Challenges of interoperability with medications management

St Vincent’s Hospital in Sydney’s Darlinghurst is further down the track than most in terms of using electronic medications management (EMM), having first piloted the MedChart system way back in 2005.

The system was implemented in all wards of the hospital by 2010 and then in emergency in 2011, and is now being used for medicines reconciliation at both admission and discharge, with a current medicines list accompanying the patient throughout their journey.

The EMM is interfaced with the hospital’s electronic medical record to enable a complete list of discharge medicines to be added to the discharge summary, which is then sent up to the PCEHR and out to local GPs.

This has been working quite well for the hospital for a couple of years, but St Vincent’s is working on making the system interoperable with its pharmacy dispensing system, automatic dispensing machines and smart IV infusion pumps. It is also considering how to go about sending data – and what sort of data – to the National Prescription and Dispense Repository.

For Kate Richardson, the pharmacist in charge of eMedicines management at St Vincent’s, the ultimate will be the day when it is possible to directly import medicines information out of the PCEHR or GP systems straight into MedChart, particularly for the medicines on admission list.

However, as Ms Richardson told the eHealth Interoperability Conference in Sydney recently, a lot of work needs to be done to achieve true interoperability between the different clinical systems used in hospitals, as well as the challenges being faced in mapping the Australian Medicines Terminology (AMT) to SNOMED CT-AU.

“My nirvana is that I’m actually going to be able to magically import the medicines out of these documents into my meds management system, specifically into my meds on admissions list,” Ms Richardson said. “I want to create a list of medicines that I know that patient is currently taking and then possibly record things that they took in the past.

“[For] allergies and adverse reactions, they are going to magically likewise be imported into your clinical information system of preference. We’re going to need both AMT and SNOMED CT terminologies to support the identification of medicines and adverse reactions, but also there is a lot more coding and atomisation of data across both primary and acute care to actually enable true interoperability.

“We are going to have to do a lot more work on to have get this interoperability happening.”

Ms Richardson said St Vincent’s uses its medicines on admission list to reconcile medications throughout patient transfer and the patient journey, with all wards and ICU using the same system so clinicians don’t have to re-enter information.

MedChart is used for all of St Vincent’s prescribing, administration, pharmacy reviews and reconciliation throughout the whole patient journey, and at discharge the hospital can create a complete list of discharge medicines in the EMM.

“We import those directly into the electronic discharge summary and then we shoot them up to the PCEHR and send them point to point to our GPs,” she said.

What Ms Richardson wants to see is three-fold: complete, accurate and safe on-screen display of medicines information; the clear articulation of the method of administration; and systems that fit medical and nursing workflows while also enabling sophisticated use of clinical decision support.

To get there, however, will require a lot more work. St Vincent’s is using the AMT to overcome the most obvious difference between primary and acute care prescribing practices – GPs prescribe by brand while hospitals use generic terms – but the AMT is still very much a work in progress.

Dose strengths and instructions are also described very differently, and routes of administration are much more complex in the hospital setting.

“The other thing we do is take three medicines or three prescriptions and we blend them into one,” she said. “So this is where a GP prescribes a 10mg, a 25 and a 50mg capsule, because we take one of each twice a day for an 85mg dose.

“But in hospital we just have one order on the chart. Doctors hate having to edit every time a dose changes, having to cease the 25 mg, change the 10 to a 20mg because your dose has changed to 70, then after three days your therapeutic drug monitoring comes back and you’ve got the change your dose again.

“They want one order on the chart, it needs to describe everything about that drug order satisfactorily, and the nurses only want one order to administer off. They’ve got to do co-signs, they’ve got to get double checks. They don’t want to have to get three signatures for the three different products every time they sign off.”

St Vincent’s has overcome some of the problems by writing its own clinical decision support and is also working with the AMT team at NEHTA to add more information to the descriptors for generic drugs.

It has also created its own synonyms for certain descriptors so that how things are described in the prescribing system links to the AMT and to the NSW Hospital Product Pharmacy List for the dispensing label so all terms marry together.

When it comes to discharge, however, the terminologies used within the hospital cannot yet be turned back into the original GP product concepts, she said.

“At discharge, we have a complete list of medicines and we’ve got a whole lot of processes to make sure everything is reconciled and all the things that are withheld with admission are put back on the discharge list.

“We then send it off to a discharge summary and we’ve got no transcription errors here as it’s a simple click and send process.

“But at this stage we’re not asking the doctors or the pharmacists to retype all of these back into those original GP product concepts. So I have been looking for help from the clever programmers to be able to do this. I’m not going to ask my doctors to go and spend more time, particularly when they are dealing with 20-plus medicines at discharge, to go and retype them all out in the beautiful format that will be in the primary care AMT concepts.

“Others may choose to do that, but I think I need the eHealth community to give me a really good business case to prove the value-add to my doctors about this before we go forward.”

Despite these hurdles, St Vincent’s has been successful in sending out vastly improved medication information, she said. Independent research shows that 93 per cent of orders are complete in the electronic discharge summary.

“They are not in beautiful AMT-CDA discharge summary acceptable terms, but they are going out and they are legible.”

Similar problems are obvious with allergies and adverse reactions. Documenting allergies at admission is tricky, Ms Richardson said, as hospitals are often relying on anecdotal evidence from the patient.

“You’re going to have patients that present to hospital and they’ve written down ‘? penicillin’ [as an allergy]. Is that all the penicillins? Did they self-diagnose? How do I code a question mark? And an allergy is a specific type of immune response so this term shouldn’t be used.”

Ms Richardson is an advocate for a change to the terminologies used for allergies and adverse reactions, believing it is far more useful to talk about intolerances, sensitivities, hypersensitivities, side effects and severity.

When it comes to interoperability, however, this has wider problems. Drug sensitivities are one thing, but there are also food intolerances that have to be mapped within the CBORD dietetics system, sensitivities to agents such as dyes used in radiology, and other categories such as allergies to latex, bee stings and cat dander.

This all then needs to be mapped to how agents are described in SNOMED CT, which is not fit for use with medicines, she said.

The key consideration for allergies and adverse reactions is what should be the source of truth, she said. “It definitely has got to be where your clinical decision support lies.

“In GP and retail pharmacy land is quite easy for them, because they’ve just got one system. They’ve got their practice software system, but in hospitals we’ve got heaps of different systems. So where is your source of truth? We haven’t quite solved it.

“We actually can’t enter a drug allergy in our EMR. You get plonked over to the EMM and it writes back straight away, so we’ve got a record in both. One day it will be beautiful because we’ll have SNOMED and they will talk to one another, but I think that’s what we’ve got to do in the interim.”

Even mapping terms such as plasters is difficult. Plasters is a generic term and appears in SNOMED, but most systems will list them under brand names such as Band-Aids, Micropore or Elastoplast.

“When is Brazil nut just a nut? Well, luckily in SNOMED it can be both, but in the EMR system it needs to just be nut, because when it gets down to CBORD and dietetics, it just needs to be nuts.

“There is no standardised class structure anywhere. Every reference text, every knowledge base will have their own. They have all developed their own and they’re all very good, but they are not all the same.”

While these challenges are extraordinarily complex, there is light at the end of the tunnel, she said. “I’m not going back to paper and we’ve got work to do, but I think it is a very exciting space to work in over the next few years.”

Telstra and Dimension Data launch government cloud services

Telstra and Dimension Data both launched cloud environments aimed specifically at the government sector this week in moves showing governments are taking ‘cloud-first’ policies seriously.

Telstra has named its service the Government Cloud, which it said will significantly increase the ability of government organisations to access highly secure and compliant cloud services for both unclassified and protected level data.

Telstra, which has had a long relationship with the federal Department of Human Services, will launch the platform in the first half of next year.

Telstra’s executive director of cloud services Erez Yarkoni said that as governments move into a new era of service delivery transformation to meet the current and future digital expectations of citizens, the ability to use protected cloud services is as critical to their future plans as it is to the private sector.

“Importantly, Telstra’s Government Cloud will provide confidence that the data is safe and hosted in Australia,” Mr Yarkoni said. “It will also help enable the public sector to achieve greater efficiency and generate more value from its ICT investments.”

Dimension Data will open a new managed cloud platform (MCPs) in Canberra at the same time. The company says the MCP will be the first large-scale platform in Canberra designed solely for the Australian government.

The Canberra MCP is housed in a new TIA 942 design-compliant facility, under final construction by Canberra Data Centres. Dimension Data counts the National Disability Insurance Agency as one of its clients.

Dimension Data CEO Rodd Cunico said the Canberra MCP will provide capabilities available across Dimension Data’s global cloud platform, including Infrastructure-as-a-Service, Microsoft solutions on the cloud and support for enterprise applications like SAP ERP.

The moves follow Microsoft’s recent announcement that it will host its Azure cloud platform in two data centres in Sydney and Melbourne, which it says will encourage public sector organisations to migrate to the cloud by addressing data sovereignty concerns.

Telstra has also announced that it is rolling out its small cell technology to 50 towns in regional Australia that will allow them to use 4G data services.

The technology was first trialled in Yangan, a small town on Queensland’s Darling Downs, and will switch it on in towns in Victoria, NSW and Queensland before the end of the year, with some more to come online in the New Year.

While the service will not yet support voice services, Telstra says it plans to add voice over LTE in 2015, when voice and even video calls will be possible.

UWS to offer health information management specialisation

The University of Western Sydney (UWS) will offer a new specialisation in health information management (HIM) as part of its Bachelor of Information and Communications Technology (B.ICT) degree from next year.

UWS said the decision to offer the specialisation within the B.ICT domain was based on the increasing use of electronic medical records and other digital healthcare systems, as well as the national implementation of a health funding system based on actual resourcing of patient care.

According to UWS, future HIM graduates need a fundamental foundation in ICT to effectively manage the increasing volume of patient data that needs to be available in accurate, reliable and standards-based digital form.

The director of the academic program for the B.ICT in UWS’s School of Computing, Engineering and Mathematics, Joanne Curry, said discussions with management from both the public and private health sector were the driving force behind developing the course, as it will provide direct entry into the health workforce due to the shortage of newly skilled resources entering the market.

“I am very excited to be offering this degree, the first HIM qualification in the world that will be based on a computing degree,” Dr Curry said. “This will make UWS graduates from this course highly desirable to employers. I anticipate competition for degree places will be strong as there is guaranteed job placements with at least 500 job vacancies currently available.”

Dr Curry said HIMs will be planning healthcare computing and information systems, developing health policy and identifying current and future health information needs within the health service environment.

In addition, HIMs apply information technology to the collection, storage, retrieval, use and transmission of information to meet the clinical, legal, professional, ethical and administrative record keeping requirements of health care organisations.

The CEO of the Health Information Management Association of Australia (HIMAA), Richard Lawrance, said that for students who don’t necessarily want to be at the front line of clinical care but nevertheless have the desire to make a difference in healthcare, health information management provided the perfect career path.

“On one hand, you learn the clinical knowledge to be able to meet the point of care informational needs of clinicians and other front line healthcare practitioners,” Mr Lawrance said. “On the other you are engaging with the technical capability of a healthcare system to generate and manage accurate data.

“At the same time, you are managing the translation of that data into meaningful information for each contributor to the health care service, including financing and resourcing.

“It’s challenging but amazingly engaging work and a great foundation from which to branch out into other specialisations. HIMs are, literally, everywhere.”

HIMAA will be working with UWS to provide support from the profession for B.ICT (HIM) students, including the offer of two scholarships.

The HIM component of the degree will include two specific opportunities to get an insight into the profession. One is a health service management practice unit, involving a 20-day work placement over the length of the semester, and the other is a professional experience project for a health-based client.

UWS said students will also have the opportunity to develop in student entrepreneurship and innovation as an activity to achieve engaged learning, creating for example a mobile app for storing individual health information.

eHealth NSW plans to corral acronym soup into eClinical record

eHealth NSW is currently conducting a tender process to create a panel of electronic medications management (eMM) solutions that local health districts will be able to choose from, and is also evaluating responses to a tender for an incident management system (IMS) that will be rolled out statewide.

These are just two of a large number of projects that the new agency is involved in following its official establishment on July 1. In addition to eight complex clinical programs currently in progress, eHealth NSW is also in charge of the corporate ICT program for the NSW health department.

At the moment, it is working on a large infrastructure upgrade to provide all hospitals with a minimum of 1GB of bandwidth, a new rural eHealth strategy involving the six non-metro LHDs, and the single email system that Health Minister Jillian Skinner has wanted since the March 2011 election.

eHealth NSW’s new heads – chief information officer Michael Walsh and chief clinical information officer John Lambert – outlined the agency’s corporate and clinical strategies at a meeting of the Australian Information Industry Association’s (AIIA) NSW Healthcare special interest group in Sydney yesterday.

Mr Walsh, who is also eHealth NSW CEO, has been in the position for less than two months, and Dr Lambert less than two weeks. However, they are building on a great deal of work done over the last few years by former Healthshare CEO Mike Rillstone and former CIO Greg Wells to create and implement the Blueprint for eHealth in NSW, released in December last year.

The blueprint outlines a federated approach to ICT in NSW Health and details how the government expects to spend the $400 million allocated to ICT programs, in addition to its specific plan for eHealth in rural and remote NSW.

“eHealth NSW was an idea that was generated after the last election in NSW and it was the idea that we needed to work in partnership across a federated system,” Mr Walsh said. “eHealth NSW has been in existence for 58 days, since the first of July, and it has an executive council chaired by [NSW Health director-general] Mary Foley that meets monthly to give strategic oversight.

“One of the things people will see next in the public arena around eHealth NSW is a draft strategic plan that will come out later this year for public consultation. That will forecast the next areas of focus and investment that we need to look at into the future.

“What we need to improve is the connectivity between where eHealth was going in relation to its priorities, and the clinical workforce. The appointment of a chief clinical information officer is that start of that strengthened partnership.”

Corporate programs

Mr Walsh outlined some of the corporate programs for eHealth NSW that will also have an effect on clinical systems and clinicians themselves. This includes the establishment of StaffLink, the human resources system that covers the 105,000 people working in NSW Health.

“The important thing about StaffLink as a service-wide HR system is that it has now become the core and the single point of truth for people identity,” Mr Walsh said. “We are now able, across our system, to identify who each individual is, which means that we can now move to a single email system.

“We can move to messaging services that allow us to ensure that the right messages get to the right location. We can connect all of our other systems to the hierarchy of the organisational structure, so we can do permissions and security based on StaffLink. This is a huge step forward, and we can now move some services into the cloud because we can manage single identities.”

Mr Walsh said eHealth NSW was currently finalising the build of a new rostering system that is being piloted at Concord Hospital and should be rolled out statewide next year. This online system will allow staff to view rosters at home and request changes, and for managers to publish rosters electronically.

A single asset management system for NSW’s 220-odd hospitals is also close to completion, which will provide a single, consolidated view of all assets, starting with real estate.

A large infrastructure upgrade is currently underway, with the majority of metropolitan and regional LHDs already upgraded to the new Health Wide Area Network (HWAN), which promises a minimum of 1GB of bandwidth in every site. This is now moving to rural sites, which Mr Walsh said was incredibly challenging considering the vast distances between some of those sites.

He said the HWAN would improve reliability for both corporate and clinical systems, but would also enable more video conferencing and collaborative tools to be used to reduce travel. NSW Health has invested in Microsoft’s Lync system, which is integrating more closely with Skype, and will roll it out over the next year.

With the single identity system up and running, it is now possible to have a single email address across NSW Health. All staff will have a health.gov.nsw.au extension within the next 12 to 18 months, and this is live in six LHDs now.

He said there were a large number of building blocks already in place, both corporate and clinical, but there are also other programs that are currently in progress. One is the pooling of eHealth resources between the six rural LHDs, which Mr Walsh said was an innovative model that was still in its early stages.

There is also the integrated care strategy announced by Ms Skinner earlier this year, which will attempt to ensure primary and community care is more closely aligned with acute care in order to provide better, more streamlined healthcare.

“We clearly have to support the integrated care strategy for the department,” he said. “eHealth has a big role to play there. As soon as you talk about integrated care, it is a huge challenge. NSW Health doesn’t have any jurisdiction in primary healthcare, and yet what happens in primary healthcare has a big impact on us as a service.

“The other interesting challenge as we create greater reliance on our electronic systems is the ability to provide support almost instantaneously for a clinician.”

Clinical programs

Although he has only been in the job since August 18, new CCIO John Lambert has quickly come to grips with the acronym soup that represents the clinical systems he is now responsible for.

An intensive care specialist at Orange Hospital and director of intensive care for the Western NSW Local Health District for almost 13 years, Dr Lambert has also been involved in his family’s IT firm, Deltra, for almost three decades.

Deltra’s software development arm, Jaffle Software, coined from Dr Lambert’s nickname, produces the Practice Pro brand of clinical software.

In his new job, Dr Lambert is responsible for a huge investment in existing and new clinical systems, including the electronic medical record (EMR), electronic medications management (EMM), the enterprise image repository (EIR), the outpatient medical record (CHIME, soon to become CHOC), the intensive care clinical information system (ICCIS), the PCEHR-linked HealtheNet and its enterprise service bus (ESB), the incident management system (IMS) and the clinical information access portal (CIAP).

While these acronyms are a mouthful, they do not represent just one system each but a number of clinical software packages and systems. Dr Lambert hopes to bring them all under the umbrella term of eCR – electronic clinical record.

“Although we use one name to reflect the electronic medical record, it is not one system,” he said. “We have multiple systems providing electronic medical record functionality across the state and we are in the middle of a tender process to create a panel of electronic medication management solutions.

“These programs run essentially independently. My hope is that soon we will be dealing with a slightly different arrangement. I’ve used use eCR – electronic clinical record – deliberately because no one else uses that term. I’d like to think that the various programs that we currently have running are going to work as a unified view of the world.

“As far as the clinicians are concerned, they don’t care what software packages they are using. There is one patient and there is one record about that patient. They don’t care how architecturally we deliver that. Given we are going to have these systems for a long time, we want to be able to deliver that unified view. If we don’t have an overview or a vision that groups those entities together, then I don’t think we can provide that view.”

Dr Lambert said the EIR, which was built in-house by NSW Health, is an impressive project that also involves an enterprise patient registry (EPR) and now allowed clinicians to cross the boundaries between LHDs to enable access to patient images throughout the state.

He praised the clinical engagement that had gone into the selection of ICCIS – which will be provided by iMDSoft’s well-respected MetaVision system – and will be rolled out to all ICUs in NSW over the next few years.

The tender process for a new state-wide IMS has closed and bids are currently being evaluated. While it will also include the corporate side, Dr Lambert said IMS was essential in understanding where incidents were occurring and in which clinical domains.

“HealtheNet is another very important structure,” he said. “This is our internal version of the PCEHR and it is allowing an interface between different parts of the system to the PCEHR. It will be wonderful to see what can happen with the PCEHR when it is populated with a high level of information.”

He said HealtheNet was going to be a useful tool to cross interstate lines as well for the interface with the PCEHR and other outside systems.

“It will allow various elements of the electronic medical record, which in some cases might be inside an application and in some cases it might be split between different applications, and it will cross the boundaries between the LHDs and the area health services which all do things differently in a federated model,” he said.

“HealtheNet and the enterprise service bus will be the glue that sticks all of these elements of the electronic medical record together. It will allow a lot of things that are currently happening separately to come together.

“Mike Rillstone used to talk about ‘EMR first’ – I agree with that principle, that the clinicians have to have somewhere they know to find all of the different information – but ‘EMR first’ does not mean everything in the EMR. There may be a pool of systems and they have to work together.”

Telehealth demonstration project: build it and see who comes

A telehealth demonstration project that has been running in New Zealand’s Bay of Plenty region over the last 18 months is soon to come to an end, having experienced good uptake in Maori health clinics but coming across a number of challenges for district nurses and residential aged care.

The project, funded by the Ministry of Business, Innovation and Employment (MBIE) to demonstrate the capability of telehealth to improve healthcare delivery as part of the roll-out of the Ultra-Fast Broadband and Rural Broadband initiatives, was designed to see what would happen if a dedicated project facilitator was put in place to actively provide assistance to healthcare providers to get started using telehealth.

While there are several other regions using telehealth – including Canterbury, which provides services to the west coast, and throughout Northland – this project aimed to get a better understanding of what the drivers of the broadband roll-out would be in the health sector.

Project facilitator Ernie Newman said the Bay of Plenty region was chosen as the national demonstrator, with a focus on primary and community care rather than hospitals. The Tairawhiti region then came onboard, with the project concentrating on the long stretch of coastline on the east coast between Opotiki and Gisborne.

“The National Health IT Board and the Ministry of Business, Innovation and Employment are partners as well, so we’ve had 18 months to see what can be done if you put a project facilitator in place and go around offering people assistance to actually get telehealth started, then leave them and see what emerges and see what doesn’t,” Mr Newman said.

“The terminology I use sometimes is ‘build it and see who comes’. It’s a matter of targeting health sector people who face issues with isolation and who are change-receptive, and giving them video facilities. They’ve usually already got the connectivity and they’ve already got the computer – and all the project has to do is give them a high-speed, high-definition camera on long-term loan and work with them on how to build video into their business models and clinical pathways.”

The project is using the free version of Cisco’s Jabber rather than Skype, for security and quality reasons. The quality of Jabber cameras is excellent, Mr Newman said, but there is a concern about the long-term support Cisco is planning to provide to the platform.

“The hard part is to inculcate this into clinical workflows and practices. Software is the least of our worries. There are other systems there that could pick it up if by any chance Jabber falls over.”

While video conferencing has been used in the hospital sector for a number of years, predominantly for case conferencing and education, this project was aimed at healthcare provision beyond the hospital sector.

“We didn’t look to reinvent what was already happening so that’s why our mission has been to go out into GP practices, Maori health clinics, hospices, aged care, and other health premises where we can see the potential for the use of this technology,” Mr Newman said. “We’ve had a focus particularly on areas where remoteness is an issue.”

This is where the project has had some early successes, such as the Matakana Island video doctor service. The small island situated in Tauranga Harbour has a population of about 300 and was formerly visited by a GP from the mainland every fortnight.

Now, the GP is accessible by video every weekday. Mr Newman said this had proven both more economical for the health system and more flexible for the island residents, who no longer have to take as many trips onshore.

Opotiki Telehealth Community

Another success has been the Opotiki Telehealth Community, where every GP now has video capability, both in their clinics and at home. The small Opotiki Community Health Centre, which has a handful of in-patient beds predominantly for maternity patients, is staffed by nurses who periodically get an emergency case.

Nurses can contact the duty GP after hours at his or her home, and they can also directly link to the emergency department at Whakatane Hospital if needed. “That’s being used quite regularly now and is resulting in much better decisions about how to handle those cases,” Mr Newman said.

“Also, it’s providing a lot of comfort to the patient and their family because they can see that the doctor is not just an inanimate voice at the end of a one-way phone call. That one’s working pretty well.”

Several other of the small health clinics and Maori medical centres dotted along the coastline between Opotiki and Gisborne are also hooked up.

“If you take the long way around East Cape it’s about 340 kilometres to Gisborne,” he said. “There are a couple of population centers but you’re talking about a dairy, gas station and a pub and nothing much else.

“Most of those centres have a health clinic operated by, in most cases, a Maori health provider organisation. There are nine of these, and we have put video capability into all of those nine. Much of the time they are staffed just by a nurse with doctors who rotate and visit a different clinic each day.

“The benefit of telehealth is that the nurse can then call up the doctor if they need to over video, and the doctor and the nurse together can evaluate the patient and they can share the decision about the pathway for them.”

While Tauranga Hospital has extensive video capability for internal staff, the project hopes to encourage some hospital-based services, particularly for mental health and long-term conditions, to also be delivered by telehealth into the community.

It is also working well for patients with diabetes to receive dietary advice and to keep in regularly contact with care teams, as well as with smoking cessation programs.

“With those sorts of programs, the patient benefits from a brief video session every week, rather than just a longer one once every three months,” he said. “They can come down to the clinic and they can meet with the person running the program by video.

“And increasingly other hospital services are starting to come in behind that. We’ve got hopes that a lot of long-term conditions can be monitored with a balance between physical visits and video.

“What we’re doing is not rocket science. It’s simply applying some resources for busy clinicians who otherwise would be too preoccupied with business as usual. We’re giving them the encouragement and support to innovate, in the expectation of starting a chain reaction.”

Challenges in aged and home care

Not everything the project has tried has worked, with a number of challenges in district nursing and aged care. Mr Newman said the use of video by district nurses was one area the project hoped to see good uptake, but bandwidth in residential areas has proved a problem.

“There’s a lot of health premises where bandwidth is available and is running really well, and the reason we’ve been able to connect all of those clinics is that there is now fibre optic right around there which was put in for the government’s rural broadband initiative to strengthen the cell phone network in rural areas.

“That fibre optic cable enables a wireless link to be set up from the nearest link point through to the health clinic, and support very acceptable video quality. But we haven’t yet got the cellular network to a point that they can take video into a patient’s home and have a reasonable chance of being able to video back to base with the patient in the picture.

“The rural cellular network has strengthened the voice network, but to get the data on it requires a directional aerial on the roof of the premises pointing at the nearest cell site. That’s workable for health clinics, because they’re using this with some regularity. But obviously in a domestic situation, the cost of that purely to support a visiting nurse doesn’t add up. We’re not quite ready for that yet.”

For aged care, the main barrier seems to be that GPs still prefer to see a patient in person, even if that means transporting an elderly, frail person away from their bed. This is a complicated sector of healthcare that has a number of unique challenges, Mr Newman said.

“To my mind, video for aged care facilities should be universal. My personal view is that every aged care facility should have video, and every GP working in the aged care service ought to be able to connect from time to time by that means. But it’s not that easy to actually convince busy GPs to give it a try.

“There are a number of reasons for that including the remuneration model, and the sense that it looks a lot more complicated to connect with a patient by video than to have them join their place in the queue in the doctor’s rooms. And medico-legal risks have not really been addressed.

“All of those are valid concerns, and until we can get around those telehealth in aged care facilities is going to be quite challenging, but I see that as an area of real potential for telehealth.”

Now that the designated timeframe for the Telehealth Demonstration Project has come to an end, it seems likely that the government will encourage the District Health Boards to take over responsibility for promoting telehealth, Mr Newman said. The next steps are still being discussed, but what the project has been able to investigate is what works and what doesn’t at the moment.

“It’s all about creating and building up the networks so that over time it will become an expectation that every health premises is video connected just as you’d expect them to have a telephone.”

Telstra buys Medinexus as DCA eHealth rebrands

Telstra Health has bought the Sydney-based Medinexus radiology and pathology secure messaging solution, adding to a growing portfolio of eHealth companies it has acquired since the division was established last year.

Telstra’s head of health, Shane Solomon, said the company had acquired Medinexus earlier this month and looked forward “to the opportunities this provides for both parties”.

“We will be keeping the business operating as usual with the same staff and customer relationships as well as flagging our commitment to investing in the business to continue to improve the solution,” Mr Solomon said.

“We are continuing to acquire key capabilities in our e-Health strategy and will be providing a full update in coming weeks.”

One of those other capabilities is DCA eHealth Solutions, which Telstra acquired outright from DCA in August last year. DCA eHealth Solutions has now rebranded as HealthConnex in a move it says reflects its commitment to better integration of health services.

HealthConnex, which owns the Argus secure messaging service, aged and community care software package TCM, indigenous and community care clinical information system Communicare and the ConnectingCare point of care communications platform, also manages the National Health Services Directory (NHSD) on behalf of Healthdirect Australia.

It plans to release a new consumer-directed care version of TCM at the Health Informatics Conference in Melbourne next month, along with a new community telehealth solution.

Telstra first signalled its intentions in the healthcare sector with its investment in online directory and appointment booking service HealthEngine in May last year. That was followed by its purchase of DCA eHealth Solutions and a 50 per cent share in pharmacy software vendor Fred IT. It also invested in Verdi, the new name of acute care information access specialist IP Health.

Telstra also secured a licence to distribute the Dr Foster risk-adjusted quality measurement tool for hospitals in Australia, and it has an interest in personal health records through US company Get Real Health.

Mr Solomon told Pulse+IT last year that the plan was to build on Telstra’s strengths in connectivity and secure data storage by assembling specialised eHealth capabilities in the areas of provider applications, telehealth, care co-ordination, consumer health portals, enabling technologies and data analytics.

“We have identified what we think are six really big-ticket issues in health and if you can put together the six capabilities, you can bring to the mainstream health system a solution,” he said.

Telstra Health’s community care leads, former Victorian minister for health Bronwyn Pike and former Australian Home Care Services CEO Michael Boyce, told the Information Technology in Aged Care (ITAC) conference in Hobart last week that the company also plans to create a link between aged care, general practice and pharmacy software systems, and to ramp up its activity in the integrated telehealth market.

Medinexus is another addition to the portfolio. The Sydney-based company works with radiology and pathology practices and hospitals to deliver a view of diagnostic images and reports to referring doctors, partnering with secure messaging providers Argus, HealthLink and Medical-Objects.

It is integrated into GP and specialist practice management systems such as Best Practice, Medical Director, Zedmed, Genie, Shexie and Medtech. Allied health practitioners are also able to access reports and images directly from patient management systems, web browsers, mobile devices and tablets.

Diagnostic reports and images are securely stored in a data centre, not in the practitioner’s system, and patients can also be given access by the radiology practice.

Field is open wide for rural teledentistry

The University of Melbourne’s Institute for a Broadband-Enabled Society (IBES) has released a report on a field trial of paediatric teledentistry that showed it was popular with children and parents, saved them time and travel costs, and provided a platform for potential expansion into service provision to the elderly and those living in regional and remote areas.

The authors of the study, Paediatric Teledentistry: delivering oral health services to rural and regional children, say that additional economic modelling is required to fully assess the practice and inform the development of sustainable business models, but that the vast majority of parents saw it as a positive experience and a beneficial way to obtain dental services. The kids seemed to like it too.

The study involved three dental practitioners in Rosebud, Shepparton and Geelong who were trained to conduct video consultations with orthodontists and specialists in cleft lip and palate at the Melbourne Dental School and the Royal Children’s Hospital in Melbourne. Google also provided financial support.

It involved both video consultations using Citrix GoToMeeting and store-and-forward for video clips, photos and scans, and a Soprolife intra-oral camera connected to a computer. Intra-oral cameras can provide both real-time video and still images for store-and-forward.

In fact, intra-oral cameras can produce images that are as good as or superior to conventional real-time visual or tactile oral examination, the researchers say. Other studies have shown that their use has improved diagnosis of oral diseases, especially dental caries, and that they are less intrusive and stressful for children than traditional methods.

The main technological hurdle is bandwidth, they say. While store-and-forward offers a way around this, low-speed, high-latency connections like those typically found in rural and remote regions have a negative effect on real-time consultations.

“This project assessed the capabilities of the proposed technical solution in the IBES Lab before deploying the technology in the field,” they write. “The software compressed and encoded the 25 frame-per-second video into an MP4 … video stream of a minimum of 3Mbit/sec data transfer rate – and preferably using 5Mbit/s bandwidth if network conditions allowed.

“These bandwidths gave the clinician sufficient resolution quality to interpret the images received and also removed image blurring due to camera motion. Based on the results of these tests it was ascertained that clinicians had sufficient video quality to interpret the images received based upon the expected bandwidth available at the remote sites.”

The project aimed to connect children who required specialist attention due to cleft lip and palate, dental trauma and orthodontic needs, although trauma was in the end not assessed as no case turned up during the data collection period. One child had Cohen syndrome, a genetic disorder which can involve palate and jaw abnormalities.

In addition to developing a treatment plan by video conference, the specialists were able to provide general advice to the local dentist and to the parents.

Forty-three remote assessments with children between two and 18 were conducted, and the study showed that it was particularly well suited to children and received greater cooperation by younger children and toddlers as no instruments need to be inserted into their mouth. As the researchers write, all children like to see their teeth on screen.

They say there is the potential for more advanced teledentistry implementations involving a larger number of dentists and patients from a wider geographic area, with additional technologies including digital impression, 3D printing to develop dental models, saliva testing and advanced assessment tools.

“Future trials are expected to increase demand for access to local oral health care services, while increasing the level of general oral health in the community,” they say.

“This could be achieved in remote areas with an appropriately equipped and financed mobile unit, which could also service other under-serviced segments of the population, such as the elderly.

“Deployable nodes providing targeted interventions and treatment to address the oral health demand in rural, regional and remote Australia would support the mobile dental unit.”

The researchers include Rodrigo Mariño, David Manton, Matthew Hopcraft and Michael McCullough of the Oral Health Cooperative Research Centre at the Melbourne Dental School, Kerrod Hallett from the Royal Children’s Hospital, Ken Clarke from IBES and Ann Borda of the Victorian eResearch Strategic Initiative (VeRSI).

Alert service for medicines shortages

Pharmacists and prescribers can sign up to an alert service to receive email or RSS feed notifications of new and updated information on drug shortages through the new Medicine Shortages Information website.

The website is being managed by the Therapeutic Goods Administration (TGA) to provide information to consumers and health professionals on anticipated shortages of certain medicines as well as products that are being discontinued.

Current prescription medicine shortages are displayed by default but it also includes several search functions to sort by active ingredient, brand name and therapeutic class.

Clicking on an active ingredient opens a new web page with a detailed view on the medicine selected and other medicines with the same active ingredient whether they are anticipated, current, resolved, or have been discontinued.

The information on the website is gathered by the TGA from drug companies, and the site has been developed in association with Medicines Australia and the Generic Medicines Industry Association. Only those medicines listed on the Australian Register of Therapeutic Goods are included.

The TGA says the predicted shortage start and end dates are included on the website as soon as the information is received from the sponsor. In the majority of cases, it says, this will be all that is required to help health professionals and consumers during a shortage period.

The information available on the website for each medicine shortage includes sponsor name and contact details; the active ingredient and trade name, strength, dose form and ARTG number, a drop-down menu providing the reason for the shortage; the estimated duration of the shortage and the shortage type; and information about substitute medicines or therapeutic alternatives as appropriate.

RACGP: support for PCEHR review, little for co-pay

The Royal Australian College of General Practitioners has given certain aspects of the Royle review into the PCEHR its support, particularly its focus on improved usability, but remains resolute in its opposition to the proposed $7 co-pay for standard GP consultations.

RACGP president Liz Marles said the college’s key concerns about the operation of the PCEHR in terms of usability seemed to have been taken on board, but that the recommendation of moving to an opt-out system need more consultation.

Dr Marles said the college had not been consulted at all on the introduction of a co-pay and she did not believe the government had any understanding of the practical implications and costs for general practice in administering the fee.

“They have talked about an additional $2 to GPs, where there is a $5 cut in the rebate but a $7 co-pay and they say you’ll be $2 ahead,” she said.

“In fact, the bulk billing practices will have to install a billing system or to collect cash and also to train their staff, and there is more staff time involved [in collecting it]. There’s an estimate that’s about $2.54, so you are behind from the outset, and that’s not even taking into consideration any patients for whom you may wish to waive the fee.

“It wasn’t obviously discussed with us in any detail. We knew like everyone else a co-pay was on the table so we put forward our view, but there was no discussion whatsoever, until we saw the details, that they’d be cutting the rebate.”

On the PCEHR, Dr Marles said a focus on clinical usability of the system had been lost since its introduction and the college was very pleased to see an improved focus on how doctors actually use it. “We are particularly pleased at the focus on secure messaging systems, which had been lost before,” she said.

In terms of the recommendation that the system move to an opt-out model, she said the college recognised “the importance of that in terms of an increase in patient and clinician uptake, and we’ll certainly be working with the government to try and make that as operational as possible.”

What needs to be taken into consideration, however, is the extra time it will mean for GPs and the issue of a continuing lack of remuneration, she said.

“If they’re going to be reviewing item numbers to take into account increasing work on the PCEHR, we would certainly be supportive of that. There is a little bit of concern around the privacy for minors in terms of the opt-out system, particularly when it’s around sensitive information like mental health and reproductive health, and I think those issues still need to be addressed.”

However, GPs will only use the system if they see the clinical benefit, she said, and there were also concerns that doctors who did not want to use it would be forced to do so.

“They talked about including it in the [practice incentives program] and that is about trying to force GPs to use it, but I think we really need to be careful about requiring GPs to do more work when they can’t see the clinical benefit.

“If there is a clinical benefit that comes through, because GPs discover just how valuable being able to access all of that information is, then we won’t have a problem.

“It’s a bit like moving to computerisation in the first place. There’s been a really high uptake although there is still a small percentage of people out there who use paper records, but I think when you see the advantages you get the uptake. If the patients are driving it as well then GPs will always try and meet the needs of their patients.”

One of the review panel’s other key recommendations was the creation of a ‘minimum composite of records’ that would include basic details on demographics, medications and adverse events, and discharge summaries. The review panel said that with this information available at a glance, it would bring an immediate value proposition to clinicians.

However, Dr Marles said it would be more likely to bring value to other clinicians rather than the GP, as the GP is the one who is writing it in the first place.

“The other issue of course is that every time you change a medication or add something to the history, you’ve got to remember to update it on the PCEHR otherwise you will lose the value,” she said. “That has to be taken into account and the Medicare schedule has to reflect that.”

Medicare to act on duplicate and intertwined records

The Department of Human Services (DHS) has established a program of work to identify and cleanse the Medicare Consumer Directory of duplicate or intertwined records, which an Auditor-General’s report says can pose a clinical safety risk.

Last week, the Australian National Audit Office (ANAO) released the results of an independent
performance audit of the integrity of Medicare customer data. While the report found that the number of duplicate and intertwined records was not significant considering the amount of data Medicare manages, corrective action still needed to be taken.

Duplicate records were a matter of concern in terms of the potential for fraud but also clinical safety. The report says that following the introduction of Individual Healthcare Identifiers (IHIs) in mid-2010, DHS undertook a data cleansing exercise to identify duplicate Medicare customer enrolments.

This recognised the risk that if both enrolments were active and the customer requested a PCEHR, their clinical data would be incomplete as it would only reflect the data recorded on one record, the report says.

Despite this data cleansing exercise, the audit found at least 18,000 possible duplicate enrolments, which posed an ongoing data integrity issue in the Medicare customer database, it said.

Another area of concern was intertwined records, defined as a record held in Medicare’s Consumer Directory database which is shared by two different customers. This gave rise to both privacy and clinical safety risks, the ANOA found.

“Intertwined records are created when customer service officers incorrectly enable two customers to use the same PIN – customers’ unique Medicare enrolment identifiers. Human Services advised that it has recorded 34 intertwined records since 2011-12, when it commenced recording identified instances,” the report says.

“These records represent a clinical safety risk to customers as their recorded health data is combined with the health data of another customer. It also represents a privacy risk if one of the customers views their personal and/or health data, including claiming history, through a Medicare Online Services account, Personally Controlled Electronic Health Record, Medicare Express Plus mobile phone application account or by requesting a copy of their claims data from Human Services.”

The report states that intertwined records are difficult to identify and have been brought to DHS’s attention by customer queries. “For example, Human Services identified one intertwined record for two children after the parent of one of the children received an immunisation certificate for the other child and contacted Human Services.”

DHS has responded to the audit by setting up a program of work that will undertake a comprehensive analysis of the Consumer Directory to identify and analyse the extent of intertwined records by June.

It has also undertaken to cleanse the directory of any intertwined records by September, and to identify “risk points” for the creation of intertwined records by October.

It will also establish an escalation framework to capture intertwined records at the time of creation to allow for prompt corrective action by the end of the year.