Lessons on implementing the PCEHR in aged care
Melbourne's mecwacare recently became the first aged care provider in Australia to upload an event summary to the PCEHR at one of its three residential aged care facilities, and is now gearing up to get the other two facilities onboard.
It certainly has not been a straightforward journey for either mecwacare or its software provider, iCareHealth, but both organisations hope that the lessons learned can provide some guidance for other providers looking to register for the system.
mecwacare's CEO, Michele Lewis, said there were a number of challenges involved and she urged the powers that be to streamline the system, but said both she and her staff were keen to participate in the hope that the promised benefits of eHealth, particularly access to full and up to date information on their residents, could be realised.
“Our staff were really keen to be able to implement eHealth and the biggest reason was that it gave them real-time, up to date data for our clients,” Ms Lewis said.
“People are coming in these days with much higher levels of co-morbidities, much older and much more frail, so having that strong medical history on that record is something that will make our nurses' jobs much easier.
“The other thing that they were keen on is that things would be faster, more accurate and more secure. The hope is that it will save our staff time and other practitioners that are coming in to see the client, it saves them time as well.”
mecwacare has had the good fortune to have two staff members who have championed the idea: Nicholas Hill, the organisation's quality advisor for residential services, and Jill Cairney, its health and safety advisor and officer in charge of iCareHealth and documentation, both of whom are part of mecwacare's quality and risk department.
Mr Hill has taken the lead in going through the notoriously time-consuming registration process, and both have worked closely with iCareHealth to test and try out the system before going live in late June at the organisation's 60-bed Sir Donald and Lady Trescowthick Centre in Prahran.
Mr Hill said he registered the organisation for its HPI-O in October last year and the networks in January this year. For Mr Hill, two of the big challenges have been keeping up to date with paperwork, and the “acronym soup” that invariably accompanies any new IT system.
“One of the challenges was knowing when forms might get updated from Medicare,” Mr Hill said. “There is a range of forms to register the organisation, to register the network and also register for participation in eHealth records, and if those forms get updated or changes are made, it's difficult to get alerted to that.
“My advice for other organisations is that obviously you need to be aware of the forms you need to fill out but in some way get informed if they get updated or changed. You do need to keep on top of it. I'm a bit complacent now because once you've done a few forms you realise the style, so it does get a bit easier as you work through them.”
Ms Cairney said the system is “quite complex and there are a vast array of acronyms”, so it was very important for the organisation to have a staff member keen to take the system on board and to champion it.
Mr Hill said that as the terminology is complicated, his advice is to try to demystify it. “If they had called the system the Bob Brown most people would have been a bit more friendly and accommodating towards it,” he said. “We've developed an action plan and at the bottom of the action plan is an abbreviation list. That helped out a lot.”
Mr Hill said he was keen to take part as he could see the benefits of the system in the long run.
“I've worked long enough in the industry to see its complexity, and information management is one of the big challenges that we have. There was an opportunity to address that in some way. It is another tool – that's the way I saw it.”
Getting nurses and GPs registered
Ms Cairney and Mr Hill both worked with iCareHealth to ready the system for use, including using it in a test environment to create records and upload and download them. At mecwacare, the only people who have access to residents' records are registered nurses and visiting GPs, who all have their HPI-Is registered within the system.
“There are three GPs registered with HPI-Is in our system and they see the majority of the 60 residents within that home,” Mr Hill said. “All three GPs were happy to come on board. Two work in the same practice, which was already eHealth-ready, and the other doctor was more than accommodating.”
Only nurses with an HPI-I have access to the eHealth tab within iCareHealth, and while other staff can see the eHealth tab, they can't access it, Ms Cairney said.
Nurses wanting to use the system must obtain their allocated HPI-I from AHPRA, and then they are registered with the HI Service through HPOS, using the organisation maintenance officer's (OMO) PKI certificate. Their HPI-I also needs to be registered within iCareHealth.
For GPs, it is important that they register with the organisation and the network where they are going to be visiting, Mr Hill said.
“They can only register for the network where they visit – we can't register them for somewhere where they don't see residents,” he said. “That is part of the policy and procedure. But from a PKI/NASH point of view, depending on the IT system, they might be here but the communication with the PCEHR might be with the organisation, so it is important to register them in both areas.
“And that is essentially it. They are then using our system to access eHealth records and they fall under our privacy obligations and our policy and procedures. If they access eHealth records from their own practice then they are under their own privacy obligations and legislation.
“It is one thing for organisations to be aware of – whoever is using their system, the responsible officer (RO) of the organisation is responsible for the activity of each person. In essence we sponsor GPs and other health professionals through the use of our system. It is a bit of a caution for other organisations to be aware of.”
Getting residents registered
In terms of registering residents, mecwacare started out with one who was happy to participate and sign up for a PCEHR, and that was the resident for whom the event summary was created. The resident does not yet have a shared health summary, so the event summary consists primarily of a basic progress note.
While shared health summaries and hospital discharge summaries will provide the bulk of health information for each resident, the event summary will also be hugely important for aged care. The summary has been designed to allow free text notes to be uploaded, thus providing a truly up to date record of important healthcare events.
A major challenge all aged care providers will face is getting residents registered in the first place. Mr Hill hopes that in time, residents will have a PCEHR before they enter the facility. In the meantime, aged care providers can use the assisted registration tool (ART) to register clients, but there are severe restrictions on this as well.
“We can assist residents to sign up to the PCEHR but there are some very strict rules around assisting people to do so,” he said. “The main one is that you need to use the assisted registration tool that is provided by the government, and you can only sign up cognitively intact residents.”
For residents with cognitive impairment, the person with medical power of attorney can do so, but they must go to a Medicare office or register by phone. Several people recently commented on a letter to the editor published by Pulse+IT in which one GP showed just how difficult it could be to register people who are not able to do so themselves.
Emphasising that it is his personal opinion, Mr Hill said the focus must be on getting people signed up to eHealth before they get to aged care.
“You can't be reliant on the industry to be the driver of recruitment around this,” he said. “Once people get to aged care they are not necessarily cognitively intact and it can be an issue. I believe people should be signed up before they get here, at a GP level or a hospital level, before they come into aged care.
“A comment made from someone outside the organisation was that if they had their time again, if they'd just focused on aged care from the very beginning, and not the acute sector, you might have found a lot more use for it or a lot more positive take up of it.
“For us, to a degree, our clients are the children of the residents. They want to know that mum and dad's health information is being managed well.”
Mr Hill said the main challenge facing mecwacare now was providing the right information to residents and families about the benefits and getting them signed up. “While I might not like it too much, that is our role at the moment because there is no one else really driving it.”
Advice for other providers
Mr Hill and Ms Cairney have provided the following advice for other providers looking to participate in the PCEHR.
- Set up: all organisations need to evaluate their additional IT requirements, as they might find that the system now uses more RAM, Mr Hill said. “It's important that they see what their hardware capabilities are. That was one thing we came across as we worked through – the new version of iCareHealth uses more RAM than the previous version.”
- Research: “There have been a lot of publications in the last six months with flow charts and brochures for providers, so research, research, research,” he said. “Compared to 12 months ago, there is a lot more information now so know what your requirements are.”
- Action plan: Mr Hill strongly recommends that providers write an action plan. “One of the challenges is what steps you can take at what stage. There are some avenues you need to go down before you can go to the next step. You can't get eHealth record information without the right software, without the right certificates. Understand that part and properly document it.”
- Acronyms: create a glossary of the different terminology and acronyms used, as you will need it.
- Education: both Mr Hill and Ms Cairney say it is essential to educate not only the residents and their families, but colleagues as well. “There is a fair bit of learning, at least a couple of hours, for people within the organisation to be able to understand what the requirements are,” Ms Cairney said.
- Policies and procedures: “There are three key policy requirements, one being participating in the PCEHR system, a policy around the ART tool, and you also need a policy in relation to NASH certificates,” Mr Hill said. “And it is important that you have someone who is going to use the HI Service so you need an individual PKI certificate to access the HI Service. You can do a lot of forms by using HPOS.”
One of his prime tips is about how the RO goes about registering the seed organisation's OMO. It is possible for the RO to sponsor the seed organisation's OMO so that they don't need to provide 100 points of identity verification.
“Don't do that,” he said. “Get the seed organisation's OMO and the RO to provide 100 points. That means you can use the HI Service more effectively. The RO is typically going to be the chief executive. The seed OMO should be someone who has within their normal working day time to manage the system.”
While there is a huge amount of work that needs to be done in getting started, mecwacare believes it is worth it in the long run. The organisation now plans to focus on rolling it out to its two other facilities in the next few months.
Mr Hill said the team will need to start talking a lot more to the residents but also to their families, so information evenings are being planned. “Our Medicare Local office is also quite supportive in the way they are giving their time and coming to speak to residents as well,” he said. “It is about getting the information out to people at this stage and getting them signed up.”
Ms Cairney said that while it will take time to get used to the system, she believed that the use of the system will eventually become part of nurses' normal documentation processes over time.
“Because it is built into iCareHealth they don't have to access a separate system and that's really important, because anything that can save time is a benefit,” she said. “For aged care, it will predominantly be about communication with hospitals – specialists to a certain extent, but predominantly hospitals – and that communication pathway is sometimes really tricky.”
This is something that CEO Michele Lewis agrees with. She believes that in addition to access to information for aged care nurses and visiting GPs, the main benefit will be in the relationship between aged care and acute care, particularly in alerting hospital clinicians to the wishes of residents.
“There are two issues around the interface with a hospital,” she said. “One is when a resident goes into hospital and they get treated actively whether they like it or not.
“You might have a 93-year-old or a 95-year-old who has had a fall, and [hospital clinicians] are actively engaging them in treatment when the family might have clearly outlined in the aged care facility that their end of life wishes are a dignified, calm death.
“The idea of having a record that the hospital can actually look at and it stares them in the face that they don't want active treatment, they are just there for assessment and guidance in how to care for them given what has happened, that is critical.
“In the same way, when they come out we get a discharge summary so we can look at it and see what they have done, why they have changed the medication. If we could get some of that information then the resident's wishes are better respected, and we are able to deliver care more accurately because we understand the thinking of the people in the hospital, so there is no tyranny of distance.
“If you are there in the nursing home and wondering why they have changed this medication, you can't just pick up the phone and ring the doctor. It doesn't work that way. Whereas if you have a good understanding through their records, through the discharge summary, then we would have way better resident outcomes and a healthier and happier resident, or a person who is at least dying with dignity.
“Aged care is about understanding people’s wishes and their needs.”
Ms Lewis said her advice for other aged care providers looking to take part was that it is a good idea, but there is a “lot of education needed, a big time commitment, and a lot of documentation. It's not for the faint hearted but if you want better outcomes for your clients, it's a good thing to do.”
Posted in Aged Care