The 2015 NZ eHealth year in review

The announcement by Health Minister Jonathan Coleman at the HiNZ conference in Christchurch that New Zealand would build and roll out the basics of a national electronic health record (EHR) by 2018 was big news on both sides of the Tasman in October, and helped to round off a year in which NZ continued on its steady, sensible path towards a health system supported by sound, functioning health IT initiatives.

The general consensus of opinion from Pulse+IT’s informal survey at HiNZ of reaction to the announcement was that if there was one country that was at the right level of maturity and would do the job with the minimum of fuss, it was New Zealand. Unlike certain other countries that shall remain nameless, there were no large sums of money thrown around and no exaggerated promises of what could be achieved.

While the announcement of the national EHR – and the equally interesting plan to develop a digital hospital blueprint – was unexpected, it was known that this would be a year in which a new health IT plan would be announced to accompany the review of the New Zealand Health Strategy, which had its last update in 2000.

But while those announcements were to pop up at the end of the year, at the beginning of the year the industry was digesting the results of a stocktake of telehealth activity by district health boards, part one of a two-part plan to gauge the extend of telehealth use in New Zealand. The stocktake found that telehealth was at a “tipping point” in NZ, with all of the DHBs making use of telehealth technology to some degree.

The next phase saw the NZ Telehealth Forum look at the use of telehealth by primary health organisations and non-government organisations, and they didn’t have far to look as news began to surface of a new start-up telehealth service called Doctor2Go. Run by an Auckland company called Concierge Medical Services, itself a division of Waitemata practice Third Age Health, the service said it would use WebRTC technology for video conferencing and its GPs would use the MyPractice patient management system hosted in the cloud.

That venture was overtaken somewhat later in the year by the announcement that Homecare Medical had won the contract to provide New Zealand’s new national telehealth service, which saw it take over some existing services from Medibank Health Solutions such as the Healthline nurse triage and advice service.

Homecare Medical is a partnership between Canterbury PHO Pegasus Health and Auckland PHO ProCare. While the majority of the telehealth service provision is telephone-based with some web-based information portals, the company does expect to introduce video conferencing in the future.

In February, Midlands Health Network announced that 1000 Waikato newborns had been enrolled on the new National Child Health Information Platform (NCHIP). Developed in association with the Ministry of Health, the National Health IT Board, Orion Health and BPAC, the service includes shared data repository as well as a telephone-based coordination service based in Hamilton. It is being rolled out to Taranaki next month and the Lakes region in March.

Also in February, Orion Health and the five South Island DHBs signed a new agreement covering the roll out of the South Island Patient Information Care System (SI PICS). Set to replace seven legacy patient administration systems used in hospitals in the region, it is set to go live at Christchurch’s Burwood Hospital in April or May, followed by Nelson Marlborough DHB in September and the rest of Canterbury DHB in early 2017. It will then roll out to the other three DHBs in time.

In what would prove to be the last hurrah for Health Benefits Limited, four DHBs signed on to migrate to the national infrastructure platform developed by IBM. By mid-year, eleven DHBs had signed on and seven more had given verbal assurance they would too. The NIP will consolidate the 40 different data centres currently being used into two IBM data centres, one in Auckland and one in Christchurch.

Responsibility for the platform moved over to NZ Health Partnerships, the DHB-led organisation that has replaced HBL, which was axed in November last year, with the NIP the only one of HBL’s four business cases that was on track. While it was set up to allegedly consolidate services and save on duplication, it was widely seen as a cost-cutting exercise.

The Ministry of Health also signed on to IBM’s specifically designed cloud-based managed infrastructure service for a minimum of five years. The platform will support the National Health Index database and other national health systems.

It was a huge year for Orion Health following its keenly observed listing on both the NZ and Australian stock exchanges in December 2014 for a paper value of $1 billion. Shares were priced at $5.70 on listing but had dropped to $3.10 a year later, but this was always expected as the company announced it was putting a large amount of capital and effort into R&D and would continue trading at a loss for the next few years.

Orion Health has been a big supporter of the development of the FHIR standard, with Orion’s product strategist David Hay writing a white paper on its potential. The company was one of the first in the world if not the first to add FHIR capabilities to a commercial product, adding it to Rhapsody integration engine in February.

It was a big year for Rhapsody too, with a long-term release launched in December and the announcement that it would be used as the link between civilian healthcare facilities and the new electronic health record being built by the US Department of Defense as part of the monumental Defense Healthcare Management System Modernization (Dim-sum) project, which is costing $US4.3 billion.

Apart from the revised health IT plan, perhaps the most high-profile effort from the National Health IT Board and the minister himself was the push to expand the use of patient portals. The use of portals was a big part of the existing health IT plan and the board had originally hoped they would be available to all New Zealanders by the end of 2014. That was certainly overly ambitious and the target was halved in February 2014, but by the end of 2015, only about one in four practices were offering one.

To give the technology and the policy a bit of a boost, last year the then health minister, Tony Ryall, announced a group of seven ‘eHealth ambassadors’ hired to encourage GPs to establish a portal, and later managed to snare $3 million to assist in the roll-out. However, there is still a lot of reticence among GPs for a number of reasons, high on the list of which is the cost, with some portal vendors even charging for training. A number of PHOs are now looking at models where licences are purchased in bulk on behalf of member practices.

Later in the year, Patients First released modelling commissioned from Sapere Research Group that provided different scenarios in which practices could gauge the benefit of patient portals on a number of different criteria, including time and money saved. They also developed an interactive tool that allows practices to add their patient population data to help model what effect a portal would have on their particular practice.

While Patients First CEO Jayden MacRae would not go so far as to describe GP reaction to patient portals as reticence, he did say that like any new technology or initiative, it can take a while to build up a head of steam. Sapere’s Tom Love gave a presentation at HINZ in October in which he said research showed that doctors’ fears that patients would start stalking them with persistent emails about clinical matters were unfounded.

In July, HealthLink announced a new capability for GPs to lodge medical certificates with Work and Income New Zealand (WINZ) electronically, rather than having to print them out and give them to the patient. While it may sound a bit ho-hum, Pulse+IT believes that this new SmartForms technology, based on HISO standards and integrated into all of the PMSs, is going to be truly revolutionary for the general practice sector, in New Zealand and Australia.

HealthLink uses similar technology for its CareSelect eReferral system, which in August it made available to all GPs in NZ for secure ‘any to any’ referrals to specialists, allied health and non-government organisations. It has also offered the CareConnect eReferral service for GP to hospital referrals in the Auckland region for about three years. A real breakthrough in the WINZ case is in developing the capability for the data contained in the medical certificates to be integrated into the Ministry of Social Development’s own systems, as well as for GPs to send it off with just a click of the mouse. Australian PMS vendor MedicalDirector is about to go live with this capability and we believed both countries will be hearing a lot more about this technology in 2016.

Everyone then got a big surprise when connected care system vendor HSAGlobal sold up to Whanau Tahi, the IT arm of west Auckland healthcare provider the Waipareira Trust. HSAGlobal’s Connected Care Management Solution (CCMS) is widely used in NZ, including for Auckland’s shared care plan program and Canterbury’s collaborative care program, as well as new one aimed at at-risk individuals in Counties-Manukau.

When HSAGlobal was liquidated the next month, it became obvious just how hard it is to market shared care planning systems. CCMS has now been rebranded as the Whanau Tahi Connected Care (WHCC) system, and is being deployed by Hawke’s Bay DHB to support the coordination of community services for its over 65 patient population.

As the end of the year approached, all eyes turned to Christchurch, where HiNZ was holding its annual conference. The Wigram Air Base Museum proved an excellent, intimate venue for HiNZ, easily accounting for the 700 or so delegates and plenty of exhibitors. There were a number of announcements – Canterbury and West Coast DHBs announced they’d implement a new digital patient observation and alert response system called Patientrack, licensed from the NHS by MKM Health, and an excellent presentation on New Zealand’s move from using Read codes to SNOMED, which St John is using for its new electronic patient report form (ePRF) – but the big news was the announcement by Jonathan Coleman and NHITB director Graeme Osborne that NZ will introduce a national EHR.

Mr Osborne said the project would move into a design phase that will see three iterative cycles of design over the next six to nine months towards the goal of standing up a basic national EHR with medicines, problem lists, allergies and alerts by the middle of 2018, and that all DHBs will undergo an EMR maturity model survey in May-June next year to create a benchmark for productive digital hospitals in New Zealand.

He later told Pulse+IT that Deloitte, in the independent review it produced earlier in the year for the minister, had found that the NZ health system had matured to a point where investing in a single EHR solution was achievable. Unlike certain other attempts at a national EHR, NZ was ready and already had most of the building blocks in place.

He also said there is every possibility that rather than build or buy a new solution, NZ will put together existing solutions such as Health Connect South, HealthOne or TestSafe, all of which have some of the capability essential to an EHR with provider and public access.

The EMR adoption survey will be carried out next May and June, based on a project that surveyed five hospitals in 2013. While many hospitals are well on their way up the HIMSS ladder, it is expected that the average will actually be very low – around level 2 – as few have taken the step of introducing electronic nursing documentation.

As the ramifications of these announcements were still being digested, the year was rounded out by the announcement by three of the biggest vendors – Orion Health, Medtech Global and CSC – that they were getting together to work on bringing together their strengths in different fields in the health IT industry to position New Zealand at the forefront of precision medicine, an extended version of personalised medicine in which data from multiple sources is brought together with emerging disciplines such as genomics to treat and care for people on an individual level, including targeting medications for particular blips in a person’s genome.

Precision medicine is already happening, but the trio have decided to put New Zealand forward a world leader in introducing solutions on a national level. The initial three companies were quickly joined by more.

As many Australians who Pulse+IT spoke to about the national EHR plan reckoned, if any country outside of Scandinavia or Singapore can do it and do it well, it’s New Zealand.

Primary care

GP desktop software market leader Medtech Global releaseda new version in March, featuring new functionality for nurse practitioners, improvements to the ManageMyHealth portal and a new online chat function for customer support. As well as launching its Medtech Evolution cloud-hosted product on the Australian market in September, Metech also expanded its presence in the US market for its ManageMyHealth portal technology following the acquisition of the remaining shares in Colorado firm ConSova Corporation in November.

Plunket went live with its new cloud-based electronic Plunket Health Record (ePHR) application, built on Microsoft technologies and due to be deployed on around 800 Windows tablets to Plunket nurses across New Zealand. The app will replace the paper-based child health record, and is fully hosted in the cloud. Plunket is currently running a campaign to raise money to roll it out nationwide.

Secondary care

Despite the intense lobbying effort of specialist doctors, the three Wellington DHBs went ahead with outsourcing their pathology service infrastructure to Southern Community Laboratories (SCL), a subsidiary of Australian private hospital and laboratory provider Healthscope. The argument from the DHBs was that SCL would build a multimillion dollar, state of the art central lab with increased IT capabilities at Wellington Hospital and upgrade equipment at Wairarapa, Hutt and Kenepuru hospitals, something the DHBs said they didn’t have the money to do.

Lakes DHB rolled out the Midland region ePharmacy system at Rotorua and Taupo hospitals in April, joining Tairawhiti DHB and set to be followed by Waikato, Bay of Plenty and Taranaki. The $2.6 million roll-out is part of a regional shared solution approach from the DHBs, which are also currently implementing CSC’s MedChart electronic medications management (EMM) system as part of the nationwide roll-out. The progress of EMM is sure to be in the spotlight next year as part of the development of the national digital hospitals blueprint program, part of which will see all DHBs ranked on the HIMSS EMRAM scale. Closed-loop EMM is essential to qualify for HIMSS level 6.

Aged care

Data on the health of elderly people living at home in the South Island was released by the SI Alliance’s Health of Older People’s Group using tools developed by InterRAI. New Zealand is a world leader in the use of interRAI tools for its aged population, both in residential care and in the community.

MidCentral DHB agreed to fund some of the set-up costs to enable a full roll out of the Medi-Map electronic medications chart in all of the area’s aged care facilities and their supplying pharmacies. Medi-Map has been designed by Christchurch-based pharmacist Greg Garratt to give GPs, pharmacists and aged care nurses access to a shared interface for residents’ medications charts, which can be updated in real time and are accessible from any device. Medi-Map has received a waiver from the Ministry of Health to allow GPs to chart medications through the system.

A long-standing study by the University of Auckland and Gore Health released some more results, which showed that robots may lessen social isolation but also help with the provision of medical care. While the study is very small, it is being looked on with interest for its potential to help older people stay in their own homes for longer, particularly in rural areas.

Some of the more interesting software, apps and new players in the market that caught our eye this year included:

Pulse+IT is taking a break over the festive season but will be back in the new year with our regular fortnightly bulletins on New Zealand eHealth and health IT.

The New Zealand health IT hot top 20

The announcement that New Zealand will create a national electronic health record (EHR) for all of its citizens was unsurprisingly the most-read Kiwi story on Pulse+IT in 2015. It’s also very apparent that anything to do with Orion Health is of real interest to readers, which again is no surprise.

Patient portals were of interest, as were new developments from GP desktop market leader Medtech, and the growing interest in telehealth also became apparent. Australian company Best Practice’s unexpected decision to buy Hamilton firm Houston Medical raised some eyebrows, as did the demise of Auckland’s HSAGlobal.

1. The national EHR announcement at HiNZ 2015 in Christchurch in October got massive hits

2. Best Practice’s buy-out of Houston Medical also rated highly on both sides of the Tasman

3. Three big names in NZ health IT got together to form NZ Health Inc

4. Orion’s Rhapsody is being used as part of the $4.3bn US armed forces EMR project

5. Telehealth start-up Doctor2Go made the news with its click and call’ service

6. Orion Health was probably the first vendor off the blocks to support FHIR

7. Patients First released economic modelling to support the take-up of patient portals

8. HealthLink went national with CareSelect for ‘any to any’ referrals for GPs

9. The NZ health minister is keen on patient portals

10. A study using robots for the elderly in Gore proved internationally popular

11. The NZ Health IT Board kicked off its national EHR design phase

12. Orion and the South Island formalised their agreement for new PICS system

13. Orion’s international plans were also of interest in NZ and Australia

14. Medicines New Zealand has a five-year plan, with IT at the heart

15. In May, a bunch of NZ health IT companies pitched across the ditch

16. HSAGlobal was wound up after the sale of its assets to Whanau Tahi

17. More on patient portals and how they are being used in general practice

18. The controversial Health Benefits Ltd was dumped and its assets returned to DHBs

19. National telehealth service provider Homecare Medical named its tech partners

20. Medtech geared up for a new release with enhanced ManageMyHealth capabilities

NZ Health Inc grows as big and small vendors come on board

Leading health IT vendors Sysmex and Simpl have expressed interest in working with the three foundation members of the recently announced precision medicine collaborative, along with international players such as HP, IBM and Microsoft.

Orion Health, Medtech and CSC announced a fortnight ago that they were teaming up to build a platform for precision medicine by joining up hospital-level clinical data with primary care and personal health data to develop a new model of healthcare for the country.

Orion Health CEO Ian McCrae said the three companies had all worked together in the past so were well placed to help NZ be one of the first countries in the world to do precision medicine, which he described as an extension of personalised medicine that takes into account the information coming out of genomic sequencing and new sources of information such as proteomics and microbiomics.

Other expressions of interest have come from companies such as Atlantis Healthcare, Healthpoint, Incisive Software, Konnect NET, MKM Health and Pathway Navigator, along with primary care provider Green Cross Health and government bodies NZ Trade and Enterprise and Callaghan Innovation.

The plan is to create a strong national health IT grouping and ‘NZ Inc’ brand that will improve the health of millions of New Zealanders. The collaboration also has an eye on working with the government on its plans for a national electronic health record (EHR).

Scott Arrol, CEO of peak body NZ Health IT (NZHIT), said the organisation strongly supports the initiative and had an agreement with the NZ Health IT Board to deliver an interoperability charter, which will see this collaboration in action.

“A strong industry-led collaboration, and an interoperable landscape, are integral components in supporting the development of a world-leading health system,” Mr Arrol said in a statement.

“It will help to showcase how NZ organisations, and our partners on the international stage, can work together towards enabling improved health outcomes for New Zealanders.”

Orion Health, Medtech and CSC held working sessions this week with initial discussions about potential project areas, which will include additional partners over time.

These projects include a collective intent to work together to resolve delays across existing projects, better connections between community and secondary care, and enriching patient portals.

Digital health ‘climate change’ workshop next step for NZ EHR

The National Health IT Board will hold a second workshop in late March to further flesh out the design of the national electronic health record (EHR) following an initial discovery workshop held in early December that covered the new health IT program’s four areas of focus.

The board is running a co-design phase for the EHR, first announced by Health Minister Jonathan Coleman at the HINZ conference in Christchurch in October.

The plan is to have the design ready by the middle of the year, when the board will also hold a survey of the country’s hospitals to measure their digital capabilities against the HIMSS electronic medical record adoption model (EMRAM).

The plan is to develop a blueprint for digital hospitals in NZ by the end of the year.

The next step is to hold a ‘digital health climate change’ workshop in March. The board has also set up an EHR design core group that is working on the preliminary design and scope.

NHITB director Graeme Osborne said there was strong agreement at the December workshop about the direction the board was heading, as well as many good ideas on what the EHR could include. The idea is to develop a high-level, consumer-centric view for the EHR and digital hospitals.

eHealth clinical lead Sadhana Maraj said workshop participants focused on creating a customer-centric health IT environment through the use of personas.

“Working on the personas helped to flesh out the actual users of the EHR (consumers and health professionals) to understand their needs, challenges and aspirations,” Dr Maraj said.

Coleman spruiks benefits to telehealth of broadband roll-out

Health Minister Jonathan Coleman has highlighted the benefits to telehealth of the government’s rural broadband initiative (RBI), which has succeeded in hooking up all rural public hospitals and integrated family health centres to high speed broadband.

The 39 facilities were identified by district health boards as candidates for the RBI and are now all able to connect to fibre capable of peak speeds of at least 100 Mbps.

Dr Coleman said faster broadband would enabled healthcare to be delivered in new ways, including the ability to offer safer, more efficient healthcare closer to home.

“A good example of this is telehealth,” he said. “This technology enables patients to be seen by their health professional remotely which improves health monitoring, lowers healthcare costs, and gives more flexibility to patients and health professionals.

“Telehealth not only breaks down geographic barriers within New Zealand, but it also enables health practitioners to more easily discuss cases and exchange information with colleagues all over the world.”

Communications Minister Amy Adams said the government will extend the RBI, having allocated an extra $100 million to the project.

Photo courtesy of Vodafone.

NZ to set up national CERT as part of cyber security strategy

New Zealand has launched a revision of its 2011 national cyber security strategy, which will now include an annual action plan to keep pace with emerging threats and the establishment of a CERT, or computer emergency response team.

Communications Minister Amy Adams said there were growing threats to the economy from cyber intrusions with serious implications for national security.

While New Zealand has yet to experience a significant cyber attack, Ms Adams said it was estimated that economic losses reached $257 million 2014.

According to research, 56 per cent of New Zealand businesses experience an information technology security attack at least once a year and only 65 per cent of businesses are confident that their IT security systems are effective.

Ms Adams said the government and the private sector needed to work together on cyber security by finding ways to share information and expertise to address risks.

The refreshed strategy will rely on a close and active public-private partnership through the Connect Smart initiative.

She said a key “action” in the new strategy is the development of a national CERT to reduce harm from cyber security incidents and improve New Zealand’s ability to deal with attacks.

The CERT will act as a single entry point for organisations or individuals needing assistance, and provide information to businesses, including small and medium enterprises, government and individuals.

“New Zealand’s key international partners each have a national CERT of some form, and creation of our national CERT brings us into alignment,” she said.

CERT is intended as a partnership between the public and private sectors and will work with companies and government agencies depending on the nature of the issue, she said.

The 2015 eHealth year in review: part four

The summer season for eHealth and health IT kicked off with a tip that the membership of a committee charged with paving the way for the creation of a new digital health agency was set to be announced. The establishment of an Australian Commission for eHealth (ACeH) was a recommendation by the Royle review into the PCEHR and the suggestion was supported warmly by the government.

A week later we received a list containing what turned out to be close to the full committee make-up from well-placed sources, and while the minister’s office stayed shtum, we published the names of five of them. Those tips turned out to be spot on and the government announced the full list for the grandly named Implementation Taskforce Steering Committee three days later.

Since then, silence. We hear that the committee members have been barred from speaking to the media and a distinct lack of returned phone calls bears this out.

Early in October there was good news for people living in rural and remote areas of the country when the NBN company announced it had successfully launched the first of its long-term satellites, which promise an increased capacity to provide telehealth services. While former communications minister Malcolm Turnbull once infamously claimed the satellites weren’t necessary as commercial operations could carry the load, he seemed to be mighty chuffed when Sky Muster rocketed upwards.

The peak bodies representing the health information sector – the Health Information Management Association of Australia (HIMAA), the Australasian College of Health Informatics (ACHI) and the Health Informatics Society of Australia (HISA) – got together to organise a summit on the looming shortages facing the health information workforce. HIMAA has been beating the drum on this for several years as the situation is becoming critical.

The summit, held in late October, heard that as many as one in three health facilities in Australia are facing vacancies they can’t fill for clinical coders, and one in five are facing the same challenge with health information managers (HIM).

October saw an increase in the already intense interest, particularly from the primary health networks (PHNs), about where the trial sites for the opt-out models for the PCEHR would be held. The government eventually released the selection criteria, and late that month the minister announced the two successful sites: Nepean Blue Mountains and north Queensland.

Confusingly, however, it was also revealed that the department was still open to ideas for innovative ways to boost participation in the PCEHR as part of the current opt-in model. While the current rate of opt-in participation is nowhere near the disaster some people make it out to be – it’s in line with local and international experience – the complete lack of basic marketing of the system over the last three and a half years has not helped.

The government’s legislation enabling the minister to run the trials and then move the system to an opt-out model, along with changing its name to My Health Record, authority to establish ACeH and other odds and sods, made its way through parliament reasonably quickly. While Labor supported the bill, it did recommend that the upper house have a think on the privacy aspects of an opt-out model.

Meanwhile, a parliamentary joint committee on human rights also questioned some of the privacy provisions, leading the privacy lobby to get its knickers in a knot and causing a bit of a flap in the media, but there was never any doubt the legislation would pass. For those who were around when the original legislation and concept of operations for the PCEHR was being developed in 2010, it was deja vu all over again.

A Senate committee duly held a quick-fire inquiry and recommended that the legislation be passed, which it duly was on November 12. We farewelled the Pecker, but My Health Record is still not gaining much love in the acronym stakes.

A bucketload of peak healthcare bodies got together in mid-October to demand action from the state and federal governments on doctor shopping and the glacial rate of movement towards implementing the Electronic Recording and Reporting of Controlled Drugs (ERRCD) system.

Comprising the Australian Medical Association, the Royal Australian College of General Practitioners, the Pharmacy Guild, the Medical Software Industry Association, the Royal Australasian College of Physicians, the Pharmaceutical Society, the Society of Hospital Pharmacists and the Consumers Health Forum, the organisations issued a strongly worded letter to assorted health ministers telling them that in the absence of action, “avoidable deaths involving prescription medicines continue to occur at an alarming rate”.

Information released under freedom of information showed that former health minister Peter Dutton had written strongly worded letters himself to two states in particular in 2014, urging them to get with the ERRCD program. This is an issue that is not going to go away, and we will continue to follow developments in the new year.

In good news for the newly renamed PCEHR, specialist letters are now being uploaded to the system. While neither NEHTA nor the Department of Health bothered to let anyone know, small numbers suddenly appeared on the department’s new My Health Record Statistics page on the ehealth.gov.au website, and when Pulse+IT asked politely what that was all about, we received an interesting answer.

St Vincent’s Hospital and its vendor partner Emerging Systems first developed the functionality, but according to NEHTA, the bulk of the numbers were coming from the Northern Territory. Specialist letters turned out to be just one of the clinical documents that are now flowing through to the national system as part of the NT’s M2N project, which in addition to NT Health, NEHTA and DoH, includes technology partners DWS, Chamonix and Ocean Informatics. Next thing you know, diagnostic imaging reports are popping up too.

Submissions to the feds on their proposals to tie “active and meaningful use” of the PCEHR to ePIP payments also started to flow, almost all of them resolutely opposed to the idea. The RACGP led the charge, making the very good point that the ePIP is a practice support payment, not one for individuals, and therefore should not be tied to an individual’s choice on whether or not to use the PCEHR by uploading shared health summaries to it.

The college also made the excellent point that GPs saw little or no value in the PCEHR as yet and that the system lacks basic utility. The AMA also rejected the PCEHR-ePIP link, although ACRRM hedged its bets.

The Australian Association of Practice Management (AAPM) argued that with multiple high-level reviews and projects already taking place, the last thing general practice needed was another big thing to deal with. “The industry is already fatigued by constant changes,” AAPM CEO Gillian Leach said.

Health Minister Sussan Ley gave a speech high on techno-jargon but low on detail to the National Press Club in late October. Ms Ley said she wants My Aged Care to be more like Trip Advisor and that she wants to give consumers “open source” access to their health data as part of a “great digital health revolution”.

“[Malcolm Turnbull] has made it clear we want to deliver a 21st century government that embraces the digital economy and health is no different,” Ms Ley said. “We need to embrace digital health and innovation in the health sector if we are to deliver integrated care.”

In its annual report released in November, NEHTA said it plans to spend its last months in operation concentrating on getting the pathology and diagnostic imaging sectors connected to the PCEHR and ensuring its IP is handed over to the new digital health agency that is being set up to replace it. The annual report repeated previous statements that NEHTA had “laid the foundations for eHealth” in Australia. Whether what has been achieved was worth the almost $1 billion in state and federal funding NEHTA received over the last decade is the question.

One area where Telstra Health has flown a bit under the radar is its work with the NT government and the National Health CIO Forum on building the National Telehealth Connection Service (NTCS). This service will allow hospitals and external healthcare providers such as GPs to hook into health-grade telehealth networks through a common platform that also handles scheduling, referrals and clinical document exchange as well as a virtual meeting room for video conferencing.

Telstra is working on helping out the NT first to get a whole host of Aboriginal Medical Services hooked up to health-grade broadband and secure video connections solely for telehealth, but over the next few years expect to see it working in other states. Telstra Health’s chief health information officer David Doolan says the company will build a platform that will allow existing state-based telehealth networks – which are pretty good – to connect to external providers, with Telstra providing the meat in the sandwich.

Pulse+IT also predicts we’ll hear a lot more about this next year: eForms in general practice software systems. While it may sound like pretty basic technology it is in fact very hard to do, especially considering the volumes of different forms GPs have to deal with and how to get the data they contain to integrate directly into receiving systems. It is hard work but secure messaging vendor HealthLink seems to have cracked it in New Zealand, and it is now coming to Australia.

As MedicalDirector’s medical director Andrew Magennis told us, the new eForms functionality that will be part of the next big release could very well revolutionise the day-to-day work of a GP. From next year, they will begin to be able to select forms, pre-populated with demographic and clinical data for the individual patient from their own PMS, and shoot it off with just the click of a mouse. While MedicalDirector is the first to announce the technology in its systems, it will soon enough be available to everyone.

As the year came to a close, DoH secretary Martin Bowles took to the international stage, giving a speech in New York outlining Australia’s approach to eHealth. Echoing Sussan Ley’s NPC address, Mr Bowles sees a big role for mobility and a smaller role for government, with the department simply providing the platform to share health data and the private sector picking up the ball and running with it. Both the minister and the secretary have outlined their commitment to the My Health Record for the foreseeable future, so despite all the hand-wringing and the naysayers, it looks like they are ready and willing to get on with it.

Acute care

It’s a brave move to be sure to rip out clinical systems that have only been in place for a couple of years and install in their place a new system from a sole vendor, but that’s exactly what Macquarie University Hospital in Sydney did this year. It is still having to deal with paper, but it now has an end-to-end solution using InterSystems’ TrakCare. Digitising pre-admission, integrating medical devices and creating a patient portal are next on the list.

After threatening to become Queensland’s version of how not to do hospital IT – or at least, unlike Fiona Stanley Hospital and Royal Adelaide, able to keep it out of the papers – Brisbane’s Lady Cilento Children’s Hospital (LCCH) received a cash injection of $5.8 million to support the roll-out of the state ieMR. LCCH had major problems with its medical record when it opened last year, as half of its staff and patients had come from the Royal Children’s Hospital (RCH), where an electronic medical record was in use, and the other half from Mater Children’s Hospital (MCH), where one wasn’t. An independent review found that MCH staff were not given enough training, and upon opening, sick kids were presenting with no medical record in sight.

In a big year of news for paediatric hospitals, attendees at the HIMAA conference in Sydney in October got a glimpse of the extraordinarily detailed work going on behind the scenes as the Royal Children’s Hospital in Melbourne prepares to go live with the first implementation in Australia of an Epic EMR. The $48 million system will be switched on in full next April, qualifying immediately for HIMSS Stage 6, with only patient administration, radiology and pathology not planned to go live. RCH is using existing systems for the time being.

Rumour has it that people set to staff the new Perth Children’s Hospital also wanted an Epic EMR, and that Epic won the tender for the new hospital, but those plans are now on the backburner as WA Health tries to standardise statewide systems. PCH will instead get the BOSSnet DMR being used at Fiona Stanley Hospital as an interim measure. WA Health says the tender is still being evaluated, but so is the opening date of the hospital itself.

Handing down what everyone hopes is the last report into the bungles and breakdowns that have marked the short but chequered career of Fiona Stanley Hospital, a parliamentary committee ably headed by Liberal MP Graham Jacobs called on Health Minister Kim Hames to clarify exactly what is happening with the roll-out of health IT in the state’s hospitals. The committee also took a swipe at WA Health for its failure to provide relevant information to it on the performance of ICT at the hospital.

Dr Hames has come under increasing pressure over his handling of his portfolio and has announced he will retire at the next election. In the meantime, some good news is coming out of the $2 billion facility, including a smart way to boost the use of telehealth that is being adopted statewide.

Bucking the trend for hiccups in the west was St John of God Midland, which opened on time, on budget and with no worries. It is using Emerging Systems’ clinical information system EHS, which is likely to be rolled out at all St John of God hospitals over time.

Meanwhile, there’s Royal Adelaide …

Primary care

Prescription exchange service eRx released its 2015 Pharmacy eHealth Survey report in October, which showed that “paper-optional prescriptions” were the next electronic step for the community pharmacy sector with 62 per cent of pharmacists believing they could help prevent fraud and misadventure. However, while the majority of pharmacies were capable of electronic transfer of prescriptions (ETP), their biggest concern was that many of their local GPs were not.

The Pharmacy Guild fought a rear-guard action against plans to reschedule painkillers and cold and flu remedies containing codeine to prescription-only status. Rather than take that step, which modelling it commissioned showed could cost the government $316 million a year, the Guild instead argued that a real-time monitoring and clinical decision support tool would be a better option to combat misuse. In fact, the Guild already had the very thing. After some fierce behind-the-scenes argy-bargy, a decision on the rescheduling was delayed for a year, and the Guild promised to get onto the system roll-out quick-smart.

The problem of wrong scripts populating the PBS data on the PCEHR popped up again in November. We were told by the Department of Health that complaints to the PCEHR helpline about this problem are very rare, but we would argue that it probably happens a hell of lot more than is reported considering the enormous volume of scripts written and dispensed every day.

As we have also argued, it is only when PBS data is viewable on an individual’s record that mistakes are uncovered. We, like our consumer, remain irritated that it is up to the individual to approach the suspected pharmacy to attempt to sort the problem out, and we, like our consumer, remain angry that it takes vague threats of bad news stories on Pulse+IT for the helpdesk to escalate this problem to someone who can fix it.

Aged care

Telstra Health invested further in the aged and community care sector when it picked up EOS Technologies, the IT arm of WA-headquartered district nursing organisation Silver Chain. EOS makes the ComCare community care management system used by Silver Chain nurses. The company will become part of Telstra Health’s wholly owned subsidiary HealthConnex, which also makes the community care software product TCM. Both TCM and ComCare can be integrated with Telstra’s MyCareManager home device through a FHIR interface and client data viewed through its portal. Telstra also owns the market-leading residential aged care software package iCareHealth.

Dominating the last quarter of the year in aged care IT was the ITAC conference on the Gold Coast. There seemed to be a general consensus that moving responsibility for aged care back to the Department of Health was no bad thing, but it was also obvious that industry players, particularly providers, were a bit tired and emotional after the multitude of changes that have been thrown at them since the last government’s Living Longer Living Better reforms. Everyone agrees that CDC is the right way to go, but they also agree that it is hard.

Problems with a backlog of referrals for aged care services caused by new functionality in the My Aged Care system, which went live on July 1, were canvassed by DSS’s Fiona Buffinton in a keynote address. She promised to do better, including ratcheting up plans to link My Aged Care with My Health Record.

Hills Health Solutions was on hand to launch its beautifully designed, silicon-based pendant for nurse call systems aimed at people with arthritis, Telstra Health announced it was working on an iOS version of its MyCareManager app, and Health Metrics announced it was integrating SimaVita’s ‘electronic underpants’ incontinence system with its eCase electronic care plan solution.

But the big winner was Webstercare, which took out the title of ICT company of the year for its RxMedChart, a computer-generated version of the National Residential Medication Chart (NRMC). This promises to massively improve medications management – prescribing, dispensing and administration – in residential aged care and for the first time will allow GPs to prescribe from the chart without having to write a separate script. More on that next year.

Some of the more interesting software, apps and new players in the market that caught our eye in the fourth quarter included:

We hope you have enjoyed this series of eHealth year in reviews. If you missed out on any of the other instalments, you can catch up with:

Pulse+IT is taking a three-week break and will be back on deck on January 11. Have a lovely Christmas from Simon, Kate and Emily.

The hot top 20: most-read stories on Pulse+IT in 2015

The emergence of HL7’s FHIR standard proved a popular topic for Pulse+IT readers this year, joining perennial favourites such as the PCEHR, primary health networks/Medicare Locals and the Telstra Health juggernaut with several entries in the top 20 most-read stories.

Any news on three particular hospitals – Perth’s Fiona Stanley, St Stephen’s at Hervey Bay and the new and old Royal Adelaide – also drew in the eyeballs, for reasons both good and bad.

But it was an ambitious, long-term, well-written strategy from a state government, accompanied by a billion-dollar price tag, that scored top spot this year. eHealth Queensland has appointed a new CEO/CIO in Colin McCririck to oversee the work. Good luck to him.

1. The Queensland government stepped boldly into the future with its 20-year, $1.26 billion health ICT strategy

2. After buying up big, Telstra Health began to show its strategic hand

3. There were few new faces when the successful bidders for the PHNs were announced

4. Telstra’s investment in eHealth topped $100 million in February, but is about double that by now

5. Telstra Health’s subsidiary HealthConnex was behind the launch of this FHIR-powered telehealth solution

6. The federal government came through with some big bucks to “reboot” the PCEHR

7. FHIR-starter Grahame Grieve explained why eHealth interoperability is so hard

8. Fiona Stanley Hospital has an enduring IT headache

9. Telstra launches its ‘doc around the clock’ telehealth service

10. General, specialist and allied health practices were warned about opening Windows

11. The cuzzy bros announce plans to build a a national EHR

12. The future of NEHTA and the PCEHR hung in the balance

13. The company formerly known as Sonoa Health explained its plans for world domination

14. NSW goes all out for Cerner for EMR and EMM

15. All eyes on Royal Adelaide Hospital and the ongoing EPAS saga

16. General practice was up in arms over plans to tie ePIP payments to the PCEHR

17. St Stephen’s Hospital has integrated medical devices with its EMR

18. The $33 million Diabetes Care Project came to an unfortunate end

19. Large and small vendors are increasingly keen on playing with FHIR

20. DoH special adviser Paul Madden has a big, complicated gig.

Anything you’d like us to cover in more depth next year? Let us know.

The 2015 eHealth year in review: part three

July got off to a bright start with the go-live of the electronic referral and central client record aspects of the My Aged Care (MAC) system, or so it would seem. Some early teething problems became quickly apparent as an underestimation by the Department of Human Services (DHS) of demand for the system caused a backlog of referrals, and a failure to consult GPs on how they’d like to use the system caused an explosion of complaints.

These petered out quickly enough after a month or two but they may have been behind the decision to delay adding aged care assessment teams (ACATs) to the assessor portal until next February. In the meantime, the aged care industry continued to call for a link to be established between the MAC and the PCEHR systems.

On the PCEHR, the Department of Health released a report by Deloitte that summarised the outcomes of a series of public consultations held last year following the release of the Royle review into the system. The paper found that a significant majority of those consulted supported the concept of the PCEHR and wanted to see much more widespread adoption. There was also support for the opt-out model, and we began to hear a lot more about the concept of “meaningful use”.

The RACGP made its opposition known on linking uploads to the PCEHR with receiving certain payments – in this case, claiming MBS items for creating care plans. The reaction of several groups later in the year to suggestions that ePIP payments be tied to meaningful use could only be described as going ballistic.

In the ongoing EPAS saga, SA Health revealed that contingency plans were being developed to ensure legacy systems could be used at the new Royal Adelaide Hospital should EPAS not be ready in time for the hospital’s opening. This news came just months after it was announced that SA Health was abandoning plans to implement EPAS at the existing hospital to wait for the new one to open.

SA auditor-general Andrew Richardson reported that there were also potential risks for the $19 million state-wide medical imaging system ESMI and its implementation at the new RAH, and it later became clear that the problems with EPAS would have a flow-on effect on the Enterprise Pathology Laboratory Information System (EPLIS), as the latter was reliant on an interface with the former.

The federal government has never admitted it made a mistake when it axed the after-hours GP helpline run by Healthdirect Australia in the May budget. Some GPs deplored the service as a waste as there was no evidence it was reducing low acuity presentations at emergency departments, but it soon became obvious that the service was valuable enough for rural and remote areas as the decision was quickly reversed. Funding, albeit for a reduced scope, was quietly restored.

The Queensland government then began to roll out a few announcements about health ICT, delivering a nice $179 million in the July budget along with some money to ensure that the operational commissioning of the Sunshine Coast Public University Hospital (the ‘public’ in the name has since been dropped) did not suffer the same ill fate as Lady Cilento Children’s Hospital.

Upon further inquiries, it turns out that most of the money was for the continued roll-out of the Cerner integrated electronic medical record (ieMR) as well as an oncology management system and an interoperability platform for information sharing. There was no money this year for a replacement for the ancient HBCIS patient administration system, although Queensland Health said this was a priority and was being planned.

Six weeks later, Queensland Health would unveil an immense, detailed and far-reaching strategy for health ICT, set to cost a seemingly immense $1.26 billion over 20 years. The strategy estimates that $730 million will be required for clinical software alone, with a further $300 million for ICT infrastructure, $100 million for business systems and $130 million for the interoperability platform and related standards.

Of the $730m for clinical software, a probable $210m will be required to replace HBCIS, $75m will be needed for a new pathology system, and a further $376m will be needed to roll out the ieMR to a further 25 hospitals. This will be a huge job for eHealth Queensland CEO/CIO Colin McCririck, who was appointed to the role just last week after acting as CTO since the start of the year.

Mr McCririck has already had to fend off accusations put to him by we reptiles in the media that the budget for the ieMR at the first nine hospitals it was implemented in had been massively overrun. He rejected those claims – although our source is sticking to their guns – but did admit that the move to roll out release three of the ieMR, aka the Digital Hospital release, at Cairns Hospital would be delayed until next February. The release went live at Princess Alexandra Hospital in November and we reptiles have heard nary a peep of discontent.

While Queensland continues on its bold path towards digitisation of its hospitals, the dramas surrounding the original and the best have never stopped. An independent review into clinical services and patient care at Perth’s Fiona Stanley Hospital (FSH) found that IT systems, which were blamed for delaying the opening of the $2 billion facility in 2014, were still causing headaches for clinicians and patients.

The review found problems with the patient entertainment system, the cardiac telemetry system, the BOSSnet digital medical record and with the IT helpdesk. This report was then followed by a parliamentary inquiry into the transition to and operation of services at FSH, which heard explosive evidence from a senior doctor in August that little if any of the clinical IT worked as hoped. While the criticism of the IT may have been a bit harsh, it was nothing like the tongue-lashing he gave to the health department.

Later in the year, this committee would report that many of the problems with clinical IT seem to have been overcome, but even the Liberal members of the committee were critical of the performance of Health Minister Kim Hames.

Back in Queensland, a state coroner echoed her counterparts in Victoria and South Australia in calling for a new system to be implemented with some urgency to provide information in real time to doctors and pharmacists dealing with potential prescription shoppers following the death of a Toowoomba nurse from an overdose of prescription opioids. The calls were backed by the RACGP the the same week, and the Pharmacy Guild also began to ramp up the pressure.

Queensland also hosted this year’s Health Informatics Conference (HIC), where state health minister Cameron Dick announced the formation of eHealth Queensland, bringing together the responsibilities of the Health Services Information Agency (HSIA) with the office of the chief health information officer. Also at HIC, federal health minister Sussan Ley argued that the PCEHR did not need to be perfect but it did need to be functional, practical and beneficial, which it clearly wasn’t.

In some positive news for the PCEHR, a NEHTA report found that the benefits being experienced with the Northern Territory’s My eHealth Record “validated the value proposition” of the PCEHR if the national system could follow the local solution in gaining a critical mass of users.

There was also positive news for telehealth, with the results of the CSIRO’s NBN-enabled telehealth project showing that at-home monitoring of vital signs in older patients with chronic disease can lead to significant savings over time and can also reduce mortality rates by up to 37 per cent.

The Abbott government went through with its threat to defund research body National ICT Australia (NICTA), in effect forcing it into a merger with the CSIRO to have any chance of surviving. To be renamed Data61, the merged entity was then later partly re-funded by the Turnbull government as a piece in its $1.2 billion innovation program. Mr Turnbull therefore had the odd experience of both defunding and re-funding ICT research within the space of four months.

Taking a gamble due to a distinct lack of information emanating from the minister’s office, we reported that no decision had been made on the location or design of the trial sites for opt-out models of the PCEHR, and there was no sign of the bill that would enable an opt-out model to happen. We were right on the first claim but looked pretty foolish three days later when the minister popped up in parliament with some name-changing legislation.

As we looked forward to the last quarter of the year, the Department of Health put a cat among some very unhappy pigeons when it released a discussion paper suggesting that the eHealth Practice Incentive Program payment (ePIP) be tied to real and meaningful use of the PCEHR. DoH figures showed that despite the majority of general practices claiming the ePIP, very few were using the system. While the discussion paper canvassed other options, it was this suggestion that got some blood boiling and a mooted start date of February 2016 caused some extreme hyperventilating.

Acute care

The Sydney Adventist Hospital announced it had chosen EpiSoft’s Cancer CareZone cloud-based clinical information system for the new Integrated Cancer Centre the San is building as part of its $200 million redevelopment.

Significant delays in building and commissioning Brisbane’s Lady Cilento Children’s Hospital (LCCH) caused excessive workloads on ICT staff both during the build and at the time of practical completion, leading to a budget blow-out and reduced scope of integration, the final report into the commissioning of the hospital found.

Embattled WA Health Minister Kim Hames announced he’d delay the opening of the $1.2 billion Perth Children’s Hospital (PCH) if necessary if it meant avoiding the same problems experienced with the commissioning and opening of Fiona Stanley, while his Queensland counterpart Cameron Dick hired a commissioning expert for the Sunshine Coast University Hospital try to avoid the problems that plagued Lady Cilento.

Primary care

General practices were abuzz with incoming advice from software vendors in July when Windows 10, the well-received replacement for the disastrous Windows 8, was released. Over-enthusiastic early adopters of new operating systems have been known to break software, especially programs that have interfaces with third-party, external systems such as Medicare. It all seems to have gone quite smoothly, however, with no reports of blue screens of death.

Primary Health Care’s new MD Peter Gregg announced his first financial results following the retirement of founder Ed Bateman. The company is looking to increase its portfolio of multi-disciplinary medical centres in Australia as well as use the strategic position of its wholly owned health IT subsidiary MedicalDirector to develop new income streams or to potentially find a buyer for all or part of MD. Mr Gregg alluded to potential problems as uncertainty over the federal government’s intentions on bulk billing for GP and pathology services undermined confidence in the profitability of the primary care sector. Primary’s share price took a hammering later in the year.

There were also some interesting moves in terms of mergers, acquisitions and investments in companies active in the primary healthcare sector, including the the purchase of online booking system Appointuit by Jayex Healthcare, which would go on later in the year to list on the stock exchange. Sonic Clinical Services, the Sonic Healthcare division that also includes IPN, made a strategic investment in Tasmania’s GP2U, along with Medical One founder Andrew Pascoe. Sonic Clinical Services was also busy buying Precedence Health Care at this time in an interesting move that we will keep our eye on. A bit of trivia: the original founder of Sonic Healthcare, Michael Boyd, is the new executive chairman of Jayex Healthcare.

Aged care

The aged care industry is a very patient one, not known for getting antsy, but even the nicest of sectors has its limits. In late July, the two aged care peak bodies took the extraordinary step of asking for an apology and, heaven forbid, financial restitution from DSS and DHS over two years of breakdowns in electronic claiming. Some not-for-profit aged care providers were owed up to $3 million at one stage, causing massive cash flow problems.

The 2013 decision to move aged care from the Department of Health to the Department of Social Services (DSS) was reversed in late September following new Prime Minister Malcolm Turnbull’s ministerial reshuffle, with Health Minister Sussan Ley quick to claim ageing and aged care back to her portfolio once former aged care minister Mitch Fifield was diverted to the communications portfolio. Ageing moved back in dribs and drabs in November and December, raising the question of why the split had been ordered in the first place.

The Queensland government funded a new portal called the Community Care Smart Assistive Technology Collaborative Platform that its developers plan to use as a one-stop-shop for information on smart assistive technologies. The project won an ITAC award later in the year. While wearables are the technology du jour for the fit and the worried well, it’s in aged and community care where they are most likely to have a lasting effect.

In a big year for Telstra Health’s wholly owned subsidiary HealthConnex, the Victorian company launched a new version of its The Care Manager (TCM) case management software for aged and community care that can interoperate with the company’s MyCareManager client portal through a FHIR interface. HealthConnex also designed the MyCareManager device to work with FHIR and has been at the forefront of releasing it into the wild. It also launched a new version of its ConnectingCare secure messaging and referral platform for community care organisations that is interoperable with the Argus secure messaging service widely used by GPs, which HealthConnex also owns.

Some of the more interesting software, apps and new players in the market that caught our eye in the third quarter included:

As we will cover in the final instalment of our eHealth year in review tomorrow, a vague threat to the legislation enabling an opt-out PCEHR arose in October when a federal parliamentary committee on human rights asked some questions about the privacy implications of the model. This caused a minor sensation in some media quarters but we pretty much ignored it. The legislation had bi-partisan support and despite Labor in the lower house asking its colleagues in the upper house to hold a quick-fire inquiry, the legislation was always going to pass. And so, as we saw when the year came to an end, it did.

Missed the first instalment in this series? Here it is: The 2015 eHealth year in review: part one

Then get a load of the second: The 2015 eHealth year in review: part two

Pharmacy error again to blame for incorrect scripts on My Health Record

A series of errors by a pharmacist has been blamed for incorrect data about six prescriptions appearing on one consumer’s My Health Record last month.

The consumer contacted Pulse+IT after finding six scripts that were not prescribed for her in the Pharmaceutical Benefits report section of her My Health Record (MyHR, formerly PCEHR). The section receives an automatic feed of new dispensed prescriptions for that patient from the PBS.

In this case, six prescriptions for a combination antibiotic, a contraceptive pill, a different antibiotic, an asthma inhaler and an oral corticosteroid were incorrectly recorded as being dispensed to the consumer on three different days in 2014.

The consumer was advised by Pulse+IT to ring the PCEHR hotline to have the data removed from her record as soon as possible, but when she rang on a Sunday, was told to ring back on Monday as weekend staff did not have access to individual records. When she rang back on Monday evening, she was told to ring back during business hours.

Like Pulse+IT’s own situation, the consumer was told it was likely an error at her regular pharmacy and that she herself would need to contact the pharmacist to find out how the data was added to her record. Unhappy with this, the consumer pressed for more information and was given a number to ring at the PBS. When she rang that number, she was referred back to the PCEHR helpline again.

She then rang the MyGov helpline, given the same number for the PBS and was transferred to another line, which turned out to the PCEHR helpline again, where she was put on hold.

Not impressed, the consumer contacted Pulse+IT again. We raised a bit of a stink with a Department of Health contact, who then arranged for someone at DHS to call the consumer personally, and she was soon contacted, given instructions on how to remove any incorrect documents from view, and told that the situation had been referred for investigation by Medicare.

She was then contacted by email and told that Medicare had investigated the six items in question and had spoken to the pharmacy.

“The pharmacy had submitted incorrect patient information resulting in the items appearing in your record,” a DHS representative wrote in the email. “This has now been corrected and the items have been removed from your record.

“It would be appreciated if you could please log on to your eHealth record and confirm these items are no longer appearing. On receipt of your confirmation we will consider the issue resolved.”

However, the consumer wanted some more answers on exactly why and how this had occurred, so was provided with the number of a person at the PBS – the same PBS that she had previously tried to call but had been passed back to the PCEHR helpline.

The PBS representative confirmed that it was a pharmacy error but could not say which pharmacist or pharmacy due to “privacy reasons”. It appears that another person with the same name as the consumer presented at the pharmacy and their script was put against the consumer’s name in the pharmacy system, but that does not explain why it happened again four months later, as the scripts were not a repeat.

Finally defeated in trying to understand the intricacies of the PBS claiming system, the consumer now considers the situation resolved.