The 2014 eHealth year in review: part four

In what was a big year of budgets, reviews and belt-tightening, it was the major investments being made by Telstra Health that caught the attention as the year came to a close. Health IT is a sceptical industry at the best of times and its people will reserve their judgement, but it is hard not to proclaim 2014 as the year of Telstra.

In early October, UnitingCare director and noted reviewer Richard Royle got to show off his $96 million baby when St Stephen’s Private Hospital in Hervey Bay opened. The fully integrated hospital predominantly runs off a suite of clinical software from Cerner, a set-up that Mr Royle compared favourably to the best of breed approach taken at another landmark hospital that opened this year, Fiona Stanley in Perth.

St Stephen’s would receive notification in December that it had achieved HIMSS level 6 due to its super-duper, closed-loop medications management system. It also received special dispensation from the federal government to trial paperless prescribing.

The tiny towns of Tara and Wandoan in the western Darling Downs joined Dalby, Chinchilla and Miles as part of the Centre for Online Health’s Health-e-Regions project, allowing patients and local clinicians to video conference with specialists from hospitals in Toowoomba and Brisbane.

In mid-October, the long-awaited boundaries for the 30 new Primary Health Networks (PHNs) were released, the number a little higher than expected. We speculated that many regional sub-offices will need to be established for rural areas in WA, SA, Queensland and western NSW considering the vast distances the PHN will be responsible for. (The individual PHNs can be viewed on the National Health Performance Authority’s My Healthy Communities website.)

There was plenty of action in the online appointment booking market this year, with MedicalDirector announcing back in August that it plans to offer an online appointments booking module fully integrated into PracSoft in its next release.

Launceston-based DocAppointments added a number of new features to its various offerings throughout the year, including a patient demographics and survey app and a customised app service, but the big shake-up in the market came at the end of October, when market leader HealthEngine announced it would offer its online booking system to AGPAL-accredited practices for free.

The second half of the year turned out to be a relatively quiet time for the primary care software vendors, which would have come as a relief after the huge amount of work they have been asked to do in preparing for the PCEHR and the requirements of the eHealth Practice Incentives Program (ePIP) over the last couple of years. Most vendors were able to turn their attention to developing new features and attending to the needs of their users, although they were briefly threatened with having to drop everything to prepare for the proposed $7 GP co-payment. Most vendors we spoke to weren’t having a bar of it.

In aged care, things got interesting as the sector became increasingly nervous about the Department of Social Services’ (DSS) plans for the Aged Care Gateway and the associated central client record. Back in July, a room full of aged care movers and shakers at the ITAC conference got a bit het up about the ”policy silliness” of the possibility that they’d have to deal with two eHealth records rather than one.

In November, DSS tried to hose down concerns by saying that the central client record would not include medical information, but it also admitted that the record would go live without a link to the PCEHR. What the aged care sector wants is to see the two records integrated through the same platform, or better yet, a single record.

In acute care, a few problems were emerging. A bug was discovered in the MetaVision intensive care software package being rolled out in several Brisbane hospitals with the potential to cause serious harm. It turned out that a fix was being prepared but that didn’t stop some from going to town on the situation.

In South Australia, the grumblings about the implementation of the new Electronic Patient Administration System (EPAS) from Allscripts grew to a bit of a roar with the release of a report by the SA Auditor-General, Simon O’Neill. Mr O’Neill warned that the delay in the system’s roll-out, mounting costs and a backlash from clinicians at at least one of the three hospitals it is installed in would have a serious effect on the design and build of the new Royal Adelaide Hospital, due to open in 2016.

EPAS also turns out to be the reason why the three hospitals have had to switch off PCEHR functionality for the time being.

News on the PCEHR was predominantly confined to the ongoing drama that is the design of a model to upload pathology and diagnostic imaging reports, as well as how to get the private hospital sector on board. A few eyebrows were raised – not the least in the aged care sector, which has received no incentive to partake – when funds, small as there were, became available to connect private hospitals.

As reported in August, it appeared that the Department of Health had decided to drop the previously favoured authority to post method for uploading pathology reports in favour of an automatic upload with a seven-day delay before consumers could see them. This reared up again in late October when the new RACGP president got wind of it and arced up a bit.

To allay some of the fears of general practitioners, DoH said it was working on a way to ensure that a method was devised so that sensitive reports didn’t go up or that uploads could be prevented if a consumer withdrew their consent.

Debate still rumbled, however. Pulse+IT had the pleasure of publishing a very timely article prepared by the Australasian College of Health Informatics’ (ACHI) program evaluation sub-committee, which involved a review of the evidence of benefit or harm from allowing patients to view their test results.

The RACGP put forward its view, as did the Consumers Health Forum, but as it turns out, release five of the PCEHR went live with a spot for pathology and DI reports anyway. (Not that any reports will go up any time soon, as the high-level design for the model is not yet complete.)

The drawn-out battle to get the national Electronic Reporting and Recording of Controlled Drugs (ERRCD) system up and running reared its head again, following the release of another coroner’s report into a misadventure with prescription drugs. The AMA’s Victorian branch kept up its lobbying for its introduction, this time to the newly elected Labor government, but in the meantime, electronic prescription exchange vendor MediSecure announced it might have a simpler, faster alternative. The RACGP announced it would prefer the ERRCD with a few changes, but was open to accepting an interim measure.

Adoption of the cloud for healthcare purposes got a massive boost in October when Microsoft announced it had opened two new data centres in Victoria and NSW for its Azure cloud platform. The hope is that the new Azure Australia geographies will encourage the government to do more in cloud services if data sovereignty is assured. Telstra and Dimension Data also announced in December that they were both launching government-centred cloud services.

Things that caught our eye at the end of the year include:

The Year of Telstra

As Pulse+IT’s list of our top 20 news stories for 2014 shows, a huge amount of interest was garnered by the various doings of Telstra Health, which kept on coming in the final quarter of the year and lets us safely name 2014 as the Year of Telstra.

Evidence of that interest was felt with Telstra Health’s attendance at ITAC and HIC but it built to a crescendo when the business unit had its official launch in Sydney in October, where it announced a number of new ventures, not the least of which was the establishment of a new telehealth service called Telstra ReadyCare, which will allow patients to consult directly with GPs over the phone or by video conference, 24 hours a day.

The move did gain some criticism from the AMA and ACRRM, but as Telstra Health managing director Shane Solomon explained, the plan was to offer the service to GPs, particularly in rural and remote areas.

Telstra also announced it had been chosen by NT Health to build a National Telehealth Connection Service to become a foundation for connecting video consultations around the country.

Then the investments and acquisitions began to flow. In addition to last year’s investments in firms like HealthEngine, Fred IT, Verdi and HealthConnex, and July’s acquisition of Medinexus, in quick succession Telstra announced:

Telstra Health now has a portfolio of companies, products and investments that reaches into every facet of Australia’s healthcare system, from GPs to pharmacy, community care, residential aged care, hospitals and telehealth. Next year, it will be fascinating to see what comes of it all.

The hot top 20: most-read stories on Pulse+IT in 2014

In a year dominated by the PCEHR, the budget, the fate of Medicare Locals and the emergence of Telstra Health as a major player in the health IT sector, it was the first step into the Australian market by a US firm that registered as the most popular story for Pulse+IT readers in 2014.

1. Epic wins the tender to deliver an EMR for Melbourne’s Royal Children’s Hospital

2. The 61 Medicare Locals got sliced and diced into 30 PHNs

3. Orion Health announces its plans to play with the big boys

4. It’s a story from last year, but that didn’t stop people reading about Telstra’s plans for eHealth

5. Medibank decided not to pursue its personal health record, healthbook

6. Telstra’s big telehealth announcement garnered big views

7. Health Minister Peter Dutton says Medicare Locals will be cut, but that he had no plan B for the GP co-pay

8. PCEHR stories rated well, including this one on $140 million to keep it going for another year

9. And this one, on the belated release of the Royle review

10. This was a surprise: the Triple Zero app for emergencies

11. Telstra’s acquisition of aged care market leader iCareHealth added to its burgeoning portfolio

12. The fully integrated St Stephen’s Private at Hervey Bay was a publicity machine for UnitingCare

13. Security expert Steve Wilson gave good headline for this story on a security flaw in the myGov website

14. As did Telstra Health’s Bronwyn Pike for this story on Telstra’s jumbo telehealth plans

15. There’s that name again, this time for the acquisition of Emerging Systems

16. The news that Medicare Locals had lost funding for their eHealth programs was not unexpected

17. As Pulse+IT had reported the cuts in April

18. Professor Horvath’s review of Medicare Locals was pretty much accepted in full by the government

19. All Telstra, all the time, even from last year

20. The Instagram for doctors app rounds out the top 20.

PCEHR registrations reach two million

Consumer registrations for the PCEHR have reached the two million mark, with the latest statistics from the Department of Health showing that 2,015,624 consumers have now signed up.

As of midnight on Wednesday, December 17, the figures also show that 7600 healthcare provider organisations are registered, including general practices, pharmacies, aged care facilities and hospitals.

The number of shared health summaries uploaded is still lagging considerably, with only 38,207 SHSs on the system.

However, the number of discharge summaries uploaded has reached 85,960, along with 7083 event summaries.

There are currently 1,056,788 prescription and dispense records held in the National Prescription and Dispense Repository (NPDR).

In terms of views of the system, in the week of December 4 to 10, consumers viewed their records 8485 times, but clinical views were very low during the period, with only 560 clinicians viewing the PCEHR that week.

Guest editorial: Farewell Kent Spackman

I couldn’t let December pass without highlighting a major challenge for the world of health informatics. Kent Spackman has been the major force behind SNOMED since 1997. In October 2014 Kent announced to the world that he is standing down from his position at the International Health Terminology Standards Development Organisation (IHTSDO) as Chief Terminologist (IHTSDO, 2014). Kent is retiring as of 1st January 2015[1]. What does this mean for us?

Let me step back and explain what SNOMED CT is and why it is important. SNOMED CT allows health systems to seamlessly interchange the meaning of data elements. The meaning is modelled into the terminology. How can something as complex as bacterial infection of the lung be meaningfully modelled? All of the lower level components such as anatomy, bacteria and pathogenic processes are also defined into the terminology. A bit like LEGO, these low level attributes are combined in logical statements to define the concepts, of which there are over 300,000.

At a recent meeting in Amsterdam it was highlighted to me how important the SNOMED CT reference terminology is in terms of integration between enterprises. Denmark has recently implemented a national microbial surveillance database (MiBa). In her talk[2], Marianne highlighted the challenges of mapping microorganism results from 12 different regional labs, all with their own local codes for every bug. At the meeting was a health informatician from Biomerieux , a company that produces the major share of bacterial identification and susceptibility equipment used in labs today. Biomerieux is looking at whether they can code the organisms identified by instruments such as Vitek 2 and Vitek MS in SNOMED CT so that this mapping is done once and not repeated, at great expense, everywhere.

In Australia, SNOMED CT is content is managed by the National eHealth transitory Authority (NEHTA) who have a small team of dedicated clinical terminologists . Australia is one of the founding member countries having originally helped to set up the IHTSDO in 2007. Australia has some of the most cutting edge SNOMED CT development tooling in the world thanks to collaboration between the CSIRO and NEHTA. The recently developed LINGO[3] web tools are making it easier to develop both the Australian extension to SNOMED CT and the Australian Medicines Terminology (AMT) which is based on SNOMED CT.

As I mentioned, one of the LEGO blocks in SNOMED CT is the Anatomy hierarchy. It is a direct dependency for many other concepts from Diseases/Disorders, Procedures and Observations. The current anatomy model in SNOMED CT has many problems[4]. Some of these critical issues have since been corrected, however the structure of the anatomy hierarchy is difficult to maintain, and is inconsistent. It is one of Kent’s many projects to make anatomy model simpler and correct the inconsistencies. He has been working on it since 2010 and the current alpha release of anatomy redesign is up to version 21. My concern is that this may be very difficult for someone else to pick up and run with when Kent retires.

Anatomy redesign is just one of 700 content improvement projects at the time of writing that IHTSDO has open on the collabNet project tracker[5]. Many of these have a heavy reliance on Kent as Chief Terminologist. Kent’s vast knowledge of SNOMED CT and Medical Informatics in general will be hard to replace. To quote the Kent Spackman retirement press release:

“In recent times he has been central to harmonization activities between IHTSDO and WHO and in the development of the linkage between SNOMED CT and ICD-11. He has also taken a lead role on behalf of IHTSDO in the harmonization of SNOMED CT and LOINC, ensuring greater interoperability between both global standards.”

IHTSDO has made a number of steps towards a more responsive corporate business model. They have implemented a hew helpdesk called FreshDesk.[6] They have recently employed a number of new terminologists and staff to help member countries with implementation and design tools, such as the IHTSDO SNOMED CT browser[7]. They have trained consultant terminologists from all across the world to help with the burden of maintaining this massive terminology.

As Don Sweete, CEO of IHTSDO says “It is our task now to take up the challenge and continue with his vision and work.”

I, for one, am hoping that the new IHTSDO structure is up to this challenge.

Bibliography

  1. IHTSDO News. http://www.ihtsdo.org/news-articles/dr-kent-spackman-to-retire
  2. IHTSDO Implementation Showcase 2014. http://ihtsdo.org/show14/present_091.pdf
  3. SNOMED CT Implementation Showcase 2014. http://ihtsdo.org/show14/present_059.pdf
  4. Alan Rector, T. S. (2011). Getting the Foot out of the Pelvis: Modelling Problems affecting Use of SNOMED-CT Hierarchies in Practical Applications. JAMIA Vol 18.
  5. IHTSDO Project Tracker. https://csfe.aceworkspace.net/sf/tracker/do/listTrackers/projects.ihtsdo/tracker
  6. IHTSDO Fresh Desk support Page. https://ihtsdo.freshdesk.com/support/home
  7. IHTSDO SNOMED CT browser. http://browser.ihtsdotools.org/

About the Author

Michael Osborne is a Pathology Informatics specialist working at the Mater Hospital in Brisbane, Queensland, and has been a representative on the IHTSDO content standing committee since 2010.

Seven-day model for PCEHR will make for good practice: CHF

The proposed model of a seven-day delay to upload pathology and diagnostic imaging reports to the PCEHR can be seen as a way of encouraging better communication between consumers and healthcare providers, the Consumer Health Forum (CHF) chief says.

The CHF recently released a special eHealth edition of its Health Voices journal and took the opportunity to give the Royal Australian College of General Practitioners (RACGP) a bit of a serve in the press release accompanying the publication, saying the RACGP was putting doctors’ interests before patients’ in its criticisms of the seven-day model on alleged safety grounds.

This week, CHF CEO Adam Stankevicius didn’t resile from his criticisms, but said that at the time, he took the view that the college wasn’t as engaged as it could be in the debate.

“It was an opportunity, with the release of that edition of Health Voices, to make a foray into the space and re-engage the RACGP on a few issues where we have seen blockages between our representatives,” Mr Stankevicius said.

“We’ve had a number of conversations since that time and we are moving towards a much better resolution of those issues.”

Mr Stankevicius said consumer groups were firm in their support for the PCEHR and believed it was essential that consumers were able to see their results, which doesn’t always happen in current practice.

“We know that a lot of times the GP will say ‘I’ll refer you off for these tests and if you don’t hear from us, everything is fine’. Consumers are still left waiting weeks later not knowing if the test results have come in, with no signal from their GP surgeries whatsoever about whether they’ve been looked at and how they might have been considered and if everything is indeed fine.

“I think at the moment we’re in a space where consumers just don’t know, and we think the seven-day proposal actually gives a way in which some boundaries can be put around that situation, so the consumers do have some certainty.”

Mr Stankevicius said the seven-day proposal for uploading pathology and diagnostic imaging reports, in which the GP can recall the patient if there are abnormal results but otherwise the report will be made available to the patient after a week, could be seen as a way of incentivising good practice.

“It’s a way of ensuring that consumers get the follow-up that’s needed, or they get some kind of indication that there is nothing for them to be worried about,” he said. “At the moment we hear a lot of feedback from consumers … they are not sure that the ‘all OK’ applies to the test is OK, or the test results haven’t come in yet, or I haven’t done the right thing, I didn’t diet at the right time and I have to go back and do it again.

“There is a whole lot of uncertainty at the moment, which arises from lack of information. The seven-day proposal is about incentivising that good communication practice between GP and consumer within a time period that means that if there are those concerns, there is an opportunity for the practitioners to do a recall of the consumer.”

Mr Stankevicius does not believe that there will be a major problem with consumers potentially misinterpreting their results, arguing that good communication between patient and provider can overcome this. He also said that contrary to the RACGP’s argument over safety, the bigger threat to safety is if the results are not made available to other treating clinicians.

“There seems to be this view from some in the industry that the results will be provided absent of any other information,” he said. “That they are just going to be up there and you won’t ever have had a conversation with your practitioner about why you got the test, or what the test might show. I think if there is a good and robust ongoing communication between consumer and practitioner, those questions will have been answered before you even go and have the test.

“We don’t think that the PCEHR is or ever will be a substitute for good and effective ongoing communication between consumer and practitioner, and I don’t think that’s anything the college would disagree with.”

Mr Stankevicius said an argument put forward by the chair of the RACGP’s national standing committee for health information systems, Nathan Pinskier, in an article in Pulse+IT last week that there were potential privacy issues with other healthcare providers having access to sensitive results, was one that he hadn’t heard raised by other doctors’ groups.

The RACGP is particularly concerned over the manner in which the majority of consumers were registered for the PCEHR through assisted registration by GPs or, as was more common last year, through Medicare Locals or Aspen Medical. The college argues that many consumers may not have understood the standing consent model or the default access controls built in to the PCEHR.

This, Dr Pinskier argued, could potentially lead to privacy breaches or even adverse events and thus to a loss of confidence in the system by consumers.

Mr Stankevicius argued that in addition to the national privacy principles, healthcare practitioners all had codes of conduct they had to adhere to.

“[Dr Pinskier’s] article is the first time that I’ve seen the potential privacy breach as a concern,” he said. “I think if there’s a question about health practitioners breaching the privacy laws as a result of the PCHER being in place and them having access to diagnostic tests, then that’s a broader legal question and a professional ethics question. It’s not a question about the PCEHR.

“The flip side is that I go and get the test on a Tuesday, the results are up on the PCEHR on the Thursday or the Friday and I’m in a car accident on Sunday, a time when most of my health professionals won’t be available, because they work an average day week, those test results may actually be quite important for my treatment in accident and emergency.

“So while there may be some concerns about privacy, I think there a both legal and professional regimes which govern the way in which professionals access and use the PCEHR. The potential offsets are also quite beneficial.”

Mr Stankevicius said he believed most people would favour an opt-out system, as recommended by the Royle review, mainly because most consumers believe information sharing between healthcare providers goes on much more than it actually does.

He also said he was not overly concerned that the momentum in registrations and uploads for the system had stalled somewhat since the new government took the reins.

“We see this when new governments come in all the time and particularly with big ticket items, they like to take a step back and get a feel for the space,” he said. “I think they did that with the Royle review and obviously changes to the board of NEHTA as well. So I think it’s quite reasonable, and particularly if we are seriously looking at moving from opt-in to opt-out, that requires a different kind of momentum and a different kind of campaign.

“There might be some frustrations from some in the industry who have been on a particular track in the software space, for example. I certainly understand those frustrations, but in terms of the government’s commitment, with something as important and significant, it’s quite reasonable that they take a bit of time to think about the way in which they want to take it forward.”

Datacom invests in SmartWard for new health solutions unit

Technology solutions provider Datacom has taken a 20 per cent stake in Canberra-based health IT firm SmartWard as the first investment in its new healthcare solutions unit, which is being headed up by former Australian Centre for Health Innovation clinical director Keith Joe.

New Zealand-owned Datacom is better known for its service, integration and bespoke software development capabilities, but has developed a long-term strategic plan to invest in new capabilities through solutions for market segments such as health, education and local government.

Dr Joe, who plans to keep working as an emergency department doctor at Cabrini Hospital in Melbourne as well as his new role as chief medical information officer for Datacom Healthcare Solutions, said that the new healthcare solutions division would focus on patient-centric technologies, of which the investment in SmartWard is the first step.

He said that while SmartWard was mainly focused on patient safety and clinical workflow in the hospital sector, there is also potential in residential care as well.

SmartWard inventor Matt Darling said the Datacom partnership was much more a collaboration than an investment.

“The collaboration with Datacom gives that blue-chip, copper-bottomed backing to an emerging technology which is so important,” Mr Darling said.

“Hospitals, when they buy new technology, need a very high level of support, and Datacom is a very geographically distributed technical services company, so this gives the ability for us to support and train and deploy systems across the whole of Australasia.”

Mr Darling has designed SmartWard primarily as a patient safety technology that improves workflow for healthcare professionals. The system automates clinical records, and also provides decision-support, thereby increasing the time staff spend with patients.

It has undergone trials in wards at two different hospitals in Melbourne, with Deakin University research showing that it reduced the amount of time that nurses spent on documentation and freed them up to spend more time with patients.

In fact, the research showed that nurses increased the proportion of time spent at patient bedsides from 32.8 per cent to 48.1 per cent, and increased the amount of time spent interacting with patients from 7.9 per cent to 23.6 per cent.

The SmartWard system displays a schedule of patient care according to priority. Staff review and accept tasks, and are provided with treatment reminders and automated forms including best practice clinical guidelines.

Treatment is recorded at the bedside and stored in the application, and if staff are interrupted by a more urgent task, the application detects that the procedure has not been completed and reschedules the task. Records are created automatically, reducing paperwork and handover time.

One of the keys to the system is a platform of Bluetooth authentication and location services. Mr Darling said Bluetooth was chosen over other technologies such as RFID and Wi-Fi for safety reasons.

“The issue with RFID is that the charge field is conical in shape so you get a lot of blackspots,” he said. “This is safety technology in that we want to have high resolution at all times. The idea of having to deploy numerous expensive sensors is not an option we would consider.

“There are also location services capabilities that are built around Wi-Fi, but the signal strength of that is very much higher than Bluetooth. Our ethos is really around patient safety so we wanted to make sure that anything we used was very low power so it could not constitute a risk to patients or staff.”

Mr Darling and his team have spent four and a half years developing the technology in close consultation with healthcare professionals. He said it allows staff to perform in a more effective manner.

“These guys are drawn to the profession because they want to help people and when they are dragged away and only able to interact with patients for less than 10 per cent of the shift, the interactions that are left over are fleeting, transactional and frustrating. They are not able to form relationships with the patient that they really want and that are of clinical benefit. A big part of our goal in this is to increase job satisfaction and reduce stress on clinical staff.”

Mr Darling said staff had a very low opinion of systems they currently have to use, characterising them as “nested, siloed, and hierarchical.”

“What this means for people entering data is a huge amount of repetition and an enormous amount of complexity. From our point of view, what we wanted to do was to remove the complexity and that repetition.

“By knowing that the healthcare professional is with a particular patient at a particular time, we can display the exact information and support that they need at that time without them having to drill down into anything. It’s what we call context.

“This is a system that puts the information you need at your fingertips. It ensures continuity so that what needs to happen in the next minute, in the next hour, in the next 24 hours or in the next week is available to the user. Unlike paper, if you walk away from the data input and display device, the system is automatically locked so not just anyone can come and read the chart. It has many features that builds patient safety, privacy and improved productivity for the user.”

While the prime goal in building the technology was patient safety and improved workflow for healthcare professionals, it also has productivity benefits that can be measured financially. A recent review by Deloitt Access Economics of the data from the clinical trials showed that SmartWard could provide significant benefits from minimising readmissions and avoiding errors.

Deloitte Access Economics estimated that the reduced length of stay would save hospitals $50,000 per bed per annum, which if delivered across a 600-bed hospital would see annual improvements of around $30 million.

“There are very significant cost savings to organisations that implement SmartWard, and this is done purely through avoiding patient harm,” Mr Darling said.

“We are not talking about changing nurse to patient ratios. We know that people are working at the limit at the moment. The Access Economics study proved one thing comprehensively, which is that the more time that healthcare professionals get to spend with patients the fewer the incidents of harm.

“That translates to something much more important than dollars and cents which is better patient outcomes, but it also does save money.”

Mr Darling said SmartWard had received feedback from clinicians who said it had improved their job satisfaction, reduced stress and allowed them to deliver clinical care of the highest possible standard.

“Now, we need to show and prove that this can work hospital-wide and that is a really key step for us,” he said.

Datacom’s director of investments Mark McWilliams said SmartWard was a unique software system that is keenly focused on improving health outcomes.

“We are looking forward to combining our organisational capability with SmartWard and working in unison to rapidly apply the benefits of their solution to address the needs of healthcare providers in our region,” he said.

How do you solve a problem like Fiona?

Faint murmurs about the problems being created by the incredible complexity of ICT operations planned for Perth’s Fiona Stanley Hospital were heard as far back as 2011, but it wasn’t until June last year that it was officially announced that the hospital’s opening would be delayed by six months. While FSH’s problems are now out in the open due to a parliamentary inquiry, many fear that the whole drama may have a negative effect on other health infrastructure in the state.

When it was first announced back in 2009, it was billed as WA’s first paperless hospital, a technological and ecological marvel to behold, a new hospital for the digital age where information technology would seamlessly integrate with communications infrastructure to provide world’s best practice in health service provision near the gently flowing waters of the Swan.

Most people with a distaste for spin would have seen these claims as the usual marketing gumpf, but at the time, it was not a stretch to accept that the new Fiona Stanley Hospital was going to be a pretty great facility. For the health IT industry, it was the chance to show off some of the best technology around in terms of wireless infrastructure, robotics and cutting-edge clinical software.

That might still turn out to be true, but there is now no doubt that it is this super-duper ICT that has held up the opening of the hospital. In April, a bipartisan parliamentary committee made short shrift of the excuses of Health Minister Kim Hames and former WA Health director-general Kim Snowball in the More than Bricks and Mortar report into the commissioning of the hospital, revealing that it was obvious as far back as 2012 that there was no way FSH would open on schedule. The blame for the delay was placed squarely on the complexity of the ICT.

“Over time, there was a litany of reports … [showing that] this was falling behind significantly and there were delays in recognising and conceding we were never going to deliver a hospital, not in April 2014,” committee chairman and Liberal MP Graham Jacobs said. “It was never going to happen. If the recognition of the delays, backed up by early reports, was actually recognised, a lot of the costs could have been mitigated.”

Dr Hames rejects the amount, but the parliamentary committee puts the cost of the delay in opening the hospital, including extra money for IT and staff wages, at an eye-watering $330 million. More money will be needed for IT – the government allocated an extra $40m in the May state budget – and that might not be the end of it.

“We need to make sure the very complex and difficult IT system that is required to ensure Fiona Stanley Hospital works safely for patients who come through the door, is paid for,” Dr Hames told Parliament. “We will put up the funds for whatever is required.”

Former WA under-treasurer Tim Marney probably put it best when he told the committee’s inquiry in February that the best of breed approach taken in kitting out FSH was probably the wrong one.

“You never build stuff that you can buy off the shelf,” Mr Marney, now the state’s mental health commissioner, told the committee. “You never build bespoke stuff that then has to be integrated with generic products. You change your business processes rather than changing the systems to suit the business processes. You never do big bang, because big bang goes boom.”

Best of breed

It is possible to open a new hospital with best-of-breed clinical systems but what that means is enormous complexity, and very few hospitals are capable of the massive integration task. Richard Royle, executive director of UnitingCare in Queensland, which is building a fully digital hospital at Hervey Bay on a much smaller scale than the 783-bed FSH, recently said he had decided on the opposite approach, plumping for an integrated EMR from Cerner that has only five other clinical interfaces, including those to pathology and radiology.

“My understanding from (Dr Hames) is that there are 158 interfaces at Fiona Stanley,” Mr Royle says. “158. They have a best of breed model [but] history is showing that the more interfaces you have to build into a system, the more challenges you will have. So what we have done is the opposite.”

The original plan for FSH was to have an EMR ready to go when the first patients were wheeled in, with interfaces to pathology, PACS/RIS, patient administration, pharmacy, clinical specialties, information management and reporting, identity management and data centres, all running off a wide area network built by BT. This is still the plan, but a big-bang EMR is not yet in sight.

The hospital that was first announced as having no storage space for paper medical files is now going to have to find some, and the identity management system is also in doubt, with the WA government announcing in late June that the $6 million it had spent trying to design a role-based, single sign-on smartcard for physical and computer access to the hospital was wasted because the solution doesn’t work.

While the problems of Fiona Stanley Hospital can be overcome, for many working in the WA public health sector the real problem lies in the flow-on effects on other planned infrastructure, particularly the new Perth Children’s Hospital that is due to open in late 2015. Several sources have told Pulse+IT – and Mr Marney backed this up in his comments to the committee – that the EMR chosen for Fiona Stanley was to have influenced the choice for the new kids’ hospital.

It is now highly likely that an off-the-shelf system will be chosen with none of the integration hassles that FSH has to wrestle with. Two industry sources have told Pulse+IT that US EMR giant Epic is the favoured candidate for the kids’ hospital, but that the company might have second thoughts after the dramas FSH has experienced so publicly. Epic, which recently won the tender for Melbourne’s Royal Children’s Hospital, is used widely in paediatric care in the US but has not yet been implemented anywhere in Australia.

Tendering for other elements of FSH has also been problematic. The planned closed-loop medications management system, which includes pharmacy robots, automated guided vehicles and automated medication units as well as prescribing software and interfaces with the WebPAS patient administration system, the LIS and RIS systems and iPharmacy, is a huge undertaking that only the largest companies can handle, ruling out many smaller vendors that can offer quality software systems but not the whole hardware deal. The tender for that system is still open.

Pissed off public servants

A lot of the problems seem to come back to poor planning. The full contract with Serco, which is in charge of building and operating the hospital on the government’s behalf, is worth $4.3 billion over 20 years, $2 billion of which is the actual build of the hospital. However, Mr Marney told the February committee inquiry that Treasury had only been given two weeks to review the contract before it went to cabinet, and that Treasury was quite rightly “pissed off” about it.

Dr Hames rejected this in WA’s parliament, saying that a person contracted to Treasury was on the organising committee the whole time. “The under-treasurer was, to use his words, ‘pissed off’ in the end with the time he had to look at the final contract, but I can tell members that a few people in health might have been ‘pissed off’ with him as well, in terms of how a very detailed and complex contract was worked through with Treasury.”

Former director-general Kim Snowball also defended his role in the contract negotiations and planning for the hospital. “Those being criticised are the same people who have worked incredibly hard to deliver for the state, including the Treasury, the biggest health infrastructure project of all time, on time and on budget in Fiona Stanley Hospital,” he said.

“In fact all of the major projects under construction in health were on time and on budget at the time I left the role. This doesn’t happen by accident, but by good, solid and careful management.”

While the reasons are unclear, it is pertinent to note that WA has not had a permanent director-general for health since Mr Snowball resigned in December 2012, standing down officially the following March. Nor has there been a permanent appointment as CIO of Health Information Network (HIN), the WA Health agency that oversees clinical IT. Bill Leonard was appointed as acting CIO in January after Andy Robertson stood down from the role, also acting, after just over a year.

Lack of integration

Not much of this should have come as a surprise to experts in the health IT field. In fact, Di Mantell, the hospital’s general manager for facilities management, is quite open about the huge complexity of the hospital build and operation. While she is not in charge of clinical IT, she does have intimate knowledge of the underlying ICT infrastructure behind the project.

Ms Mantell told the eHealth Interoperability Conference in September last year that the physical building would be ready by December 2013, but that the three-month transition to its planned official opening date of April 2014 was a stretch.

“What will happen is the state rehabilitation service will close at Shenton Park and our service will open in October [2014],” Ms Mantell told the conference. “That will move about 110 patients to the new service. Then over the next three phases we will gradually build up the service until it is fully operational by April 2015.

“We have worn a lot of flack for it in the media – they are having a field day with us – but you get that. If the building is not ready then you shouldn’t open it. You only get one chance to do this properly and it’s better to delay than to find out when it’s open that something doesn’t work.”

Ms Mantell detailed the extent of the ICT infrastructure at the hospital, both clinical and non-clinical, estimating that in addition to the big-name IT systems there were about 1600 other applications that clinicians and researchers – the West Australian Institute of Medical Research (WAIMR) is co-located on the Fiona Stanley campus – wanted to bring with them.

“We do have a pervasive wireless technology network, we do have medical equipment that has information systems installed, we will have RTLS, we are working towards enabling electronic medical records, we will have telehealth that is available across a diverse number of sites in the building, and we’re looking at secure and seamless interoperability,” she said.

“However, we are well aware that up until now what we felt was progressing comfortably and what we felt was locked down is still being resolved at different levels by different people.

“We will have those things I just mentioned, but will we have a full digital record when we walk in? No, we won’t. Will we have a full closed-loop medication management system? No, we won’t. But are we finally on the journey because we’ve got everybody on the same page to get people there? Yes, we will.”

A spokesperson for the hospital says it is currently finalising a range of clinical ICT applications for production, including some that have been developed in-house and those which have been procured externally.

These applications include:

“FSH will utilise the existing Ultra LIS and AGFA PACS/RIS systems that currently provide a common patient record across the metropolitan health services,” the spokesperson says. “General practitioner referrals will be processed through Central Referral Services.”

Update on NSW eHealth strategy at AIIA forum

Newly appointed NSW eHealth chief Michael Walsh will provide an update on the state’s $400 million eHealth strategy at an Australian Information Industry Association (AIIA) NSW healthcare forum in Sydney next week.

Mr Walsh, who took up the dual role of CEO and CIO in April, previously acted as CEO of HealthShare NSW for several months. He took over from former CEO Mike Rillstone and CIO Greg Wells, who have set up their own consulting firm and are working on a project for the NSW Department of Family and Community Services (FACS).

eHealth NSW has been set up as a separate agency from HealthShare to lead the state-wide strategy, which involves a large work program including the continued roll-out of the Cerner EMR, a $170 million electronic medications management program, the implementation of the iMDsoft MetaVision intensive care clinical information system, the expansion of the Health-e-Net program for the PCEHR and a new community-based EMR called CHOC.

There is also a detailed rural and remote eHealth strategy that will see major investments in infrastructure as well as clinical software.

The NSW government has also recently appointed Orange Hospital critical care specialist John Lambert as the new chief clinical information officer (CCIO) of eHealth NSW. Dr Lambert starts in his new role today.

Mr Walsh will provide an update on the strategy and key projects at the AIIA NSW Healthcare special interest group’s annual eHealth forum in Sydney next Wednesday. Registrations are now open.

Clinical e-Audit for asthma management

NPS MedicineWise has released the latest in its series of online clinical e-Audits, this one aimed at helping GPs to review how well their patients’ asthma is controlled.

The online audit will help GPs to identify risk factors that may contribute to poor asthma outcomes, and includes asthma treatment for children and adolescents as well as adults.

The clinical e-Audit follows recent survey findings that showed that over half of all respondents to a survey of adults with asthma said they had experienced symptoms in the past four weeks, including wheezing, breathlessness and night waking.

The survey showed that 97 per cent of adults taking asthma medication are confident they are using their medicine correctly, with 57 per cent saying they’re ‘very confident’ in their inhaler technique.

However, this does not match with figures from the Australian Asthma Handbook 2014, which reports that up to 90 per cent of Australians with asthma don’t use their inhaler correctly.

“Many patients think and tell their doctor that they have their asthma under control, but we know that half of all people with asthma live with poor control of their condition and consider this to be normal,” NPS MedicineWise clinical adviser Andrew Boyden said.

The new e-Audit allows GPs to review patients and how well their asthma is actually controlled, and then determine management based on regular review of asthma control.

It also explores the benefits of maintaining a written asthma action plan. Evidence shows that people who are provided with self-management education including a written asthma action plan have around 40 per cent fewer hospital admissions, 20 per cent fewer emergency department visits, 30 per cent fewer unscheduled visits to the doctor, 20 per cent fewer days off work or school and 30 per cent less nocturnal asthma.

Despite this, survey findings indicate that only 18 per cent of those diagnosed with asthma have a written action plan that was written by a doctor.

The asthma clinical e-Audit is recognised for the Practice Incentive Program of the Quality Prescribing Incentive. GPs can earn 40 RACGP CPD points or 30 ACRRM PRPD points for completing the activity.

It is available for free online at the NPS website.

Telehealth research centre aims to put theory into practice

The University of Queensland-led Centre of Research Excellence in Telehealth has officially launched, with a focus on translating research findings into clinical practice and education and training programs.

The CRE, announced last year with funding from the National Health and Medical Research Council (NHMRC), will provide support for teams of researchers to pursue collaborative research and develop capacity in telehealth.

It also aims to create an overall body of knowledge to understand how known, effective telehealth strategies can become part of the mainstream healthcare delivery system.

It involves six universities with telehealth expertise – the University of Queensland, Queensland University of Technology, the University of Melbourne, Flinders University, the University of Western Sydney and Griffith University – which will be complemented by specialists in the fields of health economics, IT, engineering, health informatics, workforce planning and management.

Telehealth researcher Dominique Bird, who has held positions at Monash University, QUT and with UQ’s Centre for Online Health, has been appointed as the telehealth program manager. Dr Bird has worked on a number of telehealth program, including the TLC Diabetes project project.

Chief investigators include well-known telehealth researchers and clinicians Len Gray, Deborah Theodoros, Anthony Smith and Trevor Russell, while associate investigators include Elizabeth Beattie, Colin Carati, Sisira Edirippulige and Anthony Maeder.

Professor Gray said last year that the CRE in Telehealth will focus on health service settings where access is currently challenging, such as small rural hospitals, residential aged care facilities, people’s homes and indigenous communities.

“The telehealth team has extensive research and translation experience in telemedicine in paediatrics, geriatrics, speech pathology, physiotherapy and dermatology,” he said.

Professor Gray has long emphasised the importance of developing sustainable service models that provide organisational solutions, and this will be a strong focus of the CRE.