Putting stroke rehab technology through its paces

The University of Tasmania is running a new study on the use of Canadian-designed software called Jintronix, which uses the Microsoft Kinect for Windows and virtual games to help people recovering from stroke to complete – and enjoy – their physiotherapy.

Led by UTAS lecturer and physiotherapist Marie-Louise Bird in association with Launceston General Hospital and the Tasmanian Health Organisation – North (THO-North), the randomised controlled trial will involve up to 70 patients using the Jintronix system and individualised therapy compared to traditional group therapy classes.

It will measure physical outcomes such as limb function and general physical activity on the ward using activity monitors, but also how much the client enjoys the therapy and how much time they spend in the program. Initially, the trial will look at outcomes while the patients are still in hospital, but the idea is to extend it to studying the technology when used at home.

While there are a number of other trials taking place around the country into providing stroke rehab at home through video conferencing, such as the University of Queensland’s eHab program and Flinders University’s Telehealth in the Home project, this trial will use the popular consumer device Kinect along with the Jintronix system, which has been designed specifically for stroke rehabilitation, Dr Bird said.

“The difference with our trial is the commercially available hardware – you can just go down to any retailer and just get a Kinect and a computer,” she said.

“At the moment we are trialling it in the hospital but the next part of the roll-out, and we are hoping to get more funding to make that happen, is to actually to do it in people’s homes.”

Five video game units have been set up in the physiotherapy area of the Launceston Hospital and another two in the THO-North public rehabilitation centre in Launceston. Dr Bird herself is based on the Newnham campus in Launceston but the technology allows for remote monitoring and the quick adjustment of the difficulty level of the exercises.

“For example, some of the software activities are for two minutes and some of them are for five repetitions,” she said. “At the beginning of their therapy, five repetitions might fatigue them and it will take them two or three minutes to do five repetitions. Whereas after they have practiced it for a while, they might do that in 20 seconds.

“I can then go in to the client management part of the system and have a look at the time they are spending in each program, and as well as that it will rate the accuracy.”

The software is able to calibrate the tasks every time they use the program depending on the range they have in their affected arm, using the Kinect motion sensor device. The Kinect also allows the unaffected arm to be used to switch to a new game, meaning they don’t have to use a mouse.

The games also use audio and visual cues such as music and colour changes on the screen to tell the client when they have successfully completed the exercise.

Jintronix has a suite of 12 games, and Dr Bird has been working with the Canadian developers to add more levels of difficulty to provide more targeted levels of activity for that individual.

“It actually calibrates every day that they go into the program, how much range of movement they’ve got in their affected arm,” she said. “If I say I want to just have an easy program, it will be easy for the range they’ve got. If I say I want a hard program, it will be hard for the range they’ve got.

“Over the last year we’ve been working with the developers as originally it was just low, medium, hard. Now there’s not only 10 levels of difficulty, but I can actually say, for example with a squatting activity, I want this person to squat 5cm or 10cm. And even within the game, I can just click on a little spanner and instantly change the settings. It’s amazingly configurable.”

The trial currently involves a clinician working with the client to set up the program, but once it is up and running and the parameters are all set, therapy assistants can take over. With the remote monitoring capability, allowing the clinician to see whether the game is too hard or the client is fatigued, it quite easily allows for the program to be used in the client’s home.

Dr Bird said the trial was a pragmatic one: the evidence is emerging that high levels of repetition in early physical rehabilitation results is important for good functional outcomes from stroke, and it also helps with concentration when used in association with occupational therapy. Evidence for the use of technology and gamification for rehab is also mounting, as is the need for therapy to be enjoyable.

Physiotherapists use physical activity enjoyment scales, known as PACES or PAE, to measure this factor, and Dr Bird and her team are using research by University of Melbourne physiotherapist Kelly Bower to measure enjoyment. Ms Bower has published extensively on the use of consumer devices such as Nintendo Wii for post-stroke rehabilitation.

“We are using a visual scale that was recently developed and published by Kelly Bower that looked at enjoyability, and with another paper that I’m working on, we’ve looked at technology with older adults and how they enjoy it,” Dr Bird said.

“We know that, if people enjoy physical activity, they are more likely to take it up and keep going in the longer term.”

The next stage is to recruit clients to use the system at home, such as those discharged into a transition care program, where clients receive therapy support at home for a certain amount of time. This will consist of providing the client with a computer, camera and a WiFi dongle, but does require a bit of IT configuration so the settings are correct.

One of the other trial leaders is Stuart Smith, director of the Healthy Eating, Active Living TecHnologY (HEALTHY) Research Centre, who is working with Dr Bird on extending it to rural communities.

“One of the things we would like to do is have a set-up in a community centre or a community gym,” Dr Bird said. “This could be supported by a health care worker or community champion who has a basic amount of training, and people could just go into the centre to participate in activities remote from their clinician. That way they get a little bit of socialisation, but they don’t have to then travel the 90 minutes to the hospital and 90 minutes back for their therapy.

“For stroke clients, fatigue is a huge thing, but as well for our rural clients you’ve got the other option of do you put the physio or OT in the car and they travel three or four hours. It’s just not a good use of people’s time.”

There is also a lot of interest in the technology for children with disabilities but this software itself is not yet designed with children in mind. However, Dr Bird said the back-end technology is just the same.

“There’s a huge amount of applications,” she said. “We are using it for motor control with stroke but I think for just improving physical activity to prevent cardiovascular disease, or for wheelchair-bound children, there’s a huge potential there as well. There’s lots of stuff going on.”

The trial is being funded by the National Stroke Foundation with a $20,000 seeding grant added to financial and in-kind support from the University and the Department of Health and Human Services.

Pictured on our newsletter is University of Tasmania lecturer Marie-Louise Bird, stroke survivor Anita Jupp and THO-North clinical lead physiotherapist John Cannell, courtesy of UTAS.

GP co-pay now ‘optional’ but rebates to be cut and frozen

Prime Minister Tony Abbott has announced the government will modify its original $7 co-payment scheme to rule out charging bulk-billed concession card holders and children under 16, but has also announced that the rebate will still be cut by $5 for non-concessional patients and indexation will be frozen until July 2018.

Describing it as an ‘optional’ co-payment, Mr Abbott said GPs will be able to make up the cut in the rebate by charging non-concessional bulk-billed patients a $5 co-payment, as well as all non-bulk billed patients.

The government will also not apply the original scheme to pathology and diagnostic imaging providers or GP attendances at residential aged care facilities.

In a move that is certain to raise the ire of the medical profession, the Medicare rebate will also be frozen until July 2018. Doctors groups have repeatedly called on governments to ensure indexation of Medicare rebates keeps pace with inflation.

The changes will also see a cut to the rebate for consultations that last less than 10 minutes. A standard B consultation will now need to be between 10 minutes and 20 minutes, with the government saying “it is expected that doctors will reflect any reduced rebates for short consultations through their charges to patients”.

“This change will ensure that Medicare expenditure more accurately reflects the time a GP spends with a patient. It encourages a shift away from ‘six minute medicine’ so that appropriate, comprehensive care is better rewarded over patient throughput.”

The government will still channel the $5 cut in the rebate to the planned Medical Research Future Fund.

It now appears likely that changes to general practice and diagnostic services software will not be required, as the co-payment is “optional”. Medical software vendors were forewarned last month by the Department of Human Services that new client adaptors would be needed to process the $7 co-pay and to do a verification check for concession card holders and children to ensure they were within the mooted 10-visit cap.

However, collecting a $5 fee will still require fully bulk-billing practices to install EFTPOS and credit card machines or collect and reconcile cash. Independent modelling released by the Australian Medical Association showed that the $2 “windfall” from the original $7 co-pay would almost entirely be lost through productivity decreases and red tape.

HCN rebrands as MedicalDirector

The company formerly known as Health Communication Network (HCN) has changed its business name to MedicalDirector, reflecting its primary clinical software product.

The market-leading general practice clinical software, Medical Director itself will now be known as MedicalDirector Clinical, while its general and specialist practice management products will be known as MedicalDirector PracSoft and MedicalDirector BlueChip.

The company, a subsidiary of Primary Health Care, is gearing up for a new release of both Clinical and PracSoft at the end of the year, with the latter to include a new integrated online appointments booking module that the company has developed internally.

MedicalDirector Clinical will feature one-click medical certificate functionality, multiple user access to patient records and promised improvements in performance.

The company is currently conducting a roadshow over the next few months to introduce users to the new branding and to gather feedback to help it prioritise changes for future releases. It has also revamped its website.

According to Primary Health Care’s annual report, the former HCN brought in revenues of $37 million in the 2013-2014 financial year, with earnings after tax of $20.2m. Both figures are the same as the previous year.

Fully integrated v best of breed: St Stephen’s Hervey Bay

There have been a couple of others in the running to be named Australia’s first fully integrated digital hospital, but it looks like the new St Stephen’s Private Hospital at Hervey Bay in Queensland is likely to claim the honours when it opens next week.

It will still need to scan in the paper medical records of patients previously admitted to St Stephen’s older facilities – a day hospital at Hervey Bay and a medical and surgical admissions facility at Maryborough – but when new patients begin to be admitted to the new hospital, they will all have a full electronic medical record from day one.

Operated by UnitingCare Health (UCH), the $96 million, 96-bed private hospital has been several years in the planning, with specific funding for its eHealth component coming thanks to a large grant from the Commonwealth Health and Hospital Fund.

That fund allocated $21 million to ICT and eHealth alone, and along with $15.5 million from UCH and the main software vendor, Cerner, represents a huge investment in what is hoped will prove a pilot for further digitisation of UnitingCare’s other hospital assets.

Both Macquarie University Hospital (MUH) in Sydney and Fiona Stanley Hospital (FSH) in Perth have boasted of being the first in the country to be completely paperless, but both have had well-publicised problems actually getting there.

MUH opened with an electronic medical record consisting predominantly of iSoft’s suite, including iPM (webPAS), iCM and MedChart, along with MetaVision in intensive care, but is currently in the process of changing over to InterSystems’ TrakCare.

The four-year-old hospital is predominantly digital, but before the implementation of a scanning solution and electronic discharge summaries, it was both receiving and generating paper documents.

Fiona Stanley too has had its problems and will not be completely digital for the foreseeable future, using a mixture of existing systems rather than implementing the big-bang EMR it had hoped to open with. (WA Health began moving patients from the Shenton Park rehabilitation hospital over to FSH last weekend, and acute admissions will begin next year.)

Also laying some claim to being on the way to full digitisation is Blacktown Hospital in Sydney, which has implemented a well-designed new system it is calling Paper-Lite. This includes a mixture of the Cerner EMR with other applications designed both in-house and by eHealth NSW.

For St Stephen’s, the main claim is that it will be fully integrated, achieving HIMSS level 6 on opening due mainly to its fully electronic, closed loop medications management system, probably the only one of its kind in Australia. For UnitingCare’s executive director, Richard Royle, a closed-loop EMM system is one of the key elements of a full EMR.

The St Stephen’s system involves electronic orders at the bedside, integration with the pharmacy system, and electronic drug cabinets in each ward that is also linked to Cerner. Using overseas experiences, Mr Royle said UCH had worked with pharmaceutical companies to provide single-dose blister packs for each drug.

“The doctors will order their drugs, it goes electronically to the pharmacy, they pack them up in the individual blister packs and when the nurse comes to dispense the drug, the drug cabinet opens and there will be those individual blister packs in the tray,” he said.

“That means there is also barcoded medication administration which is linked with the pharmacy order that is in the EMR, and we have also installed a number of alerts in the electronic medication system.

“If the doctor has prescribed a drug that the patient is allergic to or prescribed the wrong dosage for the size of the patient or over the total maximum, it will trigger an alert in the system. This is a very complex system and we are essentially putting the full PBS in there. I know it has been done before, but we are going one step further by making it closed loop.”

Another key element in the move to full integration is the choice of main software vendor. UCH has used variations on Cerner’s clinical information systems since 1999, when it was first implemented at the Wesley Hospital in Brisbane. While it isn’t official, Cerner is likely to be rolled out in most of Queensland’s public hospitals, probably including Hervey Bay Public Hospital, which is located adjacent to St Stephen’s.

Mr Royle is not afraid to admit that UCH has had problems with the Cerner system, but was confident with the choice. Like NSW Health, which has implemented a rectification program to iron out problems with the software, UHC has worked with the US giant to try to overcome them.

“I’m not telling tales out of school if I tell you that we, like everyone else, have had significant problems with our software vendor,” he said. “When we implemented Cerner at Wesley in 1999 we had some significant problems with it, some of which was our fault and some of which was Cerner’s fault.

“But with this sort of expensive exercise, I have to be confident that the back-up that we are going to receive is great, so I personally made sure that I got to know the people at Cerner quite well. What I have done is set up an arrangement whereby I meet with essentially the number two and number three [executives] in Cerner quarterly by video conference.

“Anything that is going awry from my perspective and I can’t get help with in Australia, I essentially get help from Cerner in the US. To give them their due, they have responded very well.”

In addition to the ease with which St Stephen’s will be able to communicate with the public system through the same clinical system, Mr Royle said it was the ability of the other clinical systems to easily integrate with Cerner that was one of the main reasons for his decision.

He compares the relatively small number of interfaces to third-party software that will be used at St Stephen’s to the decision made at Fiona Stanley, where a best of breed platform was originally devised. It is this incredibly complex integration process with clinical systems, along with the enormous amount of work needed on non-clinical infrastructure, that caused the opening of FSH to be delayed by six months.

“[St Stephen’s] will be the first fully integrated, digital architecture hospital in the country,” Mr Royle said. “What I mean by that is that we have 29 Cerner applications being put up. That includes all of the clinical side, and we have another 20 devices that link to it.”

The Cerner applications include inpatient pharmacy, surgery, anaesthetics, PowerOrders and PowerChart, critical care, clinical documentation with Dragon dictation and mPages ICU summary and mobile clinical review, as well as pathology specimen management and the CareAware suite for medical device connectivity, alarm management and care team communication.

Some of the third-party equipment includes a patient entertainment and education system, while Cerner is also providing comprehensive barcode scanning and real-time location systems both for patients and equipment.

For nursing staff, UCH has contracted Ascom to provide its workstation on wheels (WoW) solution, providing a fully integrated, fully mobile nursing station. Ascom will deliver 45 Advantech AMiS-50 WoWs together with integrated MedProx cabinets from Elliott Data as part of the solution.

“Our nurse call system is fully integrated with the EMR so every time a patient calls the nurse it is recorded on the EMR,” Mr Royle said. “The room link allows real-time location system for patients and the equipment. Every one of our clinical systems links into the EMR.

“This is integrated clinical architecture. If I look at some of the challenges and what has been happening at Fiona Stanley, one of the challenges is that … there are 158 interfaces at Fiona Stanley. 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. There are actually only five clinical interfaces into the system, including pathology and radiology. There are a total of 30 interfaces but that also includes things like our finance system.”

While the technical achievements and planning are impressive, Mr Royle makes the point that building a successful integrated hospital is more about change management than the technology. In addition to recruiting a full-time chief medical information officer in Monica Trujillo, who will serve as a bridge between the organisation’s medical and IT departments, during the building phase a lot of time and energy has been spent on working with clinicians to get them up to speed.

“We are calling it clinical transformation,” he said. “We are not simply computerising. That statement in its own right means a whole piece of work. We have seven clinical transformation workgroups. We have engaged over 60 of our staff in these teams including over 28 doctors.

“What we are trying to do is ensure that what we are developing at Hervey Bay is able to be rolled out successfully across the whole group. We have a number of very senior specialist clinicians who are based at our hospitals in Brisbane who are well respected and they have been part of this engagement so the doctors at Hervey Bay can see that the key senior clinicians are also involved in establishing this.

“It has to be clinician driven and what I mean by a clinician is in the full sense of the word – that is doctors, nurses, and allied health professionals.

“[UCH’s] director of intensive care is personally going to be up there with the clinicians and intensivists to step through any of the challenges that they have got before the system goes live, and that’s after we have done their one-on-one training,” he said.

“It is a major change piece for them. If you think about a 62-year-old surgeon who has been set in his ways for the last 30 years, you’re going to completely change the way he goes about ordering a drug. These are major change pieces that we are very very aware of.”

The hospital has also been working with local GPs to ensure they are happy with the new system. GPs will be able to network into the clinical system while their patients are in hospital and see orders and results, with referrals and discharges all done electronically. The plan is to link the hospital to the PCEHR in the future, with clinicians able to view the record from within Cerner and to send up discharge summaries.

UCH eventually hopes that St Stephen’s will act as a population health pilot for the Wide Bay area, including both public and private hospitals, GPs and aged care facilities, Mr Royle said. “There is the opportunity here, in a confined population of 100,000 people and 56 doctors, to look at developing a true population health pilot.”

While the hospital may also work as a showcase for technology, for Mr Royle, the reason behind going fully digital is four-fold: quality, safety, efficiency and staff and patient satisfaction. “You can be very efficient and you can have great quality but if you don’t have the patient or the doctor or the nurse or your staff satisfied, you aren’t ticking the boxes,” he said.

“I got together the top 50 executives across my group and we already have identified 21 KPIs that we are already measuring, which are in the areas of quality, safety, efficiency, and satisfaction. We are measuring them now and will be from measuring them for the first 12 months in significant depth for a research piece.

“There are some of the examples of what has been experienced in similar full EMR developments that have been successful in the States. There are about now just on 1000 of these around the world. I’m not anticipating that I’m going to save huge amounts of money on this but I think I’ll actually break even and that is after the additional costs from depreciation of the implementation.

“Where I believe I’m going to save the money or create benefits is in improved quality outcomes. We have already kicked some goals in that I have a number of people wanting to come and work with us. I’m quietly confident that the way that we put this together will end up continuing to attract and retain people.”

Hills partners with medical practices for Lively monitoring

Hills is partnering with two Geelong medical practices to offer the Lively in-home sensor technology to help keep elderly patients living independently at home for longer.

Lively is an attractively designed suite of passive wireless smart sensors that transmit signals to a hub containing a built-in cellular service, meaning there’s no need for an internet connection.

The hub sends data to a cloud server where it is displayed on a dashboard, which family and carers can log into to monitor an elderly person’s activity. There is also a free smartphone app.

The sensors are designed to attach to a key fob and to kitchen appliances and cupboards such as the fridge door and pantry, which allows the system to monitor whether a person leaves the house and whether they are eating and drinking regularly. There is also a pill box sensor that can monitor daily medication activity.

The sensors are able to learn a person’s normal routine, so if there is any deviation, it can send an alert by email.

Lively is a San Francisco-based start-up company established in 2012 that has just added a new personal emergency response safety watch to the suite – not yet available in Australia – with plans to release a clip-on sensor for automatic falls detection next year.

Lively signed a distribution deal with Hills earlier this year and is marketing the range online and through Hills’ distribution network for its security alarms. Hills has also just signed a partnership with the Geelong Medical & Health Group, which runs the Myers St Family Medical Practice and The Cottage Medical Centre in Geelong.

The Geelong Medical & Health Group is selling the range through its website, where it has an existing online shopfront for fitness devices and equipment for hire.

Geelong Medical & Health Group general manager Durham Green said that while the shopfront was a new venture for the practices, he doubted it would be a big source of revenue in the near future.

“We’re selling it through the website at the moment, but primarily [we are offering it] as a service to patients,” Mr Green said. “We can see the benefit, for example, for people that have their loved ones or parents in the home but they’re not quite sure whether or not they’re taking their medication right or whether they’re going to the fridge and getting food.”

Mr Green said systems such as Lively would allow older people’s carers to discreetly check on their wellbeing without constantly having to ask. For GPs, it would also take some of the guesswork out of deciding whether or not to refer the patient to other services.

“We’ll know when we need to stop and think about what other services we have to arrange, rather than guessing, whether it be getting extra rails or access in the house or providing nursing services or RDNS to help that person stay in their house.

“It also gives us the opportunity to be able to engage the patient more, so instead of seeing them once a year we might see them two or three times a year. We might go out and do an over-75 health assessment and we can actually see, on the enterprise dashboard, ‘OK, the patient’s doing this.’

”And when we ask the questions we can pick up those cues, as in ‘hang on, they’re telling us they’re doing something, but there’s no evidence to prove that.’ And discreetly we’ll input mechanisms to ensure they’re getting the support they need.”

Head of Hills Health Solutions Peta Jurd said Lively was an extremely clever and practical application of technology.

“Our research shows that three in five adult children worry about something happening to their elderly parents when they’re not with them,” Ms Jurd said.

“It also shows that just one in five elderly Australians aged over 70 ask for help when they’re not feeling 100 per cent. This technology provides comfort and independence to an ageing population but also addresses concerns felt by their loved ones.”

Mr Green said Lively’s ability to track whether elderly patients are opening their pill boxes, getting food out of the fridge or leaving the house would provide invaluable insights and peace of mind.

Lively also comes with an optional service that collects photos and greetings from family members and condenses them into ‘LivelyGrams’ that can be emailed to the older person every month.

Hills itself is working on developing a new nurse call handset for aged care residents with arthritis or limited dexterity in partnership with the University of South Australia. A project team from UniSA is working at the new Hills Innovation Centre in Adelaide to develop the handset.

Hills now owns two of the major brands in nurse call systems – Merlon and Questek – and is active in both the aged and acute care markets.

Electronic report for antipsychotics a boon for de-prescribing

Aged care provider Southern Cross Care (NSW & ACT) is currently evaluating data from the third quarter since it introduced an electronic Quality Use of Medicines (QUM) report to assist in reducing the use of antipsychotics for behavioural and psychological symptoms of dementia (BPSD).

The QUM report, designed by NPS MedicineWise in association with pharmacy software specialist Webstercare, allows aged care facilities to identify residents who have been prescribed antipsychotics for more than 12 weeks, alert them to potential problems with polypharmacy and highlight the need for a medications review.

Launched last year, the report is integrated into Webstercare’s Medications Management Software (MMS) and allows the pharmacist to quickly and easily produce a report on all residents who have been prescribed antipsychotics and for how long. Dose and strength for each medication are also recorded, as are any other drugs prescribed to deal with side-effects of the antipsychotics.

Figures from Alzheimer’s Australia show that up to 80 per cent of people with dementia and nearly half of people in residential aged care are receiving psychotropic medications. However, international data suggests that only one in five people with dementia receive any clinical benefit from these medications.

In 2012, Southern Cross Care, which has 30 aged care facilities in NSW and the ACT, identified the use of antipsychotics and unnecessary polypharmacy as an area of concern and was looking for a way to easily collate data to help it evaluate psychotropic use in its facilities and benchmark itself against other facilities around the country.

SCC’s dementia care consultant, Sonali Pinto, said that at the time the organisation was rewriting its behaviour management policy for residents with dementia, much of which was informed by the Time for Action report from the UK, an independent review of the use of antipsychotics in elderly people.

By chance, Ms Pinto and SCC’s manager of care governance and research Andrew Fleming attended a workshop at the University of Sydney, where they began chatting to clinical pharmacologist Lisa Pont and dementia researcher Lee-Fay Low about what resources could be used to institute the new policy more effectively.

Ms Pinto said it was Dr Pont who suggested talking to Webstercare and its professional services pharmacist, Christine Veal, about the resources it had that could be tapped into. Webstercare was working with NPS MedicineWise on a new antipsychotic report at the time, so a partnership group was set up to introduce it throughout SCC’s NSW and ACT facilities.

“Our policy talks about the recommendations that came out of the Time for Action report, which talked about reviewing antipsychotics at the 12-week point,” Ms Pinto said. “We were using a psychotropic drug report but not really looking at the report and analysing what was in it.

“It didn’t really match what we were trying to do with the reduction of antipsychotics because it just told you what people were on and it didn’t tell you how long they were on them for. That’s exactly what this report does. It identifies how long people have been on medications and that’s why it sat so well. It supported the policy and it was an appropriate report to use to ensure that we got culture change.”

The partnership group – comprising Ms Pinto, Dr Fleming, Dr Pont, Dr Low and Ms Veal – decided that it would extract data four times a year and do a thorough evaluation. “We are now in the third quarter … and [Ms Veal] is collating it at the moment,” Ms Pinto said.

“We knew from the second quarter that we were going really, really well. There was policy change to support what we were doing but we also changed a lot of other things to support the new practice out in our facilities. There was education about antipsychotics, how to de-prescribe, and education was discussed in consultation with our partnership group.”

SCC has now established de-prescribing teams in each of its facilities, involving registered nurses, care assistants, pharmacists and some visiting doctors. Using the QUM report, these teams are now able to make decisions on de-prescribing based upon real evidence.

“They look at each resident that features on the report,” Ms Pinto said. “They look at how long the person has been on the medication and then if they’ve been on it for more than 12 weeks, as the policy states, we look to identify what is the outcome for this person. Is the behaviour still existing, are there side effects? Is it producing more ill-being than wellbeing? We take all of that decision making into consideration.

“The collaboration also comes from the pharmacist attending at every single site, I have to say the pharmacists have been absolutely fantastic. They attend every meeting and the sort of outcomes that we’ve had is not just de-prescribing the medication, as the second quarter results have shown.

“We’ve also been able to pick up polypharmacy and prescribing cascades. When that medication is de-prescribed, we are able to say we don’t need all these other medications just because of the consequences of the side-effects the antipsychotics were producing.

“As a result of that, we’re getting feedback from the staff saying they are not scared of de-prescribing anymore. That’s a change in culture. There’s historically been the belief that the moment you de-prescribe, that all previous BPSD behaviours are going to return.”

Another benefit of the QUM report is that care staff don’t have to collate the data themselves. It is all done at the pharmacy end, with Webstercare’s MMS is able to extract all of the required information in mere minutes rather than the hours or days it would take for a nurse to do it by hand.

This also avoids transcription errors, lack of knowledge of drugs that fall into the psychotropic class and any institutional bias to make the results look better.

“It’s a lot more reliable and valid,” Ms Pinto said. “A lot of people don’t know what antipsychotics are. They don’t know what a benzodiazepine is. They can probably name a couple, but they don’t know the entire list. So it’s that old saying of rubbish in, rubbish out with report accuracy.

“Using the pharmacy system, there is no bias, and with the benchmarking that is happening, we don’t influence that in any way.”

Ms Pinto said some doctors have found the idea of de-prescribing confronting and some dislike having their prescribing decisions questioned, so SCC is using the NPS MedicineWise antipsychotic review checklist, which has been designed to streamline communication between GPs and RNs about residents using antipsychotics.

That checklist also allows de-prescribing teams to request a Revised Medication Management Review (RMMR) and other options such as slowly lowering the dose, ceasing the dose or ceasing a PRN antipsychotic, which Ms Pinto said does not work for the BPSD state.

“I felt the form really helped,” she said. “There were a few doctors that questioned it, but I think the issue is that the doctors need to feel secure that the teams know how to manage the behaviour with non-pharmacological approaches.

“In the end we had the biggest difficulty with people that had a combination of dementia and mental health. Doctors felt antipsychotics were beneficial for the mental health and that was the biggest concern, rather than the dementia, in balancing resident wellbeing.”

Ms Pinto is now working with Alzheimer’s Australia to create a DVD for GPs about the use of antipsychotics in aged care, which is endorsed by the Australian Medical Association (AMA). An official launch is set for next month.

Webstercare and SCC were awarded a high commendation in the best implementation for infrastructure category at the 2014 ITAC awards for the collaboration.

An IT approach to GP care in residential aged care facilities

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

Paper-based systems are no longer enough when it comes to the collaborative care required when caring for patients in residential aged care. GPs working in these settings should take a strategic view of their IT requirements – whether using remote access, cloud services or interacting with the facility’s clinical systems.

Contemporary primary healthcare in residential aged care facility (RACF) settings needs to be collaborative. For GP involvement to be effective, it needs to address the holistic biopsychosocial model.

The ageing process involves multiple pathological pathways needing a range of health professional inputs. Therefore, rather than a reactive process, a more proactive approach is needed to support and manage physical and psychological decline.

This requires multiple modalities of medical interaction resulting in a range of outputs, from consultation notes to comprehensive assessments incorporating a multitude of inputs and observations. This is further compounded by the setting being at a distant point of contact from the classic consulting room.

In order to address such an approach, the GP needs to stand aside and take a strategic view in formulating an appropriate solution to address these needs and information flows.

To read the full story, click here for the May 2014 issue of Pulse+IT Magazine.

Renewed calls for real-time prescription drug monitoring system

The Victorian branch of the Australian Medical Association (AMA) has renewed its recent calls for the expedited roll-out of the proposed national real-time prescription drug monitoring system at the Victorian Pharmaceutical Misuse Summit, held in Melbourne today.

Convened by the Victorian Department of Health, the summit brought together 90 representatives from the health sector, including the Pharmaceutical Society of Australia, the Pharmacy Guild of Victoria, Turning Point Alcohol & Drug Centre and the Victorian Alcohol and Drug Association (VAADA).

Speaking in advance of the summit, AMA Victoria president Stephen Parnis said the Victorian Coroners Court had shown that in 2012, 304 Victorians died from prescription drug overdose, more than the state’s road toll of 282.

Another 176 people had died from drug overdoses, 82 per cent of which were the result of prescription drugs, in the first half of 2013.

AMA Victoria has been actively campaigning for the introduction of the real-time monitoring system as part of a raft of programs aimed at reducing prescription drug misuse.

Better known as the Electronic Recording and Reporting of Controlled Drugs (ERRCD) system, licences for the Tasmanian-developed software were purchased for the states and territories by the former Minister for Health, Tanya Plibersek, in February 2012.

As the regulation of the prescribing and dispensing of controlled drugs is the responsibility of the states and territories, changes to legislation and reporting processes are required in each jurisdiction.

A spokeswoman for the federal Department of Health told Pulse+IT recently that ERRCD is currently installed on a secure host server and is operational, “waiting for each state and territory to commence utilisation”.

The NSW Ministry of Health said it is currently working through the financial and practical implications of implementing ERRCD, and that a full roll out is likely to take three years.

“There may need to be changes to legislation to require the provision of pharmacy dispensing records of controlled drugs and to enable access to records by medical practitioners and pharmacists,” a NSW Health spokesperson said.

Western Australia currently has a bill before state parliament that will support required changes to laws governing the collection, sharing and protection of personal data, but a WA Health spokesperson said there was still a lot of technical and administrative work that needed to be done before software can be rolled out.

Queensland, meanwhile, is looking at what modifications the system might require and whether it can run in conjunction with its existing Monitoring of Drugs of Dependence System (MODDS).

The system has been rolled out in Tasmania, but the Victorian and South Australian governments are still being lobbied by local AMA branches for news on its introduction.

Pulse+IT has requested an update from the NT and ACT departments of health.

Exploit vulnerabilities in CDA do not affect PCEHR core

The discovery of a set of vulnerabilities that could potentially lead to malicious content being added to clinical documents created using the clinical document architecture (CDA) standard is not a likely threat to the security of the PCEHR, a CDA expert says.

Last weekend, US physician and programmer Joshua Mandel revealed that he had discovered that certain style sheets used to display CDA documents in many commercially available electronic health record systems in the US could potentially leave those EHRs vulnerable to attacks from malicious code attached to CDA documents.

Dr Mandel alerted those vendors to the problem before revealing the vulnerabilities publicly, and has since provided an overview of three ways in which someone could potentially craft a malicious CDA document.

The vulnerabilities are of concern to Australian vendors of EHRs and secure messaging services, which also transfer CDA documents, as well as to the operators of the PCEHR, as CDA is used for all of the clinical documents uploaded to the system.

Australian CDA expert Grahame Grieve has posted a blog explaining the potential problem, which he says is not so much a CDA exploit as a problem related to the ubiquity of HTML.

Mr Grieve told a webinar organised by the Medical Software Industry Association (MSIA) that Dr Mandel had found the problem in some EHR systems that are in production use, and traced it to an HL7-designed style sheet, derivations of which are used by many EHR vendors as well as in the PCEHR to render CDA documents for viewing.

Mr Grieve said the problem was not an attack on the CDA itself but on the ‘transform’ used to view it.

“Technically, CDA is a static XML form that converts it to HTML form that you can write in the browser,” he said.

“The way you create this vulnerability is that you insert some content into the CDA that activates during the transform and does things that you do not expect once the HTML is loaded in the browser. So this is not an attack on CDA itself – it is an attack on the transform that people use to view the CDA.”

Mr Grieve – who emphasised that he was speaking as a member of the MSIA and not on behalf of NEHTA – said that in his opinion, while there was the potential to exploit this vulnerability, the threat profile for the PCEHR was very low.

“The PCEHR itself or any other CDA exchange system are completely unaffected by this,” he said. “The issue only arises when that transform runs and the documents are displayed. This includes any clinical system that views CDA documents, whether they come from the PCEHR or elsewhere, including the portals for the PCEHR, but the PCEHR core itself is not affected.

“To exploit this you need hacked CDA documents. Someone’s got to hack CDA documents to get them in the system. Access to the PCEHR to upload documents is granted to a combination of a user, which is a person or an organisation, and to software. You can’t just sit at home and try hacking this. You’ve basically got to compromise a certified system. Now that is possible, but it’s much harder work than running scripts that pursue known exploits.”

Mr Grieve said the concern was not so much people hacking incoming documents to systems, or the PCEHR itself, but as a targeted attack on an individual user or their system.

“That is my assessment of the threat profile for the PCEHR and my evaluation is that it is extremely unlikely. There are a lot easier ways to attack a person than to take that route.”

However, he said there were concerns for software vendors outside of the PCEHR context, including for secure messaging vendors that use file-based transfer to transfer documents from clinical systems to message delivery systems, as it is potentially easier to get malicious CDA documents into that sort of system.

Mr Grieve said Dr Mandel had found three potential routes of attack. One is to use nonXMLbody or unstructured information that contains HTML. This is not allowed to be used in the PCEHR but could prove a problem for point-to-point secure messaging.

Another is to insert attributes that execute JavaScript, which then gets copied into the generated HTML. Mr Grieve said the PCEHR doesn’t allow these documents, nor for the attributes to be copied so the PCEHR and any other system running the standard PCEHR viewer is immune to this attack.

The third attack is a bigger problem as it involves using links to external references such as links to websites or images that are embedded in the document or as an attachment. There are some legitimate uses for external references and it is not known if any CDA document in the PCEHR at the moment contains them.

Mr Grieve said that while it was unlikely, this method could not be ruled out and that permission to upload CDA documents containing external references through some certified systems may be revoked. He said all vendors should look closely at this issue and that Dr Mandel was preparing some best-practice security tips to avoid this and other problems.

In a statement issued by NEHTA today, the organisation said there were known vulnerabilities with the exchange of any type of document that contains links to external systems or document types.

“Vendors are aware of these risks and there is guidance available for vendors to protect their users,” the NEHTA statement reads. “CDA is a new type of document and there is similar guidance available to support vendors to address risks in these document types. The PCEHR currently has in place a number of protection mechanisms that are also available to software vendors to test their point-to-point systems.”

Mr Grieve said that if a hacker wanted to attack the PCEHR, there were much more straightforward methods than “fiddling with CDA documents”.

“This is a hard attack,” he said. “It is very low efficiency. There are much easier ways to attack a system if you want to than to do this but what we are saying is that it is possible. [With] the PCEHR it would be an extremely hard but with point-to-point it would be somewhat easier and people do need to look at that.”

Asked if he thought it was possible to attack CDA documents through SQL injection, Mr Grieve said this was highly unlikely. He said the PCEHR was “highly armoured” against SQL injections, so much so that the security measures used to defend against this threat actually caused the noted problem of people with apostrophes in their names not being able to register when the system went live in 2012.

Mr Grieve has written a plain English article looking at the lessons learned in using CDA for the PCEHR in the April issue of Pulse+IT magazine.

GP2U goes live with WebRTC video conferencing app

Telehealth provider GP2U has released a new version of its iPhone app with in-built WebRTC functionality, and is also using the technology now to conduct video conferences between GPs, specialists and patients through its website.

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.

GP2U founder James Freeman said the new version of the app allows patients to register, book, pay, video conference and get prescriptions through their iPhones.

The app is available on the App Store, with the Android version due shortly on Google Play.

A simple button has been added to the existing app to take the patient straight to GP2U’s virtual waiting room, with connections to the doctor via WebRTC proving faster and more secure than when using Skype.

Dr Freeman said he expected there to be reasonable uptake of people video conferencing through the app on their phones, but most would still use PCs, Android tablets or iPads.

The GP2U website also now includes a WebRTC link in the virtual waiting room, so once a patient has logged in, they only need one click to attend the video conference.

“If I want to see the doctor I go to the waiting room and I wait until the doctor comes to get me,” he said. “With our virtual waiting room patients simply wait the until the doctor pops up on the screen. That’s pretty easy to explain. Go to the waiting room and wait for the doctor – you don’t need to explain anything much else as it all just works.”

WebRTC currently only works natively with the Chrome or Firefox browsers, but it is also easy enough for users of Internet Explorer as IE will install Chrome’s Frame plug-in automatically.

The WebRTC standard is not yet ratified and there is still some wrangling going on – Google, for example, wants to mandate the VP8 codec, while others are still pushing for the more widely used H.264. This was initially rejected as it was a proprietary codec and involved licensing fees, but in October last year its owner, Cisco, announced the codec was being open sourced.

People can still use WebRTC now, although it does require a signalling protocol in order to exchange IP addresses, and STUN (Session Traversal Utilities for NAT) and TURN (Traversal Using Relays around NAT) servers to traverse firewalls.

Dr Freeman’s team built a signalling server itself, but has now decided to outsource to a company called TokBox, which is backed by Spanish telecoms giant Telefónica. TokBox runs the OpenTok service and is one of many new start-ups concentrating on WebRTC.

“One of the advantages of WebRTC over Skype is that because we are using a signalling server we’re not bouncing from machine to machine trying to work out where you are,” Dr Freeman said. “The bottom line is that it only takes a couple of seconds to connect so it’s much faster than Skype.

“We are continuing with the process of trying to make it as easy as possible for people to video conference. We have really smooth registration processes with patients that you can do on the phone or on the computer, it’s easy to understand as you just go to the waiting room, you click one button once to allow the camera, and it will just work.

“One of my contentions about video conferencing is that it’s still too damn complicated, but if you look at the little iPhone app, you just press a button like answering a phone call and away it goes. And then once you’ve finished you press the hang up button. The volume control is the phone’s native volume control, it’s automatically on speakerphone, so there is almost nothing to go wrong.

“From the user interface point of view what we were shooting for was a video application that works as easily as answering a phone call. One button to answer, one to hang up. Simple, but instead of a voice only call you have video as well.”

Dr Freeman and his team have been building the company up for several years, but this year plan to make a full assault on the market, having appointed Salmat to help with marketing and Red Agency to help with PR. He estimates that GP2U currently does more than 20 per cent of all the Medicare-funded specialist telehealth consults in the country, and is also looking to get into the occupational medicine market.

Last year, GP2U caused a few ripples when it launched Skype2doctor, a paid service that allows patients to video conference directly with the GP. For both GP2U and Skype2doctor, a prescription ordering service is available that allows the GP to fax a script to the patient’s pharmacy of choice, allowing them to pick it up at their leisure. Patients can also choose to have their script mailed out to them or home delivered via Terry White Chemists Online service.

The company has signed agreements with pharmacy giants Terry White Chemists and Priceline Pharmacies to help with prescription medication delivery.

“We are really grateful to both Terry White Chemists and Priceline Pharmacies for the support they have given us in this new and emerging market of online doctor consultations,” Dr Freeman said.

“Because the prescriptions are faxed through prior to the patient arriving, on many occasions they walk in to find their medications already waiting for them, so not only are patients saving time both travelling to see a doctor and sitting in a waiting room, they are also getting a very efficient service from both Terry White and Priceline.”