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.”

Posted in Australian eHealth

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