PCEHR deployment the WentWest way
Amidst all of the debate, the criticism and the acronym soup that is the government's national eHealth system, one Medicare Local in western Sydney is quietly putting some runs on the board and showing how the roll-out of the system may work in practice.
If the PCEHR is indeed ever going to work at all, then the sprawling suburbs of Greater Western Sydney could prove to be the crucible. This massive region, home to approximately 1.5 million people and dotted with many different cultures, religions and ethnicities, has high rates of chronic disease and low rates of socio-economic advantage, but it is also where the potential benefits of an electronic health record system appear to be the most promising.
This is one reason why the Greater Western Sydney region was chosen in 2011 as a test site for the implementation of the PCEHR under the Wave 2 program, and where in 2013 the actual system is being rolled out and used.
Last year, Western Sydney Medicare Local (WSML) began working on implementing aspects of the PCEHR in 50 of its practices, assisting them through the paperwork and some of the configuration of their software systems to allow them to access and use the PCEHR.
Western Sydney Medicare Local – better known as WentWest – was part of the Greater Western Sydney Wave 2 site along with its neighbour and close partner, Nepean Blue Mountains Medicare Local. The two organisations are continuing work started as part of Wave 2, which has now been incorporated into NSW Health's HealtheNet program.
This work includes developing electronic discharge summaries from local hospitals, rolling out the three new repositories for NSW clinicians – a clinical repository, an enterprise imaging repository and an electronic Blue Book for mothers and newborns – as well as an enterprise service bus for NSW Health. The electronic Blue Book is now being incorporated into the PCEHR.
In addition to this, for the next 18 months WentWest is concentrating on rolling out the PCEHR, starting with general practices in its region. WentWest is well placed to help coordinate this work, having identified a number of forward-thinking practices during the Wave 2 project that are keen to embrace eHealth.
These include large practices such as Kildare Road Medical Centre (KRMC) in Blacktown – which has a roster of 19 GPs, six nurses, a number of allied health professionals and an associated pharmacy – along with smaller practices such as the two-man Mt Druitt Medical Centre, headed by Dr Kean Seng Lim.
Both of these practices have put their hands up to become test subjects for the PCEHR, and last year both were at the forefront of using the actual production system. KRMC was the first in NSW to directly upload a shared health summary using Zedmed, and Dr Lim's practice was the first to upload a summary using HIE's Companion Gateway through Medical Director. It has also used the Pen Sidebar tool to do the same.
But while there are a core of practices keen to be part of the system, western Sydney is also a perfect example of where there is some resistance. The area has a relatively high number of solo GPs and some practices that are not accredited or even computerised.
WentWest has chosen 50 'category one' practices that it works very closely with. Paul Campbell, project manager for the PCEHR implementation at WentWest, said the organisation has a contract with NEHTA to engage and register these 50 practices for the system, help them go live, and then work over the next 18 months or so to help the other practices to register and become familiar with the system.
In addition to 15 practices that are now live, another 82 are in the process of being registered, and the remaining 250 or so are able to use the resources developed by WentWest to navigate the complex system. The WentWest team was fortunate that most of the 50 category one practices had taken part in the Wave 2 project, so were already registered for their HPI-Os and were enthusiastic about continuing the work, Maria Pipicella, the PCEHR deployment project manager for WentWest, said.
“Early on we employed a business analyst and part of his role was to work with the team to segment out practices,” Ms Pipicella said. “Our deliverables were to engage 50 practices to register and go live, so we did some needs analysis of our practices, and those first 50 were the innovators and the really active practices in terms of IT systems and data cleansing.”
It certainly was not all plain sailing, however. When the system was first introduced, there were many concerns over medico-legal issues, and the deadlock over whether GPs could claim longer MBS consultation numbers was also a bit of a stumbling block, Mr Campbell said.
“Eventually we were able to answer the medico-legal issues because we got NEHTA legal people involved doing presentations about what the insurance companies were saying,” he said. “The government then said if it does take a little bit longer to upload a shared health summary, then you can charge the next level up . So those concerns went away, and now it is, 'yes we are interested, let's get on with it, how can you help us with it?'”
WentWest is now is sending out a dedicated three-person team to practices to help them to use the PCEHR. Funded by NEHTA, the team is working in practices daily to methodically sign them up to the process.
“That has been valuable in giving practical support,” Ms Pipicella said. “There is some hand-holding to some extent to step them through the process. Practices get bombarded with so many documents and so many messages, and sometimes they just need someone to break that down, step by step, to say do this and move on to the next step.”
The PCEHR team has put together a practice toolkit to provide those step-by-step instructions, she said. The toolkit includes all of the application forms required for registering for the Healthcare Identifiers Service, for an HPI-O, registering for the PCEHR, and acquiring the correct security certificates.
Previously, practices had to first fill out a “seed” application form, which hooks the practice up to the HI Service, gets it allocated an HPI-O and asks the practice to appoint a responsible officer (RO) and an organisation maintenance officer (OMO). Then practices had to fill in another application form to register for the PCEHR itself.
“They have combined that now into one form and you just have your seed application form, so you do part A, which is the seed application, and part B, which is the registration into the eHealth records system,” she said. “That process has been simplified, which is really good.
“We go through that process of getting the HPI-O, registering the GPs in the Health Provider Directory with their HPI-Is, we insert all of those details once they are received into their clinical management system – that is one of the requirements of the ePIP – and it is also a requirement for them to do any health record for their patients.
“We register them, make sure they have a practice site certificate and if they don't we assist in the process of ordering that. After that comes in, we import that into the clinical management system because that's required to validate the health identifiers (IHIs) for their patients. We show them the process of validating in their clinical management system, and we try to put in a policy and process as to who is going to do that.
“Once all of that is done, we also register them for accessing the eHealth record system, and part of that is that they need to get a NASH certificate, and they need to sign a participation agreement.”
There are seven different types of participation agreement covering the business structure of the practice, and while the vast majority are proprietary limited companies, there are some who are managed under a trust arrangement and some sole traders.
However, the WentWest team also found an eighth type of business, Mr Campbell said. “The Aboriginal Medical Service is none of the seven – it's a co-operative. So we asked our legal team which one they should be, and they said strike out the word association and put in the word co-operative. I think all of the AMSs would be the same.”
Once the relevant agreement has been signed, the WentWest team submits it to the PCEHR system on behalf of the practice, along with the NASH certificate application.
But even then the practice is generally not ready to use the system. WentWest has been emphasising the importance of data cleansing before trying to use the PCEHR, which Ms Pipicella said would save time in the long run.
“Before they actually upload an eHealth record, we want them to look at their data,” she said. “The way we assist them is to install the Pen CAT tool. In the Pen CAT there is a tab called the data quality tab, and that will give us the four elements that will go up to a shared health summary, which is immunisations, allergies and adverse reactions, medicines and medical history.
“We analyse that and see where they are tracking. Most practices that are proactive with their data cleansing and data quality are fine, but if there is only 20 per cent recording allergies then we put a process in to ensure that when a patient comes in you record their allergies. That is to minimise the time that GPs have to take when they do upload, so they are not spending a lot of their time on data cleansing.”
Mr Campbell estimates that 80 per cent of the practices in the region use either Medical Director or Best Practice, with another 15 per cent using Zedmed, practiX, Genie or Medtech32. The remaining five per cent are not computerised, he said.
“Of the practices that we are working with very closely right now, they are about 50/50 Medical Director and Best Practice, with a couple of Zedmeds. Even though there is pretty much 50/50 those two CMSs, each installation is different. There are some very interesting implementations out there!”
Ms Pipicella said once the practice enters its HPI-O and the HPI-Is, it is relatively straight forward. The HPI-Os are normally stored in the practice details page, which contains the practice's name, address and business detail. The HPI-Is are similar.
“With the IHI, that is in the patient details screen,” she said. “It will have a validate button next to the IHI number, you press validate and it will take a few seconds and the IHI will fall into place. That is all through the HI Service, which has been integrated into every practice management system. That will happen as long as the practice PKI certificate has been inserted and we will configure the system to be able to do that.”
Again, that does not mean it is all plain sailing. Ms Pipicella said her team had come across quite a few technical issues, mainly to do with the practice not having inserted the practice PKI or not filling out the seed application to link to the HI Service.
“Sometimes if you try to validate an IHI you will get a message saying the practice PKI hasn't been inserted, so we fix that. If you then insert it and get a message saying 'not linked to the HI Service', normally that is because when we do the seed application, the practice has to give us the site PKI number, which then gets linked to the HI Service.
“When they validate IHIs, the door will open to them, so it is a form of identity verification. But when we do the seed application and they don't give us the practice PKI number, the linking doesn't take place. So we generally have to ring up the HI Service to get them to do the linking, but within a minute or two that will be done.”
While the registration process is quite complex and uses many confusing acronyms, Ms Pipicella said that once it has been done, practices don't have to worry about it again – unless the practice decides to change its software.
In addition to helping practices through the process, WentWest has also been helping them to encourage patients to register for their PCEHR. Like Barwon Medicare Local in Victoria, WentWest received some funding to employ medical students to trial how assisted registration would work.
Western Sydney's multicultural population is a perfect testing ground for how the PCEHR will work in a practical sense. In addition to very large Chinese, Vietnamese and Arabic-speaking populations, the area is also popular with Sudanese and Somali migrants, and has a sizeable Aboriginal population as well.
“Because of the multicultural nature, we employed a dozen medical or science students and put them into practices after giving them training on how to assist patients to register using the consumer portal,” Mr Campbell said. “We have Chinese, Arabic, Vietnamese and African-speaking students. The African student said unless you have an African talking to an African, they will only think it is for white people.
“We have a 25-page analysis of the population health of western Sydney, and it goes into the socio-economic and the cultural and religious and the health issues. For example, diabetes is twice the rate in western Sydney compared to any other part of NSW. There is by an almost factorial number more fast food outlets in western Sydney than say in the eastern suburbs.”
The population is also very young, with a large number of young families. WentWest's PR and marketing campaign coordinator, Jenny McCulla, said the majority of people who had registered in practices are between the ages of 30 and 45.
“In that group there are a lot of families and young parents, and a lot of them are signing up their children at the same time,” Ms McCulla said. “We've have also held a diabetes evening, where specific people came along and signed up. We are looking at a wide group of people but we are looking at it strategically.
“We have a newspaper advertising campaign and we are targeting playgroups, preschools and libraries and local communities by sharing information and putting up posters. We have some events for senior’s week and we are going to some nursing homes and sharing information with them.”
WentWest is also developing programs for specific communities and attending their social events. One group of interest is Aboriginal people, many of whom live in western Sydney but regularly travel to country NSW to visit relatives.
“The Close the Gap team at WSML and eHealth have been to Aboriginal community events and have been talking to families and older people, and it seems like they think [the PCEHR] is a good idea because a lot of them frequently travel around the state and country to see relatives,” Ms McCulla said.
The enthusiastic practices have been helping as well. Kildare Road MC in particular has taken to the idea, promoting consumer registration both within the practice and through its external digital signage.
“They are one of the more progressive practices,” Ms Pipicella said. “They are really proactive, they were the first to go live, they wanted to do it and contacted us.
“A lot of their GPs are from England so they have been exposed to eHealth back there and the whole practice is involved with it. Because they are all on board with it, the results show for themselves.”
More practices are now able to use the system with the wider roll-out of PCEHR-compatible software, with St Martins Village Medical Centre in Blacktown recently directly uploading a shared health summary using Medical Director.
Castle Hill Medical Centre has also come on board and hosted WentWest's assisted registration team, the first in the north-west of the region to do so. Other practices include the Rainbow Medical Centre at Doonside, Alpha Medical Centre at Seven Hills, and Rivaside Medical Practice at Parramatta.
Dr Alfred Wilson of Rivaside Medical Practice said the principle of eHealth records “sounded good and practical” to him.
"It will be much easier to communicate with other doctors and specialists to assist our patients when the system is fully operational, down the track," Dr Wilson said. "Of course I was reticent initially, based on medico-legal grounds, but as time has progressed these issues have been addressed and answered to my satisfaction.
"Of course there have been some teething issues along the way, but what system doesn't have these problems? In the long run it will be successful and it will work better for us all."
Posted in Australian eHealth