The 2014 eHealth year in review: part one

In 2014, as in previous years, the trials and tribulations of the PCEHR dominated developments in the eHealth sector, although this year there was the added frisson of a new government, an independent review and the very real prospect that the whole thing would be dumped by a minister with his eye on the bottom line. While the PCEHR survived to live another day, 2014 was also notable for some very interesting moves by a couple of big players in the market, including Orion Health, Hills and the growing giant that is Telstra Health.

Pulse+IT must admit that it thought the move by IT news site Delimiter to put in a freedom of information (FOI) request for the release of the Royle review into the PCEHR in early January was a little premature, coming as it did just a couple of weeks after it was first delivered to the newly elected Minister for Health, but the move proved prescient as the months stretched out with not a sniff of what it contained.

The review, written by UnitingCare executive director Richard Royle, former AMA president Steve Hambleton and Australia Post CIO Andrew Walduck, was finally released in May, a week after the budget, but in the meantime the lack of news had most of the industry on tenterhooks for months, allied to the uncertainty over the fate of Medicare Locals.

While confusion reigned, work on the system changed focus from the primary care sector to acute care, with public hospitals continuing to connect, mainly to upload discharge summaries. The National E-Health Transition Authority released a list showing 200 hospitals had connected, a figure dominated by Queensland Health – which also provides a view of the PCEHR through its The Viewer technology – while some of the other states gradually came online over the year.

In South Australia, problems would begin to emerge with its Enterprise Patient Administration System (EPAS), although back in January it all looked hunky dory as Port Augusta followed Noarlunga Hospital in rolling out the system.

How the PCEHR could have all been done differently was hinted at in a story from January on New Zealand’s Dr Info system, which allows emergency departments and after-hours GP services to access a patient’s medical and pharmacy information simply and quickly.

The Western Sydney Medicare Local also continued its work with local shared care planning, combining its LinkedEHR system for shared care with its Health Pathways clinical decision support portal. Regionally integrated solutions for primary and community care would become more important later in the year as NSW Health Minister Jillian Skinner unveiled an integrated care strategy for the state for the next five years.

A boom in medications apps and tighter integration with pharmacy systems was a feature of the year. In February, NPS launched a new MedicineList+ app that allows users to scan in barcodes and email a full medicines list. This would later be expanded in a partnership with generic pharmaceuticals firm Apotex, allowing the app to link directly to the pharmacy dispensing system.

Electronic prescription exchange provider eRx also began to roll out QR code scanning capability for its Express app, with the codes printed directly onto the paper script through GP desktop software.

Adding pathology and radiology reports to the PCEHR would become a big topic for discussion later in the year, as it had been the previous year. In the meantime, Adelaide-based eHealth technology expert Eric Browne developed a prototype viewer through which patients themselves can read their pathology results and see diagnostic images. The system can potentially link to resources such as LabTestsOnline to allow patients to cross-reference their results to better understand why the test has been taken and what the results mean.

Despite being in a bit of a hiatus, the PCEHR continued to experience problems, with clinicians reporting that the provider portal that some prefer to use rather than their clinical information systems was booting them out for using an unsupported browser. Other clinicians vented their frustrations at having to reapply for a NASH certificate by fax of all things.

Developments from the work done through the Wave 2 sites for the implementation of the PCEHR began to seem like a distant memory this year, although one of the those projects came a cropper as health insurer Medibank announced it was closing its personal health record healthbook.

At the end of February, it emerged that while the federal health minister had a copy of the PCEHR review report, the department responsible for implementing had had to wait along with the rest of us. Pulse+IT lodged an FOI request for a copy, but after being refused on the grounds that its contents were still under consideration, we also had to wait until the official release in May.

March saw Tasmanian hospitals hook up to the PCEHR, while clinical and practice management software vendor Zedmed became the third, after Communicare and Genie, to add functionality to link to the National Prescription and Dispense Repository and to release software with in-built assisted registration capability. The other vendors would gradually release this capability throughout the year.

The Victorian branch of the Australian Medical Association began agitating in earnest in March for the roll-out of real-time prescription monitoring, which turns out to be a much harder exercise than many imagined. The topic would rear its head again later in the year following yet another coroner’s report into the accidental death of a person from a combination of prescription drugs.

At the end of March, consumer registrations for the PCEHR hit 1.5 million, but as would become clear later in the year, many clinicians had simply turned off.

Telehealth and mobility

In telehealth, many were expecting it to be the year of WebRTC, and indeed there were some developments, with telehealth provider GP2U releasing a new version of its iPhone app with in-built WebRTC functionality.

WebRTC is a developing telecommunications standard that will allow people to conduct video conferences and transfer images and documents in real time through common internet browsers without the need to download a separate application such as Skype.

A number of telehealth conferences were held throughout the year that reported sure and steady progress, although telehealth researcher Victoria Wade became every eHealth headline writer’s favourite person when she described telehealth in Australia as having ”more pilots than Qantas”.

Melbourne Health made progress with its well-regarded home therapy utilising telehealth guidance and monitoring (HUG) trial, while the University of Queensland’s Centre for Online Health (COH) established a new commercial business called RES-e-CARE for residential aged care facilities.

Some of the more interesting software, apps and studies that caught our eye this year included:

The second quarter of the year, which we will look at tomorrow, would be dominated by the release of the Commission of Audit report, the shock and awe that was the May federal budget, and the belated release of the Royle review. A little bit of certainty was restored, but the drama continued to unfold.

Using portals to prevent people from becoming patients

It might send shivers of horror down many a GP’s spine, but allowing patients to access clinical notes has the effect of improving patient/doctor relationships as well as adherence to medications and recommendations.

Andrew Miller, who was named as one of seven eHealth ambassadors earlier this year as part of the National Health IT Board’s push for nationwide use of patient portals, told the HINZ conference in Auckland last month that using technologies such as Open Notes and patient portals also has the effect of cleaning up clinical notes and fundamentally changing the way they are written.

Dr Miller, a GP from the Bush Road Medical Centre in Whangerei, offers the ManageMyHealth patient portal through his practice and allows patients to read his notes. The other doctors in the practice also read the notes, which Dr Miller says has “massively” changed the way they are written.

Dr Miller said that as information sharing improves, doctors will begin to tidy up their notes and lift their game.

“We have Open Notes in my practice [and] our patients read every single thing I write,” he said. “Every doctor in our practice reads what the other doctor wrote about them and that has massively changed how notes are written.

“They’re written more colloquially, they’re written in a way that is understandable, patients can go back and look at what we’ve written, show their family members, show their friends, and that in itself makes a huge difference.”

Dr Miller, who admits to having a “wild streak of geek” in him, has been using IT in some form or another for the last 20 years and believes that it has the ability to change the whole paradigm of how health is delivered, particularly in areas like Northland where distances are large but people and resources are few.

However, he believes the change will be evolutionary rather than revolutionary because the health system does not have the capacity to change overnight.

“In Northland we’re just left to our own devices, so we’ve got quite a lot of things going on out there,” he said. “We’re an area with very few people interfering with what we’re doing, and we just get on and do it.”

While Northland has had a number of successes, such as the implementation of eReferrals, what New Zealand eHealth in general doesn’t do too well is share these successes.

Dr Miller said that after nine months of planning in 2009, an eReferral system was implemented that meant that by 2013, 100 per cent of referrals are done electronically. However, no one came up to ask how it was done, he said.

“I don’t know if we’ve got a very good way at the moment of sharing successes and working out how we can stop reinventing the wheel,” he said. “The other thing that we’re not very good at is looking at how this affects the person. I’m not talking about patients, I’m actually talking about people. I think that most people don’t want to become patients if they can avoid it.

“Hopefully patients are going to start demanding that we provide them with this as part of a transformed, integrated system. We are about the only practice in Whangerei operating a portal and people are saying to other doctors around town how come you haven’t got a portal. My own GP hasn’t got a portal.

“One thing we do in Northland is we just try things out. People are quite willing to make mistakes up north and learn from them and just get on with the thinking. You probably learn more in a week of doing something than sitting around for a year and talking about it.”

Dr Miller said the problem of lack of health literacy in patients could be overcome in part by using portals and IT tools, as evidenced by their use in leading healthcare systems such as Kaiser Permanente in the US.

All of this, however, depends on funding. “Love without a budget is not true love,” he said. “What I’m talking about doesn’t come without cost. We’re going to have to pay both vendors to make nice products and we’re going to have to pay practices to use these products, and be realistic about the fact that we can’t expect people to work for nothing. Although that sounds mercenary, it is true.”

Diabetes care by telehealth up and running in Eastern Bay

A nurse-led diabetes telehealth clinic has been launched in the Eastern Bay, offering consultations via video link to a nurse practitioner.

Part of the Bay of Plenty District Health Board’s (BOPDHB) telehealth project, the clinics are held weekly at Opotiki’s Church Street Surgery, with cases discussed with BOPDHB nurse practitioner Isabel Raiman from her office 145kms away at Tauranga Hospital.

Ms Raiman, who heads up the BOPDHB diabetes service, said clinicians at Opotiki sometimes see complex cases on which they need more advice, so rather than referring them and the patient having to go to Whakatāne, a video consultation is substituted.

“Sometimes people are working, or there might be some anxiety about going to hospital to see someone they haven’t met before, or the patient can’t afford to make the journey,” Ms Raiman said.

“It has been really successful and we’re looking at expanding it, making it more multi-disciplinary so including, for example, dieticians and podiatrists.”

Church Street Surgery registered nurse Ellen Walker said telehealth had already shown its worth.

“In one case, a complex diagnosis led to timely and appropriate treatment, whilst in another – an older lady – found her telehealth experience so good that she is asking for the dieticians to do the same,” Ms Walker said.

BOPDHB telehealth project facilitator Ernie Newman said telehealth’s cost and convenience benefits meant its use would become commonplace.

“Five or 10 years ahead it will be in everyday use, delivering huge benefits in health outcomes and efficiency, especially for elderly patients, those with long term conditions, and/or those in remote locations,” Mr Newman said.

The project was originally scheduled to run for 18 months but was recently extended to February.

Mr 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 on board, with the project concentrating on the long stretch of coastline on the east coast between Opotiki and Gisborne.

ATC 2015 rescheduled for April

The date of next year’s Australian Telehealth Conference (ATC 2015) has been rescheduled from February to April.

The program will also be compressed to two days rather than three, but the speaker line-up will remain the same.

The conference, which has the theme of integrating care: bringing health services and people together through telehealth, will now take place on April 23 and 24 in Sydney.

Organised by the Health Informatics Society of Australia (HISA), the Allied Health Professions Australia (AHPA), the Australasian Telehealth Society (ATS), the Australian College of Rural and Remote Medicine (ACRRM), the Health Information Management Association of Australia (HIMAA) and the Royal Australian College of General Practitioners (RACGP), the conference will feature a number of practical demonstrations of existing and emerging technology in the fields of home-care delivery, mental health and consumer tech and wellness management.

Speakers include eHealth NSW chief clinical information officer John Lambert on the role of telehealth in NSW; and Martin Seers, director of Homecare Medical in New Zealand, on how telehealth can integrate and support mainstream care delivery.

Wearable device with GPS tracking to provide clever care

A Hamilton-based entrepreneur has developed a new mobile health service to assist carers of elderly people or those with disabilities at home.

The idea for the Clevercare medical alarm was inspired by Maria Johnston’s mother, who was struggling to care for her husband, who had dementia and Parkinson’s disease.

The Clevercare service provides carers with their own dashboard and a wearable device for the person being monitored. Worn as a watch or as a cell phone, the Clevercare medical alarm can schedule reminders to take medication or attend appointments and raises an alert if a person triggers the emergency alarm.

GPS tracking provides the person’s exact location and can also send an alert if a person enters or leaves a pre-determined boundary using geofencing.

Ms Johnston said new features would be added in the next two months including movement and falls detection as well as direct calling to and from the device.

This will allow the carer or the Clevercare response centre to call the watch and speak to the person who is wearing it. The watch includes a loudspeaker and microphone, so the person can easily hear the caller talking and can speak back like a normal telephone conversation.

The service has a set-up fee of $299, with basic and complete packages costing $89 and $99 per month respectively.

Australian company mCareWatch has a service that offers similar functionality for Australian carers.

App to nudge drinkers in the right direction

The Hello Sunday Morning (HSM) organisation plans to release a mobile app to help participants more easily stick with the program, which aims to change their relationship with alcohol.

Medibank Health Solutions New Zealand has donated $50,000 to the development of the app, which should be available in April next year, through its Medibank Community Fund.

Hello Sunday Morning was launched in NZ in late 2011 and aims to influence behaviour through a three-month program that involves a blog, fitness and weight goals and improved mental health.

HSM general manager Jamie Moore said about 50 per cent of users access the program on their smartphones but the site is not as effective or accessible on mobile.

“The MCF grant will be used to build an advanced smartphone app that will enable HSM to support New Zealanders to have a healthier relationship with alcohol by providing them with support in the moments that the pressure to drink causes them to slip-up,” Mr Moore said.

HSM users sign up to go for three months or more without alcohol and blog about their journey. They also undertake regular questionnaires that help them assess their alcohol harm risk.

However, Mr Moore said this is too long for some people, so the app would be used to gradually nudge people towards their goals.

“It will integrate with other health apps HSM users like to use such as RunKeeper, Jawbone and MyFitnessPal and with social networking sites like Facebook, if they choose,” he said.

“Users will be able to put their drinking data on top of their fitness and sleep data and see if, for example, when they drink more they sleep and exercise less, which can help reinforce their reasons for taking a break from drinking, or drinking less.

“If people can physically see that information on their screen it makes it more real, and it’s important for them to be able to access that data and support on their mobile devices when, for example, they’re out on Saturday night.”

Easier path to approval for medical device manufacturers

The federal government plans to introduce new regulations to allow local manufacturers of medical devices to obtain market approval in Australia if they have been certified by a recognised European conformity body.

At present, medical devices must receive market approval from the Therapeutic Goods Administration (TGA) even if they have passed Europe’s CE Mark approval process.

Regulatory amendments to the Therapeutic Goods (Medical Devices) Regulations 2002 will be introduced later this year to cover applications for lower risk Class II and Class III medical devices and in vitro diagnostics (IVDs) such as hearing aids, joint implants and devices used for in vitro fertilisation procedures.

Assistant Health Minister Fiona Nash said the new rules will not apply to the very highest risk devices, such as those devices containing medicines or tissues of animal, biological or microbial origin, or Class 4 IVDs such as drug-eluting stents or tests for HIV.

“These devices will still need TGA conformity assessment,” Senator Nash said. “With these changes, Australian manufacturers can choose to either have conformity assessment conducted by the TGA or an alternative conformity assessment body, such as a European notified body.”

She said the new arrangements would bring Australian manufacturers in line with the regulations for overseas manufacturers, and in some cases would enable devices to get to market more quickly.

Medicare Locals to be sliced into 30 Primary Health Networks

The Department of Health (DoH) has released the long-awaited boundaries for the new Primary Health Networks (PHNs) that are set to replace Medicare Locals.

Thirty PHNs have been established – more than the expected 20 or 24 – which DoH says will align with state-based Local Hospital Network (LHN) boundaries.

The alignment is apparent for the PHN boundaries in NSW, Queensland, South Australia and Western Australia, which mirror those states’ LHNs.

Victoria has close to 90 LHNs centred on individual hospitals and health services rather than geographical areas, but it will have only six PHNs. As is currently the case with Medicare Locals, Tasmania, the Northern Territory and the ACT will be covered by one PHN.

Much of the reduction in ML numbers has occurred in the capital cities: the greater Sydney region will have five, Melbourne will have three, Brisbane two, Perth two and Adelaide one.

It is probable that 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 whole of WA and SA outside of the capitals will have one PHN each, covering the same areas as Country Health SA and the WA Country Health Service.

In an overview of the proposed timeline for establishing PHNs, DoH says that an approach to market (ATM) process will take place late this year for organisations to bid to operate the PHNs. The successful applicants will be announced next year, with PHNs given about three months to begin establishing themselves before the end of the financial year.

A strong emphasis on the role of PHNs in predominantly assisting general practice is apparent in the overview, with no mention of community pharmacy or aged care.

One of the roles for PHNs highlighted in the overview is to assist GPs in understanding and making meaningful use of eHealth systems. In the May budget, specific funding for Medicare Locals to carry out this role was cut.

PHNs will have five primary roles, including analysing and planning for the health needs of their local communities; helping general practices to assist patients in avoiding hospital admissions; supporting general practices in safety and quality measures; assisting GPs to use eHealth systems; and purchasing or commissioning clinical services for population health issues such as chronic disease and mental illness.

Metro North Brisbane Medicare Local CEO Abbe Anderson welcomed the decision not to increase the size of her ML, which already has a population of near 900,000.

“The news that the boundaries for the Metro North Brisbane region will remain as they currently are will be a relief to many GPs and allied health professionals,” Ms Anderson said.

“A recent survey carried out by the Medicare Local revealed that many health professionals were concerned that the increased geographical size of PHNs would mean a loss of connection with local health professionals and providers.”

Northern Sydney Medicare Local CEO Ramon del Carmen said the move to align PHN boundaries with LHN boundaries was a logical one.

“Aligning to district boundaries is an effective way of reducing service duplication and concentrating funding and effort on keeping people healthy,” Mr del Carmen said.

As Medicare Locals operate as independent companies, they are all eligible to bid to run one of the new PHNs. Pulse+IT understands that a number of the larger Medicare Locals that transferred directly from previous Divisions of General Practice are set to bid individually, while smaller, neighbouring MLs will put in a consolidated bid.

The chief executives of the Grampians, Great South Coast and Barwon Medicare Locals issued a joint statement welcoming the new boundaries. The three Victorian MLs fall within the new Grampians and Barwon South West PHN.

“We are pleased that the government values the primary health coordination role – to provide better, more sustainable, more efficient access to local health services,” they said.

“The new boundaries make sense as they align with existing Local Hospital Network boundaries, contributing to well-connected health systems in our community.”

Country North SA Medicare Local (CNSAML) CEO Kim Hosking said his organisation would be bidding to provide the new country SA network.

Mr Hosking said the decision to allocate two networks to SA was recognition of the fundamental differences in the provision of health services between the city and in the country.

“For example, country GPs are expected to provide services in local hospitals, as most country hospitals do not have salaried medical officers,” he said.

“As an organisation that covers a vast and diverse area … we are strongly positioned to tender to join the new network, in partnership with other rural stakeholders, as we have a proven track record of working with regional health providers and communities.”

Mr Hosking said CNSAML had set up six local health clusters comprising local health providers, community leaders and health consumers that could become the basis for the community advisory committees and clinical councils that the Horvath review into Medicare Locals had recommended.

“We would seek to include existing groups and partners in other parts of the state that could fulfil these roles should we be successful in our bid to provide the new country SA network,” he said.

The PHN boundaries are:

New South Wales (nine PHNs)

Victoria (six)

Queensland (seven)

South Australia

Western Australia

Tasmania

Northern Territory

Australian Capital Territory

Maps for each PHN are available on the department’s website. The former boundaries for Medicare Locals are available here.

3D modelling to pinpoint skin lesions on ApreSkin app

Brisbane-based dermatologist Brad Jones and his team from 3D Medical Software have launched a native iPad app called ApreSkin that promises to help streamline the way doctors perform skin consultations and improve the way they track and record patient data.

Aimed at dermatologists, plastic surgeons, general practitioners and skin cancer specialists, ApreSkin uses a realistic 3D model to accurately locate and record skin lesions or conditions on the model with automated localisation of the body site.

It features fully customisable pop-up lists for data entry of common diagnoses, procedures and phrases, or data can be entered via the keyboard or the iPad’s in-built voice recognition.

At the moment, many doctors type a description of the location of a skin lesion into the patient’s record or mark a spot on a 2D body map, and then scan this into the record. Clinical photos are also often taken but do not directly attach to the correct patient record.

“With the advances in technology and particularly interactive 3D software, I believe we need to modernise our current medical software especially in dermatology, which is a more visual specialty and would benefit from this change,” Dr Jones said.

“At the moment we are still using the same generic medical software that was being used 10 to 15 years ago.”

Dr Jones said that by using an iPad, clinicians can easily generate a patient report or medical record of the skin consult using realistic 3D models to accurately mark skin lesions or conditions along with automated data entry of the location.

“Then at the press of a button, simply attach photos or screenshots to aid future identification of the lesion,” he said.

The app has the ability to attach clinical photos and screen shots of the body site to be stored with the medical record, and a report of the consult can be generated at the push of a button for options such as printing, emailing to a colleague or to store in the patient’s file. Dr Jones said the long-term plan was to integrate the app more closely with practice management software such as Genie, which he uses in his practice, but this is not possible as yet.

“At this stage a report can only be linked with the patient’s record,” he said. “A report can be Air-dropped onto the desktop using software such as Drop Box, and with the new iOS 8 and Yosemite that’s just been released you will be able to Airdrop directly from iPad to Mac.”

The app includes customisable templates for skin surgery and laser procedures as well as an optional PASI template for psoriasis.

Dr Jones said all data on the app is encrypted and protected by a pin number, and can be backed up to a laptop or desktop via iTunes.

The app is available on the App Store for $129.99. An overview of how to use the app and another on how to use it for surgery, laser and PASI score treatments are available on YouTube.

Opinion: Is your storage space a data repository?

In an age where hackers and other cybercriminals seek to do us harm, can we relax when it comes to our financial and medical information? After all, those who handle them are subject to clearly defined legislation. It seems not, as indicated by a recent violation of privacy laws by a Melbourne medical centre, where 960 records of former patients were compromised in a November 2013 break-in.

While the incident received much coverage in Australia, it was also featured internationally and must have been embarrassing for the Office of the Australian Information Commissioner (OAIC), with Timothy Pilgrim, the Australian Privacy Commissioner, announcing that a garden shed is not a secure place for medical records.

Readers around the world are sure to have thought “I knew that.” However, it is clear that the comments referred to the specific situation rather than a bid to enlighten the medical profession here.

What can Australian healthcare professionals do to ensure our medical records are stored correctly and disposed of when converted to a digital format? We all appreciate that clinics and medical centres are in the business of patient care, but that business must include adherence to privacy regulations and ensure health records are secure. Enforcing this situation may well be a challenge but a necessary one to safeguard our data.

Fortunately, technology can help and when employed correctly can satisfy all technical and legal requirements.

Many healthcare providers attempt to reduce their reliance on paper-based records by creating a process for document conversion, scanning each document and accurately importing them into the appropriate clinical application. If paper records are no longer required, arrange secure disposal.

However, process completion can take some time and generally needs to be phased in, being worth the effort and allowing compliance with existing and future technology. Such conversion saves storage space that could be used as an additional office or consulting room, for example. Garden sheds could even serve their true purpose.

Digital conversion from paper can also help prevent low-tech hacking and clinical record breaches, where insecure records are compromised by burglars or unauthorised personnel. The greatest advantages lies in efficiency, as all digital records can be accessed or updated immediately.

The conversion process does not solve all problems and due diligence is necessary, especially when it comes to data storage, disaster recovery and back-ups. If using hosted cloud solutions, ensure the selected providers stores the data in Australia and that all date centres perform regular security audits that comply with both technical and legislative requirements.

Data storage or back-up solutions are essential, with on-site servers or network-attached storage (NAS) the most popular options. Those that do not wish to maintain a server can simply use NAS, a standalone solution that typically contains multiple hard drives that allow automated local back-ups to take place at scheduled intervals.

When combined with an off-site solution in the cloud, data loss is highly unlikely as several secure copies are in place at any given time.

Secure medical records are essential for all involved. In the ‘garden shed’ scenario, negative publicity affects the business, raises justifiable concerns from patients – who will more than likely change to another healthcare provider – and highlights the need for a move from paper-based storage solutions. A secure cloud environment is perhaps the best solution, one that can also improve mobile clinic solutions.

Rob Khamas is an eHealth solutions strategist with REND Tech Associates.