State by state: Victoria considering state telehealth network

As Victoria moved into caretaker mode in advance of the November 29 election, the state’s manager of telehealth strategy and development, Geraldine McDonald, provided an overview of the telehealth sector at the RMA conference.

Ms McDonald said Victoria was at an earlier stage than most of the other states in its provision of telehealth on a state-wide scale, although groups like the South West Alliance of Rural Health (SWARH) have been active in telehealth for many years.

Last year, the Health Innovation and Reform Council was asked by Victorian Health Minister David Davis to look at telehealth and investigate what Victoria needed to do better to support health services that were considering telehealth service models, Ms McDonald said.

“That working group came up with a set of recommendations, one of which was to establish a telehealth unit in the Department of Health,” she said. “There was a telehealth implementation and action plan, and that was last year.

“The current environment in Victoria is very siloed. There are a lot of proprietary systems, and we are working quite hard at the moment to try and look at what is needed for any state-wide networks. Some regions in Victoria are a bit more mature in their telehealth roll out than others, so the department is looking at how to support those that are not as advanced.”

Ms McDonald said an audit carried out earlier this year found that with some minor investment, the telehealth unit will be able to work towards having a state-wide interoperable network.

“All mental health services with an inpatient facility have been video conference-enabled, which in effect is our first state-wide telehealth system, and now other health services are looking at how they can leverage of that system,” she said.

Victoria’s after-hours urgent care program has also been provided with telehealth facilities in 14 urgent care centres in the Hume region of the state. The Victorian Stroke Telemedicine project is also being rolled out in the Hume region following its successful implementation in Loddon Mallee.

“We have been developing a number of resources in the telehealth unit and a discussion paper that will be available in the next week around what are the critical success factors in delivering telehealth services.”

The unit has also engaged DLA Piper to develop a medico-legal communique for health services around the medico-legal issues in telehealth that will be available at the end of the year, and it has also developed a web-based investment analysis tool to help health services identify the best solution on an agnostic basis.

In terms of eHealth, Ms McDonald said the aspiration was that all health services would be able to send national-standard discharge summaries point to point and with consent to the PCEHR.

“State-wide adoption is more dependent on clinical engagement and change management rather than technology and that really is the focus on our discharge summaries,” she said.

“[For electronic referrals], we have state-wide coordination tools and templates, standard referral forms for GPs. The focus is on the business flow and change management, not the technical flow.”

Last week, the government announced the winners of the Innovation eHealth & Communications Technology Fund for the purchase and installation of health information technology, first announced in the 2012 state budget.

This includes $40 million to begin implementing an electronic medical record with medications management at Monash Health, formerly known as Southern Health. This health service includes Monash Medical Centre, Monash Children’s Hospital, which is being rebuilt, Moorabbin, Dandenong and Casey hospitals and a new cardiac hospital that both the Coalition and ALP have agreed to fund.

Alfred Health will get $7.1 million towards replacement of its patient administration system, which is understood to be the legacy Homer system that is no longer supported. The Alfred has used Cerner’s clinical information system for many years and is likely to either use its PAS module or CSC’s iPM system, which is widely used in Victoria.

Grampians Rural Health Alliance will receive $4.3 million to develop and implement shared electronic medical records and health information exchange across the Grampians region, and Gippsland Health Alliance (GHA) will receive $5.6 million for the implementation of electronic clinical documentation and medication management systems into GHA’s four largest hospitals.

SWARH will receive $2.55 million for project and change management resources to accelerate the adoption of electronic medical record functionality, including electronic medication management. SWARH uses a mixture of clinical and patient administration systems including InterSystems’ TrakCare and Core Medical Solutions’ BOSSnet, and has recently rolled out TrakCare for meds management at Portland Hospital.

SWARH is also ahead of the pack in planning to implement national individual health identifier across both acute and community health.

Hume Rural Health Alliance will receive $8.5 million to replace the PAS for its 17 hospitals and health agencies and four community health services, with Mildura Base Hospital also receiving funds to replace its PAS.

Ambulance Victoria has received three separate grants: one for a feasibility study into implementing National Health Service Pathways solution for triage; one to enhance the National Health Services Directory to meet ambulance requirements; and one for a patient monitor integration to automatically and wirelessly transmit the patient’s vital signs and ECG readings directly to the hospital’s emergency department prior to ambulance arrival.

State by state: clinical portals in the ACT

The ACT’s manager for national eHealth initiatives, Ian Bull, outlined the capital’s progress in developing access portals for both clinicians and consumers at the RMA conference.

Using Orion Health technology, the ACT has developed a consumer portal called My eHealth through which people who receive care from the Canberra Hospital and its community-based services can update their personal details, check on past and future appointments and access discharge summaries from the hospital.

It has also developed internal portals to link clinicians in different settings and to link disparate systems, particularly for discharge summaries and electronic referrals.

“We are trying to coordinate our eReferrals into a common interface and we will be able to receive eReferrals from doctors’ systems directly into our system,” Mr Bull said.

The capital is also working on implementing common languages and semantic interoperability across its integrated systems, which will form the basis for its alerts management system. This will not only include alerts for allergies and adverse reactions but will allow some administrative alerts as well.

It is working on medications reconciliation, beginning with geriatric discharge summaries. This will be added to all discharge summaries in future, which the ACT has been sending to the PCEHR since March last year.

“We have Find a Health Service, which is an app you can get on a smartphone or the web,” he said. “We take a feed from the National Health Services Directory and we supplement that with health service information from the ACT.

“We are looking at bringing all of our provider directories – we have identified 10 key ones within our hospital – so we have one common database so we can get good endpoint location information from the National Health Services Directory and have common identification of clinicians.”

The ACT has also invested in digital infrastructure around the hospital, including building secure, medical-grade WiFi networks and free public WiFi, and it provides remote access to systems for clinicians through secure tokens.

There is also a concentration on secure messaging, he said. “We need to be able to get secure messaging not just between health services but from us out to the GPs. At the moment we have a problem with our VMOs – we have a policy that prevents them from sending unsecured emails – so we are looking at solutions around that.”

Mobile cardiology clinic takes to the road in rural Queensland

A mobile cardiology clinic equipped with diagnostic technology and telemedicine capabilities has taken to the road in south-western Queensland, aiming to provide specialist cardiology services to people in Dalby, Roma, Charleville, Goondiwindi and St George.

Called Heart of Australia, the clinic has been built on a retrofitted road train and contains two consultation rooms, a diagnostic suite with ultrasound and cardiac stress testing equipment, and a patient reception area.

It can share test results instantly with GPs and allow metropolitan hospital-based specialists to attend consultations through video conferencing.

The brainchild of cardiologist Rolf Gomes, who practices at the Medihearts clinic in Brisbane and Ipswich and is a visiting cardiologist at Ipswich Public Hospital, the clinic has been funded by coal seam gas firm Arrow Energy and the federal and state governments.

It will do a circuit of the towns on a fortnightly basis with a rotating roster of specialist staff, and will also provide respiratory medicine. Patients must have a referral from their GP.

Dr Gomes said the mobile service would provide diagnosis, treatment and follow-up for a range of cardiovascular and respiratory conditions.

“Heart of Australia has everything that my city practice has, so people won’t have to drive for days to see a specialist,” he said.

Dr Gomes said he had surveyed more than 180 regional GPs who were frustrated at the difficulties patients had in accessing specialist care and who “overwhelmingly supported” a Heart of Australia-type program.

GPs can send a referral via secure messaging service Medical-Objects, download a referral form as a PDF from www.heartofaustralia.com or email reception@heartofaustralia.com for a referral notepad.

Available tests include stress and transthoracic echocardiogram, exercise stress test, 24-hour and seven-day Holter monitoring, 24-hour BP monitoring, ECG and respiratory function.

Plans are afoot to extend the service to central and north-west Queensland in the future.

Device aims to reduce alarm fatigue for nurses at point of care

Wireless communications specialist Ascom Wireless Solutions is set to introduce a new mobile device specifically designed to improve nurse communications and clinical workflows to the local market early next year.

Called Myco, the device combines the capabilities of a smartphone, such as a touch screen, 3G and WiFi, along with a barcode reader for patient and medicines identification. Ascom says it has a robust design that is capable of withstanding knocks and drops as well as hygienic requirements.

The device is linked to integration software called Ascom Unite that allows it to be connected with hospital or aged care facility information systems, patient monitors and nurse call systems.

It allows nurses to drag and drop the names of their assigned patients onto their device, meaning they can receive automated messages, alerts and alarms just for those patients, helping to avoid alarm fatigue. The software also gives nurses access to patient records and results.

The device is able to filter and prioritise alerts, as well as forward and escalate them. The nurse can see on the device what type of alert or alarm it is, the severity of the alarm, and which patient it is for, even when the device is in their pocket, as all necessary information is visible on the top display.

It comes with a docking station for rapid battery swaps and has been optimised so it can be operated with one hand.

Ascom will officially launch the device in Sydney in November, with the first shipments due in the first quarter of 2015.

New Zealand to invest $3m in patient portal roll-out

New Zealand’s Ministry of Health will provide $3 million towards the roll-out of general practice patient portals as part of the National Health IT Board’s plan to provide all patients with online access to their clinical information.

While the NHITB had hoped that portals would be offered to all patients by the end of the year, there has been some resistance in the general practice community, particularly around the cost of installing the products currently on the market.

Market leaders Medtech Global and MyPractice both offer portals, Medtech through its ManageMyHealth and MyPractice through Health365.

Intrahealth also allows patient access through its Accession product, while Houston Medical is currently working with Medtech to integrate with ManageMyHealth.

All allow patients to book appointments, request repeat prescriptions and view lab results and parts of their medical records. In addition to encouraging patients to better manage their own care, portals are said to offer productivity increases for general practices by removing some of the administrative burden such as phone bookings.

They also provide a secure method for patients and practices to communicate electronically, overcoming some of the fears about allowing correspondence by email.

However, the significant upfront costs in purchasing the technology and ongoing subscription costs for practices has limited their uptake. According to Health Minister Tony Ryall, 78 general practices are currently offering a portal out of approximately 800 practices in the country.

GPs have also voiced concerns about medico-legal liability as well as confidentiality, security and permissions.

The software vendors have been working with the Royal New Zealand College of General Practitioners (RNZCGP), the Medical Council of New Zealand, GPNZ, the primary health organisations (PHOs) and the Ministry to developing a code of practice for the provision of patient portals. These organisations are also working on developing resources and guidelines on how to implement portals and register patients.

While it is not yet clear how the $3m will be distributed, Mr Ryall said it will be used to give practical support to general practices planning to introduce a portal.

South Island PICS gets the official go-ahead

The new South Island Patient Information Care System (SI PICS) has been given the official go-ahead from Health Minister Tony Ryall, with the start date for the roll out to begin next year.

SI PICS is a single patient management and administration system that is being introduced to all hospitals in the South Island and will replace systems such as HOMER that currently handles patient demographics, admissions, transfers and discharges.

The system is being built by Orion Health based on its Consult solution, a product suite that includes what was formerly known as Concerto. It aims to streamline the patient journey and help to coordinate care between different hospitals and providers and eventually reach out into community care.

The plan is to use the system to standardise patient flow across the five DHBs and will include data on patient demographics, appointments, clinical records, in-patient admissions, discharges and scheduling.

“Replacing each district health board’s patient information system with a single streamlined regional system will provide health professionals with more accurate information, and allow them to spend less time on administration and more time on caring for patients,” Mr Ryall said in a statement.

“It will also manage a number of patient services for district health boards, including patient appointments, admissions, discharges, and transfers.

“The new system will also be more timely and cost-efficient than the patient information systems it replaces. Together, the DHBs are expected to save around $40 million over the next 15 years.”

SI PICS will be introduced throughout South Island hospitals in stages, beginning in 2015 with Burwood Hospital in Christchurch and then with hospitals in the Nelson/Marlborough region.

A team from the South Island Alliance and Orion Health has been touring hospitals over the last few months to demonstrate the new system.

South Island DHBs to roll out e-incident management system

The five South Island district health boards will roll out an electronic incident management system from Canadian firm RL Solutions that will allow staff to more easily report incidents involving patient safety.

RL Solutions’ RL6 Risk system is used by 1400 healthcare organisations around the world as well as by NZ’s Health Quality & Safety Commission. It features a simple interface that allows staff to report any type of event and is complementary to the clinical audit process.

The system allows reports to be created anytime, anywhere, in various formats without IT involvement, and includes tools such as alerts and automated reporting to help reduce the time needed for staff intervention.

RL Solutions is delivering a five-phased approach to introducing the new system into each DHB. A three month IT build process is underway to enable the development of the taxonomies of incident, risk, restraint, hazard and feedback which will be used by all South Island DHBs.

Canterbury DHB will begin the roll out in November, with completion expected by May 2015. Nelson Marlborough DHB will also commence in November with a view to competing it within two months.

Southern DHB will pilot the program in two sites in November and roll out the system early in 2015 while West Coast and South Canterbury DHBs will follow suit in early to mid 2015.

The system will support each DHBs commitment to recognising that adverse events and incidents will happen from time to time, and that through promoting a transparent and open culture of reporting and information sharing, there will be ongoing improvement and refinement of patient care.

RL Solutions will provide professional service specialists, communication tools, technical set-up and training to support staff at each stage of the roll out.

Clinical dashboard to help monitor peak flow for asthma

The developers behind the Breathe Easy asthma management app are currently building an online clinical dashboard that will allow GPs and patients to monitor the results of peak flow testing and other symptoms and let patients adapt their action plans accordingly.

The Breathe Easy app was developed by Asthma New Zealand in association with John McRae, CEO of promotions and app development firm VADR, who has had asthma since childhood.

The Breathe Easy app was developed for the iPhone and launched in 2012. It allows users to monitor peak flow levels and create action plans to share with their GP, and offers reminders to take medication as well as links to important information and support from Asthma New Zealand.

Asthma New Zealand says it is essentially a digitalised system that improves on, and will eventually replace, current paper-based asthma management plans.

A key feature of the app is its ability to remind users to use their inhaler or preventer. While a wide range of asthma medication is available, as Mr McRae says, “If you don’t take it, it doesn’t work.”

The app also contains an asthma control test that allows users to record, compare and share results with practitioners.

VADR is now developing an online clinical dashboard, which will provide GPs with an overview of their patient’s symptoms. Asthma New Zealand said it would give GPs a greater understanding of the condition for individual patients.

The app is available from iTunes for free and has also been adapted for Australian and US users.

Telehealth demonstration project extended to next year

The Telehealth Demonstration Project that has been running in the Bay of Plenty region for the last 18 months has been extended for another six.

The project has been funded by the Ministry of Business, Innovation and Employment (MBIE) to demonstrate the capability of telehealth to improve healthcare delivery as part of the roll-out of the Ultra-Fast Broadband and Rural Broadband initiatives.

In addition to helping kickstart telehealth in primary and community care by providing advice and support, participants have been given high-definition web cameras on long-term loan.

Project facilitator Ernie Newman said the project would now continue until the end of February 2015, and had picked up another sponsor as well.

“There are now four sponsors – the original three were Bay of Plenty District Health Board, the Ministry of Business, Innovation and Employment, and the National Health IT Board,” Mr Newman said. “They have been joined by Tairawhiti District Health.”

The project is aimed at encouraging wider use of telehealth beyond the hospital sector. It has achieved a number of wins, including the Opotiki Telehealth Community, where all GPs are now equipped with video capability in their clinics and their homes for after-hours care.

Nurses staffing the small Opotiki Community Health Centre can video conference with the duty GP at home, and can also link to the emergency department at Whakatane Hospital if needed.

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

More work needs to be done to allow district nurses to use telehealth while in the patient’s home. Mr Newman said the cellular network in some areas is not good enough to ensure stable and fast links.

Debate continues on diagnostic reports for PCEHR

The Department of Health is holding a second round of consultations this week on the best methods to upload pathology and diagnostic imaging reports to the PCEHR.

Two consultation workshops were held in Melbourne last month to discuss a number of workflows for diagnostic services, including the development of an authority to post (ATP) method in which reports would be sent to the requesting doctor, who would then authorise the diagnostic service provider to upload a full report in PDF format to the PCEHR.

Using PDFs as an interim measure seems to have been accepted, with the ATP system now the main bone of contention.

Last week, the Royal Australian College of General Practitioners (RACGP) began a month-long survey of its members to see which model they would prefer. Options include the requesting doctor reviewing any results and sending an ATP to the pathology lab or imaging provider to upload the report from their system.

Option two involves the diagnostic provider uploading the results at the same time as they are sent to the requesting doctor, and option three involves the diagnostic provider automatically uploading the results after a fixed number of days, during which the requesting doctor can send a message to stop the upload in case of a significant result.

The Department of Health has stated it would like to see an agreed, workable method in place by December, although this might not be achievable.

Matt Nielsen, business development manager with connected healthcare software vendor InterSystems, said the July pathology meeting was positive, with more people in attendance, including other software vendors, but that there was a lot of ground work that still needed to be covered yet.

While he was sceptical in the past about suggestions that pathology reports be uploaded as PDFs, he said he had now come around to accept that it is the only way to get results up in advance of further standardisation of pathology to allow atomic data to be uploaded. However, he does not believe it will be possible to implement before the end of the year.

“I came in sceptically that the PDF was the right solution based on my experience in private networks, but having been to two previous meetings I can see now that PDF is the right solution for an open network such as the PCEHR at this time, so I agree with that,” he said.

General practitioner and former NEHTA clinical lead Nathan Pinskier said he agreed that the pathology consultation was far more constructive than in the past, but he too shared fears that the timelines were too short.

“I think it is fair to say there has been a lot of thinking around the model, a lot of work that was done in the diagnostic services working group back in the NEHTA days,” Dr Pinskier said. “The pathology sector itself is relatively well organised and mature in its thinking and they seem to be led well by [pathology informatics expert] Michael Legg, who is very knowledgeable.

“For me there seems to be a lack of clarity around the more technical stuff but I think the meeting was constructive and well chaired by [DoH CIO] Paul Madden and I think they reached a reasonable endpoint given the time constraints.

“[But] there is a general concern that the timelines are way too short … and they could rush the consultation process, rush the technical implementation, and it will struggle to be ready in December.”

Dr Pinskier said he also agreed that PDFs were the obvious, interim solution even if it was not ideal. “With the PDFs, there is still a lack of clarity around what is a report. You can put 10 panels on a report and call that one report, but in terms of making the first step the PDF, that is a way to go but it is not the ideal solution.

“[However,] the pathology industry has done a lot of work in the [Pathology Information, Terminology and Units Standardisation] PITUS project looking at the standardisation of terminologies, and that will lead to atomic down the track.”

Mr Nielsen said there were still problems to be overcome in terms of how to group pathology reports such as full blood examinations (FBE) so that GPs can easily find them in the PCEHR. There is also the problem that for a given request, results from an FBE will be available at a different time from an electrolyte panel, for example.

“Some doctors say don’t bother me with these reams of paper providing progress reports – I just want a final summary report when everything is done,” he said. “It’s not entirely clear if the doctor’s practice software is going to represent these reports as they come in with an ATP for each report as it is completed, or whether it’s going to be a summary ATP at the end.

“It’s going to be based on how the lab reports and on how the doctor’s practice software handles the reports. I think there’s a risk that if they have to provide an approval to post per report as it comes in, they’re going to get fatigue and start to ignore them.”

He also said there was a potential problem with who was accountable for ownership of the test reports. For example, a particular laboratory might conduct one test but send a sample to a reference laboratory to do another test on the same request.

“There’s no consistency in the industry on that,” he said. “To make that reference stuff work, it would be helpful to have a policy on who is going to be accountable for reporting it to the PCEHR.”

Dr Pinskier also attended the diagnostic imaging consultation meeting last month, where there is some disagreement over the authority to post method. The briefing papers for both meetings suggest that ATP be used, but while the pathology sector is leaning that way, it appears diagnostic imaging is not.

According to the department’s summary of outcomes of the first round of meetings, the DI sector argued that as the patient was often seen in person by the radiologist and provided with films of their test, a decision to upload the report of those imaging tests would be determined by the radiologist, most likely as an automatically generated upload, without having to involve the requester.

However, Dr Pinskier said he had discussed this with a radiologist colleague working in the private sector, who said he would only often see or speak to the patient if there was an unusual or significant result following a diagnostic intervention, and that was only a small percentage of all patients.

“Most of the reports these days go back electronically to the requesting practice,” he said. “The model that got raised in the discussion and the advice provided at the meeting was predominantly from hospital-based radiologists, not in private practice.”

While he was happy that some progress has been made, Dr Pinskier said he was a bit exasperated that one model might be chosen for pathology and another for diagnostic imaging. Added to that was a third model that seemed to get a bit of traction at the DI meeting, he said.

“That model is delayed upload, where all diagnostics is delayed for x number of days. That gives time for the provider or requester to review it, they can then add an instruction not to post it if it is sensitive, and then after a set number of working days it gets uploaded.

“That was discussed at the diagnostic meeting and had a little bit of traction, but that will need another round of consultation and I have no idea what the pathologists think.”

What this does raise is a further issue of diagnostic service providers having to ensure they are connected to both the PCEHR and the Healthcare Identifiers (HI) Service, Dr Pinskier said.

“In the two models that they are proposing, for pathology it will require the requester to be connected to the HI Service and to the PCEHR, and the laboratory will only need to be connected to the PCEHR. The laboratory will rely on the integrity of the healthcare identifying data sent by the requesting organisation.

“However, if you go to a direct notification model, they are proposing that the diagnostic provider be connected to the HI Service and to the PCEHR. It means that any request of any sort, as long as it is done to a connected, conformant diagnostic provider, will end up in the PCEHR.

“That will create a state of confusion for both providers and patients in that all diagnostic results may always go up but not necessarily all pathology results. If two models are implemented this will invariably impact upon both clinician and consumer adoption as some results will be clinically curated and some may not.”