by GPs would go a long way towards encouraging the federal government to allow telehealth to be considered the same as a face-to-face consultation for the purposes of the MBS.

The technology

Mr Solomon also provided more detail on how he expected the system to work in Australia. ReadyCare will involve the full offering from Medgate, which includes telemedicine-specific call management, forecasting and demand management, patient management software, protocols and performance management.

The protocols and guidelines will be adapted to the Australian setting, but the initial piece of work will involve adapting the clinical software to the expectations of Australian doctors. Mr Solomon said Australian GPs would not find the clinical software used in Switzerland adequate for their purposes.

“We’ve had the IT people out from Medgate already – they have been out here for two weeks sorting through whether we have to adapt the system to suit our circumstances,” he said. “The conclusion is that Australia’s GP clinical software is far superior to that in Switzerland, and Australian GPs working with this would not find it adequate, so we are sending a couple of people over next week to do a detailed specification.

“We will have to adapt it, and because it is linked in with the workflows of Medgate, there is a piece of integration that we have to do.”

He said Medgate’s scheduling system made the service “incredibly efficient”. The company has also built an app for common minor ailments like skin rashes so patients can upload a photo directly into Medgate’s system in advance of a consult with a doctor.

“The service promise is that something like 90 per cent of people will get a GP to call back in 30 minutes, [but] if they need to collect clinical information then it is a bit longer. All of their systems and the guidelines are built into this scheduling system.

“We are bringing the full system here but they will be adapted for Australian circumstances. I think that illustrates how important it is for Telstra Health to have both the health IT provider application capability as well as the telehealth capability.”

Medgate has a relatively basic method for prescriptions, in which a script is faxed to the patient’s pharmacy of choice and the paper script sent later. Mr Solomon said Telstra intended to start with that method in advance of much hoped for changes to legislation that will allow paperless prescribing here.

Telstra is also looking at the legislation covering what the private insurance sector can involve itself in for out-of-hospital care. In Switzerland, Medgate consultations are paid for by insurers, which under its social insurance system is subsidised by the government.

There are a number of potential payment models that Telstra is investigating in advance of federal moves to add GP-to-patient telehealth to the MBS.

“Insurance for primary healthcare regulations are about not being able to insure for something that Medicare covers,” he said. “We are looking at it but we think that there is potential here to follow one of the Swiss options which is a subscription-type model. So for a year it might cost you €150 for unlimited telemedicine access. We are looking at the legality of all that sort of thing now.”

He said Telstra would look at outsourcing the hiring of GPs to provide the consultations – several private insurance companies already have panels of salaried doctors on staff – and it would also explore how to offer the ReadyCare service to existing offerings like Healthdirect.

Telstra Health plans to have ReadyCare ready for launch in nine to 12 months.

GP reaction

Prominent GPs and eHealth advisors Mukesh Haikerwal and Nathan Pinskier gave qualified support to Telstra’s plans.

Dr Haikerwal said it was good to see a company like Telstra becoming actively involved in healthcare using technology, which is its forte.

“It’s good to have a big player that can stare down government and really advocate on behalf of us as consumers and patients and us as clinicians, rather than us having to acquiesce to government mood all the time,” he said.

He said while telehealth had existed in Australia for some time, it doesn’t work well for primary care in general.

“We’ve had telehealth in Australia but it has not worked previously because it was only available for psychiatry. Then it was available in a widespread way with the election of the Gillard government. And that was an abject failure, because the systems were not in place to make it work well and there are no standards.

”Telehealth can work well and does work well in places like Canada where the Ontario telehealth system works very well, but it takes time to get there. The issue is how is it going to integrate with current general practice.

“If there is a move to have a standalone call centre like the healthcare system, but doing the work of GPs by remote control, there will be some significant backlash I believe from the clinical community.

“Ultimately any enhancement of the capacity to do technology in the health space is to be welcomed, but it needs to be working in a good partnership relationship with existing services, rather than trying to cannibalise them.”

Dr Pinskier said that from an informatics perspective, one of the challenges would be to decide where telehealth would fit in in terms of GPs’ working process.

“I think it is fair to say that many general practices have struggled to integrate telehealth in their existing work practice, because they are already work-overloaded and they are unable to set aside the dedicated facilities or time,” Dr Pinskier said.

“There’s a question also not just around the standards, but how does it conflict with the existing medical home model, how does it compete with all the other telehealth services that currently exist around the country. How does the consumer decide? How does the consumer determine which ones are clinically accredited, clinically safe, that integrate with my regular care provider?

“So there’s a whole lot of questions I think remain unanswered and probably the biggest single question is the one around cost. Does it potentially lead to a two-tier model? Because if it’s not funded through the MBS, that means that consumers that can afford to pay are proportionally advantaged, whereas others are proportionally disadvantaged. If it is funded through the MBS, does it actually change the existing provider relationships that exist?

“The technology, as Mukesh has said, is exciting but it has been around for a while. It’s just a question of how you integrate it.”

HIMAA strategy calls for industry change

This story first appeared in the August 2014 issue of Pulse+IT Magazine.

The health information management sector is facing major workforce challenges as opportunities for post-secondary qualifications decline and a lack of understanding of the role of health information managers (HIMs) and clinical coders becomes more prevalent. HIMAA has devised a strategic plan to overcome these challenges.

In the recently launched Health Information Management Association of Australia (HIMAA) Strategic Plan for 2014-2016, the result of membership research involving over 320 member contacts, identifies workforce as the key issue. Members report workforce shortages across Australia leading to role substitution and downward pressure on existing health information managers (HIMs) and clinical coders as the cause of a decline in morale in the health information profession.

Erosion of the number of university courses available for undergraduate qualifications in health information management is another readily identified factor in workforce shortage, especially significant in NSW with the loss of the University of Sydney course in 2007.

Traditionally the profession has been valued as key providers of advice and expertise in the area of health information management and clinical coding, often undertaken as dual roles. But HIMAA research found that poorly informed management, particularly at an executive level, is seen by members as a major source of the decline in standing of health information management in healthcare facilities.

As one senior respondent to our research commented, “When people know HIMs and what they can do they are very, very positive, but we still come across those throughout the health sector who have an old-fashioned view towards medical records. Because we don’t have direct patient contact, we’re not as well known.”

Electronic prescribing shows quality results

It is not often that Victoria’s HealthSmart roll-out receives good news, having been roundly eviscerated in a report by Victorian Auditor-General John Doyle in 2013. The report concentrated on four health services that had rolled out the Cerner electronic medical record, which one hospital is understood to have abandoned, two have rolled out fully and the other is most of the way there.

In his report, Mr Doyle makes particular reference to the complexity and difficulty of introducing electronic medications ordering and management, saying that there are significant difficulties in using the system to manage complex prescriptions.

He also highlighted the common teething problems reported by clinicians with most complex health IT roll-outs, including interruptions to workflow and tedious and time-consuming new ways of doing things.

So was he right in his criticisms? While no one denies that the roll-out has been difficult, recent data seems to show that there have been major reductions in medication errors at two of the health services that introduced Cerner through the HealthSmart program, Austin Health and Peninsula Health.

The introduction of Cerner to automate prescribing and drug administration, as well as radiology and pathology ordering and reporting – including what is claimed to be the first roll-out of electronic medications management in an emergency department in Australia – won the two health services a quality improvement award from the Australian Council of Healthcare Standards (ACHS) late last year in the clinical excellence and patient safety category.

In their submission for the award, the clinical systems project teams from Peninsula Health and Austin Health cited a number of statistics to prove their point, including:

In addition, the system does seem to be usable, recording a response time of 2.29 seconds to log in, a transaction time of 0.61 seconds and 7.5 clicks per order.

Austin Health and Peninsula Health worked closely together on the project, although both developed their own communication and change management strategies. They split the roll-out into two phases: the first go live, in June 2011, involved implementing the core software system with capability from electronic pathology and radiology orders, results, centralised allergy and alerts management, discharge prescriptions, discharge summaries and electronic discharge prescribing.

The phase two go live, involving inpatient medication prescribing, dispensing and administration, went ahead in June 2012 and was completed across all sites and services (emergency, acute, sub-acute and mental health) of both health services by August 2013.

In preparation, a range of computers on wheels, tablets and mobile devices were deployed and IT infrastructure upgraded including new wireless systems.

No more paper charts

Lyn Jamieson, clinical systems project director with Peninsula Health, says the major aim of the project was full electronic management of the whole medications process. “We basically don’t have paper charts any more,” she says.

At Peninsula, doctors and pharmacists work on developing the electronic drug chart together, with the pharmacist usually taking care of the medications history and the doctor putting the drug chart together.

Doctors now prescribe electronically, including in the emergency department, predominantly ordering from order sets or what Ms Jamieson calls a set of order sentences. “We have a predefined set of order sentences that they will pick,” she says. “There is a drop-down box and they will pick the medication and the dosage and the frequencies from that drop-down box.

“They don’t have to do that if they don’t want to – they can do it from scratch if they want to – but most of them will do it from a predefined list.

“We also have what they call power plans and a lot of our doctors are now ordering from them. It is set around specific patient conditions so if a patient has got chest pains and they come into ED, there is a standardised order set that is evidence-based that we encourage the doctors to use.”

Doctors can override the power plans and pick and choose what tests and drugs they want, but most are taking advantage of the pick list and power plan functionality, she says. “We have that predefined so they just do one click and all of that will be ordered within one click.”

Peninsula first went live with the system in its sub-acute setting in July 2012, followed by mental health that August. In acute care, the service broke down the introduction into clinical areas, going live in the medicine units at Frankston Hospital in November 2013 and then at Frankston’s ED in February last year.

“We think we are the first emergency department in Australia to go live,” Ms Jamieson says. “In April we went live with surgery, women’s, children’s and adolescent health units and theatres. August was our last go live and that was Rosebud Hospital, where we went live with that whole hospital.”

Peninsula Health has been slowly gathering benefits and outcomes data, the most mature coming from sub-acute care. Ms Jamieson says her last analysis showed a 34 per cent decrease in medications incidents in sub-acute.

While Mr Doyle’s report did mention problems with the system for pharmacists, Ms Jamieson says it has proved otherwise for nursing staff. “Overwhelmingly, the majority of our nurses love medication administration electronically and that’s because they can read the drug charts and they know which doctor has ordered the drugs. Sometimes before they couldn’t work out the signature. They can also access the drug chart so there’s no fighting over that one paper drug chart.

“The nurses are mainly administering off [tablet PCs]. They were given a choice of devices and what we had available at the time … so most of them are using a Motion C5 tablet. The majority of them will use that while other nurses prefer the WOW, the workstation on wheels. Some of them like the larger screen.”

The data from pharmacy is also proving positive, with the latest analysis showing that pharmacy had a 62 per cent decrease in the number of medications omissions and a 19 per cent increase in the time that pharmacists now have to do therapeutic interventions. “That’s what they really enjoy doing and what we should have pharmacists doing.”

With antimicrobial stewardship, there is now 92 per cent compliance, as opposed to 48 per cent in the past, Ms Jamieson says. “We also have decision alerts on the system and it can allow you to structure clinical pathways better so your work processes could be more structured.

“We can actually force the clinicians into a certain way of practice which is good, although sometimes they may not think it’s good. The majority of the junior doctors do need that assistance and this is where an electronic clinical system can really help them out.”

Electronic prescribing in ED

At Austin Health, executive director of acute operations Fiona Webster says her service is now in the position to be one of the best implemented medication systems in Australia.

All medications ordered in the emergency department are done through Cerner, with medications management now highly visible throughout all departments.

“We can connect the whole drug chain,” Ms Webster says. “We all know exactly what drugs have been ordered, what drugs have been given to the patient, we know every dose of the drugs in the hospital. With a paper system you would never have had that visibility. It’s giving you a much better sense of prescribing patterns and there is a lot of data that sits underneath it that we are just starting to understand.”

While it is not unusual for doctors and nurses to be very suspicious of electronic systems, Ms Webster believes that as a lot of the work in ordering and reviewing tests is done by junior doctors, they are a lot less resistant to change than older clinicians.

“They appreciate the visibility that the system brings,” she says. “They are not having to remember dose ranges and that sort of thing, so from that point of view the junior medical staff picked that really quite quickly.

“Radiology has been able to pull out the paper system long before they expected to be able to because previously we had a situation where you wrote an order, it went into a tray, someone had to come and collect it, someone had to take it to radiology and that was entered into the radiology system, where they couldn’t read the order so they had to track the doctor down.

“Junior doctors didn’t know when the test might be scheduled so they were ringing the radiology department. None of that happens any more. They put the order in the computer, they can see when the tests are scheduled in the system and as soon as the results are available they are available for them to review.”

Ms Webster says it this this visibility of the whole process that is the most beneficial. “We now have visibility of every drug whereas before when you looked at the drug chart you couldn’t necessarily tell when people were given the drug, to see if it was given on time.

“Now we know when drugs are not given on time and we know when antibiotics are ordered. A lot of medication errors are due to legibility but all of that is gone now. Documentation of allergies has improved dramatically and clinicians can now see things on the system that they hadn’t been able to see previously.”

An edited version of this story appeared in the July 2014 issue of Pulse+IT Magazine.

ITAC: Telstra’s plans to ditch the pilot and roll out the jumbo

Telstra Health plans to bring to market an interoperable mechanism by which the data held in aged care, general practice and pharmacy software systems is more easily shared, and is also intent on developing affordable, sustainable solutions for integrated telehealth services for independent living.

Telstra Health’s two community care leads – former Victorian minister for health Bronwyn Pike and former Australian Home Care Services CEO Michael Boyce – told the ITAC conference in Hobart yesterday that they had spent the last year speaking to as many people in the aged and community care sectors as possible, and had now developed a strategy to improve information sharing and bring new products to those markets.

Telstra Health, which outlined its plans for home and aged care last year, plans to leverage the technology developed by companies it has purchased or taken a stake in – such as pharmacy market leader Fred IT, community and primary care software vendor DCA Health (which has now rebranded as HealthConnex), acute care vendor Verdi and personal health record vendor Get Real Health – to develop infrastructure that links all of the healthcare sectors together for better information sharing.

Mr Boyce told the conference that one of the problems in the existing primary and community care sectors was that it was a low-return industry with many small IT innovators. The customer market isn’t that large, he said, and there is an oversupply of vendors.

He said the sectors were also plagued by misaligned incentives and payment systems, which consumer-directed care (CDC) would hopefully help, but the main problem was fragmentation, which is where Telstra comes in.

“Somehow we need to be able to connect the dots and sometimes it needs a big player with a reasonable balance sheet to play a part in solving those problems,” Mr Boyce said.

One area Telstra Health plans to target is to create a link between healthcare practitioners involved in the care of residents of aged care facilities, including their GPs and pharmacists. While aged care, general practice and pharmacy software all holds information about individual patients and residents, that information is not shared.

Telstra plans to provide a solution to that problem, Mr Boyce said. “We have infrastructure coming across … [because] to put GP, aged care and pharmacy together we will need to put new infrastructure in place, and we plan to.”

While Mr Boyce did not go into detail, Pulse+IT understands that it involves diagnostic services messaging provider Medinexus, which Telstra has recently acquired.

“You have a number of software solutions for aged care, vendors that provide clinical management software and medication management software,” Mr Boyce said. “That information exists, it is online but basically it is not shared outside the business operation.

“You’ve got GP software like Best Practice and Medical Director and others. That information also supports health data around patients who are also residents in aged care, but that information is not shared.

“You then have a pharmacy with a pharmacy dispensing system. They hold information around a patient’s medication and that patient happens to be a resident of a residential aged care facility. That information, depending on what software you have in the residential aged care facility, is partially shared.

“So what Telstra is about through Telstra Health is connecting those three softwares to provide real-time, contemporary, relevant, valuable information at the fingertips of each of those organisations for patient care and resident care.

“If you can connect to those three – and we have a plan to do that – you can also connect to the geriatrician, you can also connect to the primary carer, the speech pathologist, to the dietitian and the various software that they use. What you need to do that is an interoperable mechanism, and we think we have that solution.”

Telstra is also planning to ramp up its activity in the integrated telehealth market, Ms Pike said. The organisation is already working with health insurer HCF to roll out vital signs monitoring systems to 3500 clients in NSW, but has plans to use the strength of its existing infrastructure and business processes to the job of solving connectivity problems in healthcare.

“Australia’s biggest telco has decided to build an eHealth business,” she said. “There are lots of reasons for that, but mainly we have seen an opportunity to contribute to the health and wellbeing of the country. There are lots of opportunities to derive productivity from a health system overall that is fundamentally inefficient and is not as productive as it could be.

“We know that Telstra has a lot of sophisticated technology and capability but it is not really about technology. I hear it all the time – we’ve got the products, we’ve got the capability, but that capability doesn’t necessarily translate into workable solutions.”

Ms Pike said one of the most common refrains from aged and community care providers was that they were absolutely sick and tired of the numerous pilot projects that are funded, succeed in their limited outcomes but are not sustainable.

“You don’t want the pilot, you want the jumbo,” she said. “The truth is though that the jumbo is not going to come with a truckload of cash from the government. It is going to come in the development of affordable and sustainable solutions.

“You said productivity sounds good but it is actually really hard to derive. For example, you might replace a nurse’s visit to someone’s home with a nurse watching someone taking [their medication] through a telehealth consultation, but before that can happen you have to send the nurse out to turn that tablet [device] on.

“That’s not a driver for productivity. So as Michael said, we are working with partners to provide solutions that are simple, affordable and can integrate with monitoring systems or aged care core systems and link to other primary and tertiary care providers.”

Ms Pike said Telstra plans to introduce a number of technologies such as client portals and devices that allow for home monitoring, telehealth and information sharing. While many of the technologies are now available, one problem that the aged and community sector had raised was that they were proprietary and did not integrate with core systems.

“We don’t want to replicate that,” she said. “We want to make sure that everything that we develop is open, can be integrated, can be seamlessly linked to legacy systems and can be seamlessly integrated into other primary care providers.”

ITAC: Leecare spins out P5 Exec for accreditation standards

Aged care software specialist Leecare Solutions has launched a standalone version of its P5 Exec application, which allows aged care providers to comply with the aged care accreditation standards one and four while retaining their existing clinical software.

P5 Exec is an integral part of Leecare’s Platinum 5.0 browser-based clinical, care and lifestyle management application, which also includes the P5 Med medications management system and P5 Finance.

Although P5 Exec was developed in 2012 as part of the Platinum 5.0 program, the company has concentrated this year on allowing it to be used as a standalone solution for aged care providers to record and monitor their management, staff, suppliers, quality and safety system requirements.

P5 Exec was officially launched at the ITAC conference in Hobart this week.

Leecare Solutions’ founder and CEO Caroline Lee said the application includes everything that aged care managers need to have an overview of management and safety requirements, including staff tasks and calendars, messages, reports and education and credentialing.

It also includes a comprehensive maintenance system that includes monitoring of suppliers and assets, as well as a full document library that can be linked to staff messages, as well as forms and report builders that can be tailored to each particular facility’s needs.

Dr Lee said P5 Exec was designed to provide a complete corporate governance package for aged care providers.

“By covering off standards one and four, which is what clinical systems don’t cover, we effectively complete the whole circle to ensure that as a manager, users can can log in no matter where they are across the country,” Dr Lee said.

“They can check each facility for where the particular quality indices are, whether it is a staff incident or it’s a quality improvement complaint or a maintenance issue.”

It also means that if an aged care provider is content with its clinical software, it can use P5 Exec to cover the other two accreditation standards. “It means that the gap that the industry has had is now filled; they’ve got everything now in an IT system,” Dr Lee said.

“You don’t have to concern yourself with having this little module on the desktop that does a certain function but doesn’t interface with others. It can be a standalone application and there’s nothing stopping our clients talking to other vendors. We are not there to replace the clinical system, we are there to be an adjunct and fill a really important gap, but in a complete way.

“It is not a token document library or a token HR system or a token maintenance system: these are fully fledged, complete components.”

Dr Lee, who has spent 22 years running an aged care consulting firm as well as designing aged care IT systems, said much of the functionality in P5 Exec comes from an intimate knowledge of the audit, HR, compliance and documentation requirements of the aged care sector.

With P5 Exec, her team has built clever internal features so that when a particular document or form is updated, it automatically updates all of the other applications linked, including in the clinical system.

For example, the staff incidents and hazards section allows managers to allocate permissions for access and who a message will be sent to. “Staff are able to log in and not worry about making a complaint about a manager or about another staff member, because they select who it goes to first,” Dr Lee said.

“Staff are contributing and managers don’t have bits of paper from each site being sent to head office, which is where the biggest time saver is going to be.

For things like education and credentialing, as the Platinum 5.0 suite is contained within a single database, a single entry can interface directly from the manager’s education calendar to the staff member’s message centre and calendar and set up the educational session for them.

“If you are doing a quality improvement form or a continuous improvement plan, you set actions for individuals and it goes straight to their calendar. They can sign that off once it is completed and the program sends the result back to the continuous improvement plan or the quality improvement plan.

“So you are never out of touch with what is going on, but you are also enabling your staff to be able to participate or contribute. It is very quick and simple for them to click on it, enter the details and save, but the information has gone into so many different places.”

Leecare has set the task calendar and staff message centre as the first dashboard seen when accessing the application, so as soon as a person logs on, they can see instantly through their alerts what tasks they have to complete and what messages have been sent.

“Staff messages can also have documents attached to them, so if you have a regulatory change you can attach a document and tell everybody to read it. That document then goes into the library automatically under the memos folder, you can attribute different clinicians to those documents in that folder so only certain people can see it, and your document library is also then linked to your staff messages, to your policies and procedures and to the repository for all of your documentation.”

The application also includes a user forms builder and a facility forms builder that allows aged care providers to build their own forms and fields, which will allow providers to build their own audit tools or incident forms that reflect their own business.

“There are a lot of good tools around that have snippets of this, but we wanted something that was absolutely complete,” Dr Lee said. “This means that standard one and standard four are complete.”

Community AF screening with iECG feasible and cost effective

A Sydney research team that has been trialling the use of the AliveCor heart monitor and iPhone ECG device in both community pharmacies and general practice has found that it is both a feasible and a cost-effective way to better screen older people for atrial fibrillation (AF), one of the leading causes of stroke.

The AliveCor device is a single-lead ECG built into an iPhone case that has an accompanying app that can analyse the readings and display them on the phone’s screen. The readings are sent to a secure website, where an algorithm can predict AF with 97 per cent accuracy. They can also be stored for review by specialist cardiologists.

Last year, the team published encouraging results from its Screening Education And Recognition in Community pHarmacies of Atrial Fibrillation (SEARCH-AF) stroke prevention study, which involved 10 pharmacies where screening was offered to all customers over the age of 65.

The pharmacists were trained in how to approach patients, how to use the device and what they should look for. Those proving positive for AF were referred to their doctor. Of the 1004 participants screened, one per cent were found to have previously unknown AF and an additional half a per cent were re-identified with AF.

The team has also been trialling the device in the general practice setting, studying its use by GPs themselves as well as for pre-consultation screening by receptionist staff and practice nurses.

In an qualitative study published last month in Australian Family Physician, the team reported that GPs were very positive about the device because of its ease of use and portability compared to a 12-lead ECG. Practice nurses were also keen on using it and were very confident in doing so, but receptionists were far more reluctant and were not convinced it fitted their role in the surgery.

That study also found that GPs thought iECG screening was useful as a prompt to concentrate on cardiovascular health.

Now, the team has published the results of its analysis of the feasibility of using the device on a greater scale in community pharmacies, as well as the cost-effectiveness for funding bodies to do so. The argument is that stroke is highly preventable in AF using warfarin or novel oral anti-coagulants but that there are large treatment gaps.

UK research has shown that systematic screening in general practice using 12-lead ECG was not cost-effective, the researchers write, and a Cochrane review of systematic screening showed that there was a need to examine alternative screening strategies.

In the journal Thrombosis and Haemostasis, the team writes that community screening using the iECG is feasible and cost effective. They found that the incremental cost-effectiveness ratio (ICER), based on 55 per cent warfarin prescription adherence, would be $5988 per quality adjusted life year gained (QALY) and $30,481 for preventing one stroke.

The costs include $20 per iECG screen, $252 for diagnostic assessment of AF (GP consult, specialist consult and 12-lead ECG) and $803 per annum for warfarin treatment, INR monitoring, three GP visits and one specialist visit.

“The estimated ICER of screening to prevent one stroke or to increase one QALY is well within the range that would be fundable on a population basis, using either warfarin or (novel oral anti-coagulants),” the researchers write.

“The high and largely preventable stroke/thromboembolism risk of those with newly identified AF highlights the likely benefits of community AF screening. Guideline recommendation of community iECG AF screening should be considered.”

In Australia, the device is TGA approved and is being distributed by Sydney company uHealth for $299. The heart monitor itself fits on most mobile devices and the accompanying app is available for iPhone and Android. Consumers are provided with secure storage and sharing functionality.

Healthcare providers are also equipped with a free web app that acts as a dashboard to help review their patient’s ECG data.