The 2014 eHealth year in review: part two

It wasn’t just the long delayed release of the Royle review into the PCEHR that had the industry on tenterhooks in the second quarter of the year. John Horvath’s review into Medicare Locals was also due to be delivered, and while Prime Minister Tony Abbott had announced before last year’s election that there would be no reductions in the number of MLs, most took that with a grain of salt considering Peter Dutton’s obvious disdain for the structure of the organisations.

In early April, Mr Dutton told the Standing Council on Health (SCoH) meeting of state and territory health ministers that the federal government was committed to an electronic health record, but whether that was the PCEHR or something else was up to interpretation.

Release five of the PCEHR was to have been made available in April and then in May, but the announcement of the Royle review and a hiatus in development work on the system meant it was pushed back to November.

Of peripheral interest was the release of the national Commission of Audit report, which besides recommending a digital by default strategy and greater use of the myGov website, turned out to be a damp squib.

The Horvath report into Medicare Locals, on the other had, turned out as expected and recommended a fundamental realignment of the 61 Medicare Locals into a minimum of 13 primary health organisations. This moniker was later changed to Primary Health Networks (PHNs), with the number set at 30.

As the budget loomed ominously, everyone got on with doing other things, including HCN – later in the year to rebranded itself as MedicalDirector – which was gearing up for a mid-year launch of its next release, featuring the PCEHR assisted registration and NPDR functionality the practice management software companies were all working on.

The primary care vendors were also taking part in the first round of NEHTA’s clinical usability program (CUP), which aimed to make usability enhancements to the PCEHR interfaces in clinical information systems.

In acute care, EMR giant Epic made a splash with the announcement it had been chosen to provide an electronic medical record for Melbourne’s Royal Children’s Hospital in a $48 million deal. It will be the first installation in Australia for the secretive US firm.

Royal Adelaide Hospital began a trial of of over-the-phone consultations and a computerised questionnaire for pre-operative assessments, dubbed Computer Health Assessment by Telephone (CHAT). It is based on a pre-screening model developed by the head of acute care medicine at the University of Adelaide Guy Ludbrook and colleagues.

The antimicrobial stewardship software program known as eASY, designed by clinicians from the Northern Sydney Local Health District (NSLHD), underwent an update, with new functionality added that provides decision support on drug dosing and multi-site levels of restriction.

In aged care, Wesley Mission Brisbane (WMB) embarked on a mobility strategy for its 12 residential aged care communities, equipping care staff with mobile devices to provide real-time access to the organisation’s roll-out of Leecare’s cloud-based Platinum 5.0 clinical information system, while the industry as a whole began to prepare for the imminent implementation of consumer-directed care (CDC).

Pharmacy market leader Fred IT was in beta testing for its new cloud-based dispense and management solution Fred NXT, while the Amcal and Guardian chains of pharmacies joined Chemmart, PharmaSave and Terry White in signing up to the MedAdvisor patient medications compliance program developed by Actavis and integrated with the Pharmacy Guild’s GuildCare software platform.

The big story, however, was the federal budget on May 13 – which funded the PCEHR for another year through a $140.6 million commitment and took all of Professor Horvath’s recommendations on board for Medicare Locals, but also introduced the loathed $7 GP co-pay – followed by the release a week later of the Royle review report into the PCEHR.

Amongst a host of recommendations, the headline ones were the move to an opt-out model and the dissolution of NEHTA.

While Mr Dutton said he wanted quick feedback on the opt-out model, by the end of the year the government still hadn’t released its reaction to the review or its plan for the PCEHR beyond June 30, 2015.

The quarter was rounded out by revelations of a major security flaw in the MyGov website – the Department of Human Services has since added an extra security layer – and a nice little scoop for Pulse+IT when we reported that former AMA president Steve Hambleton was likely to be named as the new chairman of NEHTA, despite having recommended the organisation be disbanded.

That scoop was officially confirmed the next day, and Dr Hambleton said he intended to play an active role in improving clinical input into eHealth and in influencing the direction of NEHTA.

Some of the interesting software, apps and projects that caught our eye this quarter included:

If the first half of the year was dominated by public wrangling over the PCEHR, the budget and the future of NEHTA, the second half of the year was the domain of the private sector. In the next six months the industry would see the emergence of Hills Health Solutions as a major player in acute and aged care, Orion Health aiming for the skies as it prepared for an IPO, and the 18-month-long softly softly approach by Telstra Health suddenly breaking out and garnering all of the headlines.

Missed the first instalment? Here it is:

2014 eHealth year in review: part one

Catch up with the rest of the eHealth year in review:

2014 eHealth year in review: part three

2014 eHealth year in review: part four

Telstra on Cloud9 with primary and acute software acquisition

Telstra Health has added another string to its bow with the purchase of Australian-based cloud software developer Cloud9 and its partner company IdeaObject.

In acute care, Cloud9 offers a health information exchange system called Spine and an integration engine called Synchronicity, adding a hospital information system called HealthObject following its strategic merger with Indian firm IdeaObject in September last year.

HealthObject is deployed in approximately 250 hospitals and clinics in India, Thailand, Malaysia and the UAE.

Cloud9 is best known in the primary care market for the Monet clinical information and practice management system. Monet, which was first developed by Monet Technologies in the early 2000s and purchased by IBA Health in 2005, subsequently became part of iSoft in 2009 and was then sold to Cloud9 in 2011.

Monet was used extensively within the Independent Practitioner Network (IPN) group of medical centres but is being phased out and replaced by Cloud9’s cloud-based GP software program Clarity. IPN originally planned to move all of its Monet users over to Clarity, but has since decided to instead roll out the full Best Practice clinical and practice management suite.

Clarity will still be used in by another Sonic Healthcare-owned medical and occupational health group, Sonic HealthPlus, formerly known as Kinetic Health.

Telstra Health managing director Shane Solomon said the acquisition was a key development in the the business’s maturity and placed Telstra Health in a unique position in the eHealth market in Australia and Asia.

“Cloud9 adds real breadth to our offering, providing a highly scalable health information exchange platform and enterprise master patient index (EMPI) that will serve as core elements of our of integration infrastructure as well as flexible cloud solution for GPs,” Mr Solomon said.

“The inclusion of IdeaObject also delivers us a next generation hospital information system (C-HIS) with a strong Asian footprint to build upon. The solution embraces contemporary interoperability standards and was designed from a true global perspective in a way that accommodates many of the market idiosyncrasies that have plagued the hospital sector for decades, such as a need to support multiple languages, date formats, currencies and workflows.

“The system is also highly configurable which supports a much smoother, quicker and less costly implementation.”

Mr Solomon said the move adds a key component to Telstra Health’s connected health strategy, providing a cloud-enabled, highly flexible GP desktop solution which works seamlessly with other provider solutions across the continuum of care and offers next gen functionality in areas such as telemedicine and tele-video conferencing, health analytics and contextual real-time decision support.

Jim Flynt, currently Telstra Health’s general manager of health applications, has been appointed CEO of Cloud9 while Marc Goldman, Cloud9’s founder, will serve as director of global strategy and business development. The company will continue to operate as a standalone subsidiary of Telstra Health while its capabilities will be integrated into the broader Telstra Health strategy.

NT hospitals now live with PCEHR but SA switches off

The Northern Territory’s five hospitals now have the capability to send electronic discharge summaries to the PCEHR, representing a full slate of jurisdictions connected to the system.

However, the roll-out of South Australia’s new Enterprise Patient Administration System (EPAS) has meant that three of its hospitals have had to switch off.

A spokesperson for SA Health said Noarlunga, Repatriation General and Port Augusta hospitals, which are all using EPAS, do not have connection to the PCEHR.

South Australia was one of the first to roll out PCEHR connectivity statewide and developed the Healthcare Identifier and PCEHR Services (HIPS) that enables hospitals to securely send electronic discharge summaries.

“SA Health is working to ensure the Enterprise Patient Administration System includes the functionality to connect to the Personally Controlled Electronic Health Record in the near future,” the spokesperson said.

The National E-Health Transition Authority (NEHTA) has provided an updated list of about 270 public hospitals that can connect to the system, including the NT’s Royal Darwin, Katherine, Gove, Alice Springs and Tennant Creek hospitals.

In WA, the newly opened Fiona Stanley Hospital is also connected, allowing clinicians to view the PCEHR as well as upload discharge summaries. FSH joins Royal Perth, which has had the capability to send summaries since July.

The vast majority of Queensland’s hospitals and health services have viewing and uploading capability, along with 28 hospitals and some community healthcare services in NSW. eHealth NSW plans to roll out the functionality to all public hospitals in the state by March next year.

In Victoria, Barwon Health and Eastern Health can both view the PCEHR and upload discharge summaries, as can The Canberra Hospital in the ACT.

Tasmania’s four main hospitals have discharge summary uploading capability only.

NEHTA says there are now over 5000 general practice and 1000 community pharmacies connected to the system.

Health IT Board working on next five-year plan for NZ

New Zealand’s National Health IT Board (NHITB) is developing a national health IT plan for the next five years, with a draft due to be released in March 2015.

NHITB director Graeme Osborne told the Health Informatics New Zealand (HiNZ) conference in Auckland last week that he hoped the plan would be finalised and in place by June 2015.

The NHITB released its first national health IT plan in 2010 as part of the government’s vision to provide all New Zealanders with electronic access to their core health information.

The plan involves a large program of work covering electronic medication management, national clinical solutions, regional information platforms and community-based integrated care initiatives.

The plan was updated last year, and a new plan for the next five years is now being developed to continue some of the existing foundational projects and begin to increase the focus on how to enable new and improved models of care, Mr Osborne said.

These include the use of telehealth, patient portals and care pathways as part of the move towards personalised care.

“Take two apps and call me in the morning is going to be the new prescription,” he said. “Medicine will be scientifically designed for me as an individual. How can I manage that? What about adherence? What about cost?

“The IT Board is thinking about how we can create an environment for a greater level of personalisation and ownership by the consumer.”

Mr Osborne provided an update on two major projects that are due to be rolled out nationwide: hospital ePrescribing and the National Child Health Information Program (NCHIP).

Hospital ePrescribing will go live in Canterbury District Health Board (DHB) hospitals from next year, the fourth DHB to roll out a standardised system.

Mr Osborne highlighted the logical and iterative way that these difficult health IT initiatives had been rolled out, pointing to an increased professionalism in health IT and health informatics in NZ.

“We had clinicians that were leading the project [in Canterbury] and they had been to Southland, which was the previous implementation, and they had learned how it worked,” Mr Osborne said.

“And they brought all these skills back to Canterbury to roll them out. We had clinicians in the room who took time out of their day to come and talk to us about how they found it and how good it was and how they were surprised it worked the first time.

“That’s professionalism: learning from the past, replacing and reusing the services and systems and tools and key things and processes and making sure we do a great execution job.”

Similarly, NCHIP began in the Thames region in Waikato and is now being implemented by the Midland Health Network.

NCHIP consists of a telephone-based child health coordination service located in Hamilton along with an information platform from Orion Health and BPAC. Every child aged from birth to six years will be enrolled in the program, which will provide a shared view of the child’s health milestones, including immunisations, well child checks, hearing and vision checks, and B4school checks.

Doctors will be able to log on to the system through their patient management software or a password-protected website. The plan is to roll it out nationwide once it has been established in the pilot region.

Mr Osborne said it was essential that these national systems were economically sustainable. “We need to see hard dollars,” he said. “We need to be able to measure the effectiveness and we need to be able to get some returns on investment.”

Underpinning this focus on sustainability are some of the recent developments in the national infrastructure program, including the move to put all services and systems used by the 20 DHBs into two data centres.

“What a smart idea,” he said. “It’s cost effective, it reduces future costs because we know we’re going to increase the amount of CPU and data that we’re going to need, and it’s a smart financial decision.”

Another example is the national maternity system that has gone live in Palmerston North, with a view that the 20 separate maternity systems currently operational in New Zealand will be consolidated into one platform.

“It’s also working in South Canterbury, is soon to come to Auckland and Counties, and over the next two years the national maternity system will be turned on for all 60,000 children that have been born,” he said. “And it has a neonatal system so if they do require neonatal services, it’s the same system, same processes. Exciting, sustainable, cost effective.

“NCHIP is the next stage. How do we measure all the milestones from zero to six and ultimately zero to 17?”

While the plan to have patient portals available to every New Zealander by the end of the year is not doable, progress is being made. The government has provided $3 million for the roll-out, most of which is being directed to the PHOs with some set aside for marketing.

Mr Osborne said rolling out patient portals was challenging, so the NHITB had decided that rather than standardise the portals themselves and all of the data, certain essential elements would be standardised, particularly medications and problem lists.

“Everything to do with [medications] we’re actually pitching to go to unification straight away,” he said. “Getting the medication right is more critical than anything else we do.”

Mr Osborne acknowledged that getting it right was difficult, and that it required the engagement of clinicians, funders, business managers and consumers.

“Our goal is to get something that we all agree on,” he said. “It’s high quality and good healthcare outcomes.”

Clinicians’ challenge winner, new board announced at HiNZ

Emergency department physician Tom Morton from Nelson Marlborough DHB has won this year’s Clinicians’ Challenge, picking up a prize of $10,000.

Dr Morton’s pitch for the challenge was for ‘Emergency Department at a Glance’, an information system that displays data for managing patients’ journey through the ED.

Announced at the Health Informatics New Zealand (HiNZ) conference in Auckland, Dr Morton edged out a proposal from Allister Williams, a nephrologist from Taranaki DHB, for MyKidneys, a web-based smartphone app to give people with chronic kidney disease the advice and support they need to participate in their own care.

The other runner up was Canterbury paediatrician John Garrett, who proposed a tool to electronically record information on clinical consultations about sick children or newborn babies. Both Dr Williams and Dr Garrett received $5000 each.

HiNZ also announced its new board at the conference, which saw a major boost in attendance this year. The board includes:

The Sysmex Prize for Health Informatics went to Alexandra Gower for her proposal for a medications management app connected to the New Zealand ePrescribing Service (NZePS) to help patient adherence.

HIMAA puts the focus on credentialing and workforce needs

The Health Information Management Association of Australia (HIMAA) has relaunched its Professional Credentialing Scheme as part of its strategic focus on health information workforce needs.

The revised scheme involves introducing evidence-based criteria of educational effectiveness and quality improvement to its point allocation schedule, as well as mapping to HIMAA’s health information management competency standards.

The HIMAA professional credentialing scheme offers two classes of post-nominal: certified health information manager (CHIM) or certified health information practitioner (CHIP).

HIMAA president Sallyanne Wissmann told the combined HIMAA National Centre for Classification in Health (NCCH) Conference in Darwin last week that because most HIMAA members already have a qualification, particularly those in the clinical coding (CC) and health information manager (HIM) occupations, the credentialing scheme was more focused on maintaining the currency of the member’s credential.

Workforce issues were a strong theme of the conference, with former Curtin University HIM course co-ordinator Kerryn Butler-Henderson reporting on research conducted by her firm, KBH Consulting, and Queensland University of Technology (QUT) into the effect of Health Workforce Australia’s 2013 Health Information Workforce report.

Dr Butler-Henderson told the conference that there was agreement in the profession with the report’s recommendation on the need to define the workforce and develop a coordinated strategy involving the three key professional organisations: HIMAA, the Health Informatics Society of Australia (HISA) and the Australasian College of Health Informatics (ACHI).

The HWA report highlighted the need to address known health information workforce shortages, with Dr Butler-Henderson reporting on activity in the field since it was released.

These included the recommencement of a health information management degree by QUT in 2013 and the return of a HIM degree in NSW as part of a Bachelor of Information and Communication Technology (Health Information Management) degree to be offered by the University of Western Sydney from 2015.

While Curtin University has decided to cancel what was then the only distance learning graduate entry master’s course, the University of Tasmania has stepped in to offer a Master of Health Information Management degree by distance learning from next year.

The UTAS course will combine a graduate certificate component with a master’s course otherwise designed for practising and qualified health information managers.

“We need to change the profile of the profession and stop working in silos,” Dr Butler-Henderson said. “HIMAA is already taking a number of steps in positioning and advocacy and research agenda, and I am excited about the future.”

Victorian Department of Health productivity and health information workforce manager Julie Brophy reported the successful accreditation earlier this year of a Certificate IV course in clinical classification, which has created Australia’s first dedicated VET level qualification for clinical coders.

Ms Brophy said there was interest from a number of registered training organisations in delivering the new qualification, including HIMAA.

She also told the conference that the profession needed to embrace certification as a means of better positioning the profession. Ms Brophy, who was recently appointed as chair of HIMAA’s Workforce Working Group, is amongst the first group of graduates of the Certified Health Informatician Australia (CHIA) program offered through a partnership between HISA, HIMAA and ACHI.

HIMAA has initiated discussions with ACHI and put a formal proposal to HISA for the development of a joint workforce strategy to present to government and industry.

DHS reverts to manual processing of aged care assessments

The Department of Human Services has reverted to manually processing income and assessment determination letters for elderly people entering residential aged care.

The Herald Sun is reporting that it has seen an internal DHS memo showing that approximately 10,000 means testing assessments were outstanding in both residential and home care programs due to problems with Centrelink’s aged care management payment system.

Changes to aged care assessments came into force on July 1 as part of the former Labor government’s Living Longer Living Better aged care reform package, most of which has been continued by the Coalition government.

The changes mean that any person moving into residential aged care for the first time will have their income and assets assessed by DHS. A determination letter is then sent to the applicant informing them what fee they will be asked to pay, as well as to the aged care provider.

However, according to peak body Leading Age Services Australia’s (LASA) Victoria branch, since the new system took effect on July 1, the organisation’s members had seen escalating delays in receiving completed assessments.

LASA Victoria president Ingrid Williams said that as a result, the provider has no information about what fee to apply to the required care and the older person and their family were left not knowing what they will need to contribute.

“Therefore, the older person cannot be admitted into care and is left in limbo during an often highly emotional time of their lives,” Ms Williams said.

“These unacceptable bureaucratic delays in critical information and subsequent care admissions are a direct result of the Centrelink system’s failure to deal with the recent changes.”

She said the survey also revealed that of those declined a place in residential care, over 80 per cent included referrals from hospitals.

“Without the ability for hospitals to discharge elderly patients into residential care, they remain in hospital, which begins to create a problem of ‘bed blocking’.”

Ms Williams said that in a recent survey of one third of all provider organisations across the state, almost 70 per cent of respondents reported they have declined to fill a vacancy since July 1 due to a delayed Centrelink assessment. This had affected over 370 elderly people, she said.

DHS general manager Hank Jorgen said the department was aware there had been delays in the automatic generation of assessment letters and was urgently working to resolve the issue.

“A number of the system issues have now been fixed and an increasing number of letters are now being generated automatically,” Mr Jorgen said.

“The Department of Human Services has established a dedicated team to manually generate and issue the determination letters where required.

“Many letters advising the outcome of means tests have been sent out and the team will remain in place to ensure all letters are sent to customers as soon as possible.

“The department is continuing to prioritise urgent cases and work through all of the assessments on hand as quickly as possible.”

He said that contrary to some media reports, the changes to the income asset assessment arrangements were incorporated into the department’s systems ahead of the July 1 change.

“If a delay in providing a letter is causing inconvenience, or if someone is in the position of urgently needing to access aged care, recipients or their nominee should contact us on 1800 227 475 as soon as possible,” he said.

“We sincerely apologise to affected customers and thank them for their ongoing patience whilst this issue is being resolved.”

eHealth solution to RedUSe the use of sedatives in aged care

Research has consistently shown unnecessarily high usage of benzodiazepine and antipsychotic medications in the aged care sector, both within Australia and internationally, leading international experts to dub residential aged care facilities (RACFs) “modern mental institutions for the elderly”.

Most recently in Australia this was highlighted by the Senate Committee on Community Affairs, in late March. This report (pdf) refers to an “over-reliance on medication to manage the behaviour of residents”.

This was not the first government inquiry to look into the issue. A Senate committee reported on the topic in 1995, and in 1997 a NSW ministerial taskforce looked into psychotropic use in nursing homes. Both reports recommended measures such as pharmacists reviewing psychotropic medication and staff education on the problems associated with giving psychotropic medication to older frail residents.

Promotion of alternate non-drug ways to manage behavioural problems, anxiety and sleep disturbance was strongly endorsed. Despite these reports, little substantive change has occurred within the sector.

Residents of RACFs are prescribed antipsychotics and benzodiazepines (collectively known as sedative medications) to manage behavioural problems in dementia, including aggression, agitation, calling out and wandering. However, it is well established that antipsychotics only work to reduce agitation in about one in five residents who take them.

In recent years the use of antipsychotics in people with dementia has been linked to stroke, kidney disease, increased risk of pneumonia, heart conditions and death. There is no evidence to support the use of benzodiazepines for dementia; in fact, recently published research indicates that these medications actually worsen Alzheimer’s disease.

Benzodiazepines are also used to combat sleep disturbance and anxiety, conditions very common in RACF residents. Yet, many residents become tolerant to benzodiazepines effects and these medications cause falls, day time sedation, increase pneumonia rates, cause confusion and impair resident engagement.

Research has shown that the most effective interventions to reduce psychotropic medication use in RACFs involve audit, benchmarking and feedback; staff education and interdisciplinary review.

With this in mind, a team of researchers at the University of Tasmania resolved to automate the process of auditing benzodiazepine and antipsychotic usage rates within RACFs. This process had to be quick, easy, and reliable. The most effective way to determine psychotropic usage levels within a given RACF was to extract the data from the medication packing software system used by the pharmacy that serviced the RACF.

In 2007, Juanita Westbury initiated a pilot study called Reducing the Use of Sedatives: RedUSe, which trialled this approach in 15 facilities in Tasmania. This automated audit, coupled with education and training sessions, was aimed at promoting appropriate use of sedative medicines and equipping carers with alternative strategies to manage behavioural problems.

In these training sessions nurses and carers were confronted with their RACFs sedative and antipsychotic usage levels, extracted from the medicine packing software, and challenged to explore ways of improving them.

The results of this pilot study were very encouraging. Benzodiazepines and antipsychotic medicines were significantly reduced in all participating RACFs, with little to no ill effects being reported. This study inspired a similar successful recent trial conducted by NPS MedicineWise and Webstercare that was recently reported on by Pulse+IT.

More significantly, based on the results of the pilot study, the Australian government awarded a $3 million grant to the University of Tasmania to expand this program to 150 RACFs as a nationwide implementation trial.

This implementation project commenced in 2013, and is now well underway. It is supported by Bupa Care, Southern Cross Care and a broad range of independent RACFs.

The RedUSe data extraction software can automatically extract all packed medicines for a given RACF from a range of common medicine packing systems, including FredPak, Webstercare, MPS and Minfos.

This extracted data is securely uploaded to the RedUSe web server, where each resident taking sedatives is reviewed by a RedUSe project pharmacist, a nurse from the given RACF, and the Quality Use of Medicines pharmacist that works at the facility. The data is then benchmarked against national sedative use and presented to the participating RACF, coupled with a customised training session.

The process is repeated at three months, re-iterating the message of the project, and giving the RACF an opportunity to see how their usage levels are tracking over time. A final benchmarked eHealth audit report is presented to the RACF and participating health professionals at six months.

The RedUSe project was rolled out to 27 RACFs in March this year and interim results look promising. Facilities have typically reduced benzodiazepine and antipsychotic doses at the three-month mark in somewhere between 30 and 70 per cent of their patients who were originally taking them.

Another 40 RACFs will start “RedUSing” from October 2014, followed by two more similarly sized waves in 2015.

For more information about the RedUSe project, see the RedUSe website.

Dr Ivan Bindoff is a research fellow at the School of Medicine’s unit for medication outcomes research and education, and Dr Juanita Westbury is a research fellow and lecturer in pharmacy practice, both at the University of Tasmania.

Portland Hospital to produce PBS-compliant discharge scripts

Earlier this year, Portland Hospital in Victoria’s south-west switched on medications management functionality through its TrakCare health information system in all wards of the hospital, the first facility in the South West Alliance of Rural Health (SWARH) to do so.

While implementing EMM is a difficult process that requires a lot of change management, Portland has had the benefit of using Intersystems’ TrakCare as its patient administration and clinical information system for some time, meaning staff were familiar with its processes and confident in its capability.

And as the medication management functionality is already built into TrakCare, the whole process has only cost $10,000, something that SWARH’s divisional manager for productivity and development, Katharina Redford, raises a few eyebrows at other hospitals weighing up the high cost of going electronic.

In addition to mobile access, the next step for the implementation is to integrate TrakCare with iPharmacy and develop the ability to produce PBS-compliant discharge prescriptions that patients can take to their local pharmacy.

Portland began planning for the roll-out in mid-2013 and went live in September, converting each department and ward over to the system incrementally. Ms Redford says the planning included devising change management strategies, evaluating workflows and conducting time and motion studies, as well as looking at any hardware upgrades that would be required.

While the roll-out has been reasonably smooth, as with all major changes there have been a few adjustments in that time, predominantly to ensure the system fits in with various workflows. Ms Redford says they were relatively minor and were more about developing a more nuanced understanding of the system and how it works.

“With the Gartner hype cycle, there is all this excitement and a honeymoon period when everyone is happy before there are troughs of disillusionment and we are coming out of that now,” she says. “We have identified things that really bug them and they are just usability things. ‘Did you know that you could click here or do that and that will solve the problem?’ That’s what we are working through at the moment.

“This is a huge amount of change. This is saying to the doctors that you will now follow every rule based on what is set out in the system rather than what you have always done. But it is also nurses having the opportunity to clearly understand orders and follow best practice and it is pharmacists being able to interact at the time the orders are placed rather than two days later when they get to the chart. It is a huge change.”

It is early days yet but in the months since it was fully rolled out, Ms Redford says the system has improved productivity by reducing the time it takes to write a medication chart and the time that pharmacists formerly spent walking through each ward. However, it still requires that nurses spend about the same amount of time on administration.

And while the rate of errors has not yet changed, the errors are quite different to those that occurred in the past. “Instead of an error like ‘I can’t read what has been written’, it is more ‘that is out of line with our guidelines’,” she says. “These errors aren’t necessarily incidents: they are because more collaborative, intelligent questions are being asked.”

Ms Redford says one of the benefits of having medications management integrated within the clinical information system rather than as a bolt-on is that information can readily be drawn from other functions, such as patient allergies and pathology results.

“With a paper medication chart you have to rely on someone recording the allergies on every chart and every page on every chart,” she says. “On a paper chart you might just miss that note not to prescribe penicillin. That now gets recorded within TrakCare and it is always there, so if you order penicillin and the patient is allergic to penicillin, it won’t let you do it.

“Clinicians can choose to override some things because there is sometimes good reason why you would order something that a person is allergic to, but the alert is always there.

“A difference again with a paper chart is that when the nurse checks the patient’s INR, they would write that on the chart, but in TrakCare, that INR is within the pathology result so the doctor can go in and eyeball it and there’s no confusion about whether it’s a nine or a four. These are the sort of benefits of the patient-centred approach. You choose the person, you understand what’s happening with that person.”

Bring your own network

Portland has decided against equipping nurses with tablet computers to use the medications module for the time being and instead went with computers on wheels (COWs) for practical reasons. Like the other hospitals in the SWARH alliance, the hospital has very good wireless access so laptops on a trolley proved suitable, and the nurses also like to keep their hands free and have a place to keep their thermometers, containers of Agarol or Mylanta and the like.

Portland will go down the mobile route as part of SWARH’s BYOD strategy and is looking forward to the next version of TrakCare, which will enable mobile medications management. It won’t matter what kind of device the system is installed on because it will detect whether it’s a PC or other mobile device.

SWARH has a long-term mobile strategy in place and has moved now beyond BYOD into BYON, or bring your own network. As many hospitals are in rural areas that give GPs visiting rights, the alliance has rolled out Citrix’s NetScaler application, which enables GPs and consultants to log into the network wherever they are. GPs are also able to purchase time on the SWARH high-speed, microwave broadband-based network if they so choose.

That said, Ms Redford is not convinced that clinicians will all take to BYOD, particularly nurses. As a nurse herself, she believes they are more likely to want to use a hospital-issued device rather than a personally owned one, as opposed to consultants, who need to use a device for both clinical and private business purposes.

Integration with iPharmacy

Ms Redford says most medications management systems don’t have an integrated pharmacy module, so what Portland Hospital’s pharmacists are using a link between TrakCare and their iPharmacy system. They can access TrakCare on one screen and iPharmacy on another.

“The pharmacists do their ward rounds in the pharmacy system, which saves a whole of time, and they will check each new drug as it is ordered because they get a notification,” she says.

“They can write their notes as they would with a coloured pen on a paper chart, they can put medications on hold, and within TrakCare they have configured messaging so the pharmacist can send a doctor a message saying ‘did you really mean this dose’ or ‘under the antimicrobial stewardship program you can only order this for three days’.

“The message goes to the account so when I log on as a doctor I get a notification that there is a message waiting for me and then I can send it back to the pharmacist.”

Once the two systems are integrated, Portland Hospital hopes to start producing discharge prescriptions. “We can already produce discharge lists and we can put meds on the discharge summary, but what I’d like to do is to produce a PBS prescription so they can take that prescription to the community pharmacy,” she says.

In the future, there is the possibility of providing patients themselves with some sort of electronic view of their medications. At present, discharge summaries are printed out but often they don’t come with instructions for the patient or carer on when they should take their new medications and whether they should continue to take their current ones.

“It’s also possible that when they go home they can manage their own medications so there is proper medications reconciliation, which is the biggest safety driver,” Ms Redford says. “When you come into hospital a professional sits down with you and gets out of you or your relatives what tablets you take every day. Not what you are ordered to by the doctor but what you actually take, as they are often different things.

“You might be ordered to take four different things by the doctor but you also might take a couple of complementary therapies and you might also take Aunt Bessie’s heart tablets because she had high blood pressure and you have it now and you just take hers. That happens all the time.”

As it is early days yet there are no statistics on medication misadventure, but SWARH expects to be able to provide a full account this time next year. Ms Redford is not at liberty to say when the other hospitals in the alliance that use TrakCare will also switch on EMM, but she says they are all keen to do so. They also plan to begin using TrakCare to connect to the PCEHR.

iPad version of ACE dementia test automatically calculates scores

Australian and UK researchers have released a free iPad version of Addenbrooke’s Cognitive Examination (ACE), a popular screening test for dementia and other cognitive disorders, which will allow clinicians to automatically calculate patients’ scores and create a report for their medical records.

Developed by Neuroscience Research Australia’s (NeuRA) Professor John Hodges and colleagues at Plymouth University in the UK, the ACEmobile app contains the latest version of the ACE test, ACE-III, and will mean users no longer have to refer to the paper administration manual or calculate scores in their head.

The ACE-III test is considered more comprehensive than other tools like the Mini Mental State Exam (MMSE). In a 100-point score, people with scores below 88 may have early dementia and scores below 82 increases the certainty.

The test is normally administered with paper and pencil and requires clinicians to calculate the score. It also requires clinicians to use an administration manual to ensure the correct wording is used.

The ACEmobile iPad version will do both of these functions automatically, and will also create a report that can be printed out or emailed. It is also aimed at allowing nurses and non-medical staff to administer the test.

Professor Hodges, who designed the original test, said he and his colleagues adhered to the philosophy of creating tests for clinicians at no cost. ACE has always been a free test and is used around the world, including in developing countries.

He said ACE as an online medical tool meant greater access to early and decisive diagnoses. “A diagnosis can now be made anywhere there is an internet connection, which is particularly important in parts of the world where resources are limited,” he said.

“The Plymouth team have done a great job producing such an attractive and user-friendly app which I’m sure will find wide usage.”

Computerising the test also means that it can be used more easily for audit and research purposes. The research team will collect anonymised data to develop better normative data for different patient populations.

The team hopes to develop ACEmobile to become increasingly sensitive to early disease onset and any changes experienced by an individual.

ACEmobile is available for free from the iTunes store.