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Introduction

As highlighted in the last edition of Pulse+IT, secure electronic communication has enormous potential in the health sector. There are many reasons that this potential has not yet been realised, however the purpose of this article is not to examine these issues.

Instead, this article is designed to demonstrate a working secure messaging scenario involving software technology that is available now!

Fortunately, the example presented in this report isn’t an isolated one, however it is not feasible to deal with all or even several of these examples within the space constraints of one article.

Given this fact, this article will be the first in a perpetual series designed to highlight practical examples of how secure messaging can be used effectively by both Specialist and General Practices.

This article consists of three sections:

1. A brief outline of the software referenced in the article.

2. An overview of the installation and configuration procedures required to prepare the software for the demonstration.

3. A demonstration of one possible use of the combined software solution.

Given this broad scope, some of the technical explanations in this article are dealt with less comprehensively than others. Where further explanation is required, the vendors mentioned in this article will be happy to assist practices to apply the information presented to their own situation.

It Takes Three To Tango

In the context of Specialist and General Practice, there are typically three software applications used to perform secure electronic messaging:

1. The sender’s clinical software.
2. The messaging software.
3. The recipient’s clinical software.

Clinical Software

For the purpose of this article, we selected Genie and Mercury as the two clinical packages to send messages between.

Other clinical packages will be the subject of future demonstrations, however these two products deserve early recognition because of their proactive approach to secure electronic communication.

Messaging Solution

HealthLink was the secure messaging solution selected to transport the messages between the two aforementioned clinical packages. As it is compatible with both the Macintosh and Windows platform, the use of HealthLink software has not only allowed the demonstration to span different clinical software packages, but also different operating systems.

As is the case in the clinical software market, there are several vendors competing for attention in the health sector; these solutions will be recognised in future articles in this series.

The Software

Genie

Developed by Genie Solutions, Genie is a fully integrated clinical, appointments and billing system. It was originally written for the Macintosh platform, however has long been capable of running on Windows also. Genie Solutions now boasts 900 sites, and continues to grow at an impressive rate.

While Genie performs well in both GP and Specialist practice deployments, for the purposes of the demonstration it will be installed at the general practice.

Mercury

Developed by MedTech Global, Mercury is a relatively new clinical package designed primarily for the Specialist market. On the surface, Mercury resembles an email program. Unlike traditional email clients however, Mercury natively sends HL7 messages. The program can also send XML messages, optionally with attachments.

Having recently acquired Australian Healthcare Technology Limited, Medtech Global now claims to be the “second largest provider to the Australian healthcare professionals”.

Mercury will act as the Specialist clinical system for the purpose of this demonstration.

HealthLink

Hailing from New Zealand, HealthLink has been providing secure messaging solutions to Australian healthcare organisations for many years. The company has a large number of GP and Specialist sites using the software, most for the purposes of downloading pathology and radiology results.

In addition to these relatively simple tasks, Healthlink’s software can be used to send and receive other types of health correspondence, including referrals, specialist reports and discharge summaries.

Setup

Following are the steps that need to be performed before Genie and Mercury can be used to send and receive correspondence via HealthLink.

1. Register with HealthLink.
2. Update the clinical software.
3. Install the HealthLink software.
4. Configure the clinical software to interface with HealthLink.
5. Configure HealthLink to interface with the clinical software.
6. Update your clinical software address book.
7. Inform your colleagues that you are able to send/receive correspondence via HealthLink.

These steps are outlined in more detail below. While these instructions are specific to Genie and Mercury, practices using other clinical software should be able to apply significant parts of the information presented to their own circumstances.

1. Register With HealthLink

To order a HealthLink software installation pack, practices need to visit the HealthLink website and complete a short application form. This application form can be found here:

http://www.healthlink.net/apply/au.htm

The practice should receive this installation pack within a week. Along with a CD containing the HealthLink software, printed installation guides are included that detail all aspects of the HealthLink setup.

A disk containing the digital certificates used to encrypt your messages is also included in the package.

2. Update Your Clinical Software

While Genie has long integrated with HealthLink and other secure messaging solutions, recent updates have significantly improved the way the program handles electronic correspondence. As such, it is recommended that all Genie users interested in secure messaging update to the latest version of Genie via its built-in software update mechanism.

Mercury users should also ensure they are running the latest version.

3. Install HealthLink

Practices running Genie in a client-server environment are advised to install the HealthLink software on a reception or administration client computer, i.e. NOT the computer running Genie Server. All Genie computers on the network communicate with HealthLink “through” Genie via the network (i.e. folder paths do not need to be mapped). To minimise complexity, the computer hosting the practices pathology and downloading programs could be used.

Practices running Genie on a single computer (i.e. Genie Solo) obviously need to install the HealthLink software on the computer running Genie.

Mercury users can install the HealthLink software on any computer connected to the practice network.

The HealthLink software installation procedure is straightforward and well documented by the manuals included in the installation pack.

4A. Configure Genie To Use HealthLink

To let Genie “know about” the HealthLink installation, you need to:

1. Create a “Healthlink” folder inside the “Genie“ folder on the computer that now contains the HealthLink software.
2. Create “Incoming” and “Outgoing” folders within this “Healthlink” folder (see Figure 1).
3. Start Genie if it isn’t already running, then select “Practice Preferences”, which is found under the “File” menu.
4. Select your practice from the list (usually there will only be one), then click on the “Carrier Identifiers” tab at the top right of the window.
5. Enter your “HealthLink EDI” into the appropriate field on this screen. This unique identifier will be included with your installation pack.
6. Click “Save”, close any open windows then quit Genie.

4B. Configure Mercury to Use HealthLink

Mercury comes pre-configured with the necessary HealthLink folder paths (assuming HeathLink is installed on the same computer as Mercury). These settings can be reviewed or modified by selecting “Settings” from the “File” menu (see Figure 2).

Once the folder paths are confirmed as accurate, clinicians will need to enter their unique EDI into their own Mercury address book record.

5A. Configure HealthLink To Use Genie

HealthLink needs to know where to place incoming correspondence and where to look for outgoing messages. As you may have guessed, these folders are the ones we created inside the Genie folder in step 4A.

To “point” HealthLink at these folders:

1. Ensure that there are no HealthLink programs or services running.
2. Start the “HMS Advanced Options” program. This can be found in the following locations:

Microsoft Windows: C:\Program Files\HealthLink SIX Client Software\HMS Advance Options.exe

Apple Macintosh: /Applications/HealthLink/HealthLink SIX Client Software/HMS Advance Options.app

3. From the “Configuration” menu, select “User Settings”.
4. Click the “Message Types” tab.
5. Select “RSDAU” from the list on the right hand side of the window. You may need to scroll to the bottom of the list to find this entry.
6. Click the “Directories” tab. Your screen should now look like Figure 3.
7. Click the “Edit/More” button located at the bottom right hand side of the window.
8. The “Message Directories” window will appear. Update the file paths to reflect the settings shown in Figure 4 (Mac) or Figure 5 (Windows).
9. Click the “Close” button located at the bottom right hand side of the window.
10. From the “File” menu, select “Save All”.
11. From the “File menu”, select “Exit”.

5B. Configure HealthLink To Use Mercury

As Mercury uses HealthLink’s default message repository (i.e. the “HLINK” folder), no further configuration is required.

6. Update Your Address Book

Having taken the time to install and configure HealthLink, you will now need to find out which practices you can communicate with, and collect their EDI’s.

Both Genie and Mercury have integrated EDI search features that allow practices using these packages to search for other HealthLink users and automatically import their EDIs into their contact address book.

Mercury’s built-in EDI search function is located at the bottom right of the address book demographics window. Genie’s EDI search function can be accessed by clicking the “Web Search” button at the top of the address book screen.

7. Contact Your Colleagues

Regardless of whether the colleagues that you wish to correspond with are already using HealthLink, it is a good idea to let them know about your plans to commence secure electronic communication with them.

Demonstration

Having outlined the process involved with installing and configuring HealthLink for use with both Genie and Mercury, this section of the article will demonstrate how this combination of products can be used to communicate in a typical, real-world scenario.

Meet The Doctors

Dr Edwina Hutton is a GP from Clovelly. Dr Hutton’s practice runs Genie on Macintosh computers. Dr Tim Bettington is a Neurologist from Randwick. Dr Bettington runs Mercury on a laptop running Windows XP.

Both practices have HealthLink installed and configured correctly, and correspond using the solution regularly.

The Scenario

For the purposes of this demonstration, the following “patient flow” scenario has been constructed:

Louise Joseph bumps her head on the steps at the Clovelly beach. With the assistance of her mother, she presents at her usual general practice, and is attended to by Dr Hutton. Louise is subsequently referred on to Dr Bettington. Dr Bettington gives Louise the “all clear”, and sends a report back to Dr Hutton.

The electronic communication interactions relating to Dr Hutton’s referral message to Dr Bettington are outlined in detail below:

1. Sending The Referral Letter

Dr Hutton opens Genie’s letter writer, addresses it to Dr Bettington and writes her referral. As shown in Figure 7, HealthLink is displayed as the preferred correspondence method. This information is populated automatically, using information retrieved from Dr Bettington’s address book entry.

Dr Hutton then ticks the “Send via 3rd party” checkbox located near the top left of Genie’s letter writer. As Genie knows HealthLink is Dr Bettington’s preferred communication method, the list of 3rd party communication options defaults to HealthLink (see Figure 8).

A dialogue box appears, asking Dr Hutton to specify the message priority (i.e. Routine/Critical/ASAP) and classify the letter (see Figure 9).

Dr Hutton then clicks “Save” (Figure 7) to close Genie’s letter writer. This action stores the referral letter within Genie’s database, and within 60 seconds, a HL7 file will be dropped into Genie’s outgoing HealthLink folder (see Figure 10):

/Applications/Genie/HealthLink/Outgoing

On a predefined schedule (or when triggered manually), the HealthLink software picks up this message, encrypts it, and sends it to HealthLink’s servers.

Time passes...

Receiving The Referral Letter

The next time Dr Bettington’s HealthLink installation is run (typically on a schedule every hour), the letter sent by Dr Hutton will be downloaded from the HealthLink servers. Once the letter is received and decrypted, it is deposited into the following folder (see Figure 11):

C:\HLINK\HL7_in\RSDAU

Importing The Referral Letter Into Mercury

Dr Bettington uses Mercury to check for new incoming messages periodically, by selecting “Check for new messages” from the “File” menu.

After importing the letter, a dialogue will appear, indicating that the letter for Dr Hutton has arrived. The letter can then be read in much the same way as an incoming message in a typical email client (see Figure 15).

Sending the ACK

Once the letter is imported, Mercury creates an acknowledgement message (ACK) and deposits this into the following directory (see Figure 12):

C:\HLINK\HL7_out\RSDAU

The next time the HealthLink software runs at Dr Bettington’s, this ACK is encrypted and sent to the HealthLink servers.

Receiving The ACK

The next time the HealthLink software runs at Dr Hutton’s practice, the ACK is downloaded from the HealthLink servers and deposited into the following directory (see Figure 13):

/Applications/Genie/Healthlink/Incoming

Within 60 seconds, Genie imports this ACK and reconciles it against the original referral letter. As shown in Figure 14, the original letter in Genie has been marked as “Delivery Acknowledged”, indicating to Dr Hutton that her referral has been imported into Mercury by Dr Bettington.

Genie also maintains a log of all electronic correspondence, both incoming and outgoing. This feature allows practitioners to easily audit the status of their sent messages, without having to open each letter individually.

What About The Specialist Report?

Because of space constraints, the journey of Dr Tim Bettington’s report back to Dr Edwina Hutton cannot be demonstrated in the same level of detail as the original referral message. This scenario however, has been detailed in an extended version of this article available via the Pulse+IT website. It has also been summarised below:

1. Dr Bettington constructs a report to Dr Hutton, which when sent via Mercury, is deposited into the outgoing “HLINK” folder.
2. The next time the HealthLink software is run at Dr Bettington’s practice, the report is encrypted and transported to the HealthLink servers.
3. The next time the HealthLink software is run at Dr Hutton’s practice, the report is downloaded from the HealthLink server, unencrypted and deposited into Genie’s “Incoming HealthLink” folder.
4. Within 60 seconds, Genie will import the message, and generate a “Genie Task” for Dr Hutton to flag the arrival of the message.
5. An ACK will be deposited into Genie’s “Outgoing HealthLink” folder, and sent to HealthLink’s servers the next time the HealthLink software is run at Dr Hutton’s practice.
6. The next time the HealthLink software is run at Dr Bettington’s practice, the ACK will be downloaded into the incoming “HLINK” folder and imported into Mercury when Dr Bettington next checks for incoming messages.

Cost

Under HealthLink’s pricing model, the sending party bears the cost of the message transmission (i.e. there is no cost involved with receiving messages). There are many pricing options available to larger health organisations (e.g. pathology labs, radiology and hospitals), however GPs and Specialists are charged a flat rate per month as follows:

• GPs: $20 + GST per month
• Specialists: $30 + GST per month

There is no cost levied for the HealthLink software or help desk assistance.

As you would expect, nether Genie Solutions or MedTech charge their users to transport secure messages via HealthLink or other secure messaging providers.

Conclusion

This article has outlined the steps involved with configuring Genie and Mercury to use HealthLink to send and receive secure electronic correspondence.

While the detailed demonstration contained in this article dealt exclusively with a GP to specialist referral, other types of correspondence can be sent and received using HealthLink, including pathology and radiology results, specialist reports and discharge summaries.

Other Clinical Software?

As Table 1 indicates, there are several clinical software packages capable of sending and receiving HL7 messages. Unfortunately, because Medical Director (MD) cannot presently generate HL7 referral messages, the vast majority of general practices will not be able to send electronic referrals via HealthLink. Fortunately however, like the other clinical packages listed, MD users can receive and import HL7 messages.

Importantly, all of the packages listed in the Table 1 have the capacity to send acknowledgement messages (ACKs) on receipt of a properly constructed incoming message.

As outlined in the demonstration and detailed in the diagram on the facing page, these ACKs are an essential part of a properly implemented secure messaging solution, and provide the necessary assurance that the original message has not only been sent, but also received by the intended recipient.

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