$$ - Secure Electronic Messaging With Argus

Introduction

This is the second article in a perpetual series of technical demonstrations designed to assist medical practices to better understand secure electronic communication.

The previous article in this series demonstrated the transmission of an electronic referral from a General Practice using Genie, to a Specialist Practice using Medtech Mercury. Healthlink was used to transport the message securely through the Internet.

Like its predecessor, this article demonstrates a secure messaging scenario using software that is available to practices now!

This article consists of three sections:

  1. A brief description of the software and companies referenced in the article.
  2. An overview of the installation and configuration procedures used 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 adapt the information presented to their own situation.

Existing users of the products referenced in this article may note that the methodology adopted by the author differs to the way in which their software has been configured. This has been done to ensure compliance with some of the important conditions that will need to be in place before widespread secure communication becomes a reality in Australia. These include:

  1. The “sending” clinical application should be the software product that creates the message to be transmitted.
  2. With the exception of encryption and decryption, this message should not be altered during transmission.
  3. The antiquated and unsuitable “PIT” messaging format should not be used at any stage in the process.
  4. The message acknowledgement process needs to start with the recipient’s clinical software and end with the clinical software that created the original message.

While these requirements may appear somewhat arduous and unrealistic, this article will demonstrate that it is possible to securely communicate with your colleagues, without compromising the quality of the end-to-end solution.

It Takes Three To Tango

The demonstration in this article is framed around the transfer of a GP referral letter to a Dermatologist. In this process, there are typically three software applications used:

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

The Sender’s Clinical Software

For the purpose of this demonstration, Best Practice will be the software used to generate the electronic referral letter.

Developed by the company with the same name, Best Practice has attracted a steady stream of converts since its first site went live in late 2004. In addition to the Best Practice clinical application, Best Practice now also develops an integrated practice management solution (Best Practice Management), and a PDA product (Top Pocket) designed to interface with the desktop software.

The Recipient’s Clinical Software

Zedmed was chosen as the software to receive the electronic referral letter.

Formerly known as Medipak, Zedmed develops both clinical and practice management solutions for GPs and Specialists. Now owned by practicing GPs, the company has a lineage stretching back nearly 30 years. During this time, the company has built a national client base, with a high concentration of sites in their home state of Victoria.

The Messaging Software

Argus has been chosen to transport the message between the GP and Dermatologist. “Argus” actually refers to a collection of interrelated products that together, allow messages to be encrypted, sent via email, then decrypted and processed by the recipient. Two Argus products will be referenced in this article:

  1. Argus Messenger is the core of the Argus suite, providing the email functionality, encryption and decryption services, and message acknowledgement handling.
  2. Argus Agent is a simple program designed to check (poll) folders for files to send. These files are then made available to Argus Messenger for encryption and sending.

Setup

Following are the steps that need to be performed before a site running Best Practice can send a secure electronic referral letter via Argus to a site running Zedmed:

  1. Establish a dedicated email account.
  2. Arrange PKI certificates.
  3. Register with ArgusConnect.
  4. Update the clinical software.
  5. Install Argus.
  6. Create message directories.
  7. Configure Argus to interface with the clinical software.
  8. Configure the clinical software to interface with Argus.
  9. Search the Argus Address User Directory.
  10. Update the Argus Address Book.
  11. Update the Best Practice address book.
  12. Inform your colleagues that you are able to send/receive correspondence via Argus.

These steps are outlined in more detail below. Please note that while these instructions are specific to Best Practice and Zedmed, practices using other clinical software should be able to apply significant parts of the information presented to their own circumstances.

1. Establish A Dedicated Email Account

As Argus uses standard email system to transport messages, practices need to setup an email address for use with Argus. While it is possible to use an existing email address, it is recommended that practices organise a new email address for the exclusive use of Argus.

If your practice has its own domain name, you may like to follow ArgusConnect conventions and simply setup the email address generically as “argus”, followed by your domain name, e.g.:

This email address is being protected from spambots. You need JavaScript enabled to view it.

If your Internet Service Provider (ISP) allocates your email addresses, or if using the above email convention isn’t possible for some reason, you may choose to prefix ‘argus’ with the initials of the practice, e.g.:

This email address is being protected from spambots. You need JavaScript enabled to view it.

Depending on your existing email arrangements, the cost of establishing this additional email address will be minimal or indeed free.

In addition to the above email address, Argus requires that practices have another email address to monitor any error messages that Argus may generate. Usually the Practice Manager’s email address would be used.

2. Arrange PKI Certificates

Public Key Infrastructure (PKI) certificates are used by Argus to encrypt messages for secure transport through the Internet.

Argus has been designed to use the same PKI certificates as those utilised by the Medicare Australia Online Claiming system (formerly HIC Online). ArgusConnect can also issue its own certificates to sites who don’t have access to their HeSA certificates, or to sites that would prefer not to use them for secure messaging.

3. Register With ArgusConnect

Once the email addresses and certificates have been organised, practices need to contact ArgusConnect to register their intent to install and begin using the Argus software suite.

4. Update The Clinical Software

As secure messaging is gaining momentum in the market, it is not surprising that many clinical software vendors have enhanced the secure messaging functionality in their products recently. Practices are therefore advised to update to the latest version of their clinical software before commencing any secure electronic correspondence.

5. Install Argus

For the uninitiated, an Argus installation and configuration can be both a daunting and time-consuming task. Fortunately, ArgusConnect undertakes to provide assistance to new customers via phone and remote access.

Because the integrity of any secure messaging solution is heavily dependent on its correct installation and configuration, the author strongly advises practices to take advantage of this service.

6A. Create Best Practice Directories

As Best Practice can both send and receive HL7 messages via Argus, the following directory structure needs to be created:

  • C:\ArgusMessages\Incoming
  • C:\ArgusMessages\Outgoing
  • C:\ArgusMessages\Outgoing\Sent

Practices are free to choose alternate names and locations for these directories, so long as any deviation from the examples listed above is replicated consistently throughout the configuration process.

6B. Create Zedmed Directories

If the following directory doesn’t already exist, Zedmed users will need to create it on their server:

C:\zedmed\download

This directory is where Argus Messenger will be configured to deposit incoming HL7 files at the recipient’s practice.

7. Configure Argus To Interface With The Clinical Software

As with the installation of Argus, its configuration should be conducted with the assistance of the ArgusConnect help desk. This process would usually occur as part of the installation.

8. Configure The Clinical Software To Interface With Argus

Now that Argus is installed and configured to send electronic correspondence, we next need to configure the clinical software to work with Argus:

Best Practice - Set HL7 Message Format

Best Practice allows outgoing HL7 messages to be created in two different formats; REF and ORU. “REF” is an abbreviation for “referral”, and is the format that Best Practice sites should use for outgoing electronic correspondence. “ORU” stands for “Observation Result / Unsolicited”, a format that is designed to be used for the delivery of HL7 lab results.

To set the message format:

  1. Navigate to the Best Practice home screen.
  2. From the “Setup” menu, select “Configuration”.
  3. From the list on the left of the screen, select “E-mail”.
  4. Set the “Default HL7 export format” to “REF”.
  5. On the same screen, ensure the “Use Argus format” checkbox is unticked (see Figure 1).
  6. Click the “Save” button to close the window.

A detailed explanation of why “Argus format” should be unticked is presented in the “Which HL7?” sidebar on page 35.

Best Practice - Specify The Output Directory

To specify the folder that Best Practice will export HL7 messages to, the user is required to export a message manually. To do this:

  1. From the Best Practice home screen, create a new letter by clicking on the Letter icon at the top of the screen.
  2. From the “File” menu, select “Export HL7”.
  3. Navigate to the outgoing Argus directory that was created in Step 6A:
  4. C:\ArgusMessages\Outgoing

  5. Click “Save” (see Figure 2).
  6. Click the “Exit” button to complete the process.

A HL7 message will be created in the aforementioned directory. As this file does not contain a real patient letter, it can be safely deleted.

As will be demonstrated later, this manual export process only has to be completed once. Best Practice will now remember the location that the HL7 message was exported to, and use this location for subsequent outgoing messages.

Best Practice - Specify The Input Directory

While this article’s focus is on sending messages from Best Practice using Argus, for completeness, the steps needed to configure Best Practice to receive electronic correspondence via Argus have been outlined below:

  1. Navigate to the Best Practice home screen.
  2. From the “Setup” menu, select “Configuration”.
  3. From the list on the left of the screen, select “Results Import” (see Figure 3).
  4. Click the “Add” button to the right of the “Report file search paths” box.
  5. Browse to and select the incoming directory that was created in step 6A:
  6. C:\ArgusMessages\Incoming

  7. Click “OK”.
  8. Click the “Add” button to the right of the “Acknowledgements” box.
  9. Enter “Argus” as the “Facility name”.
  10. Enter the following directory path into the “Acknowledgement path” field:
  11. C:\ArgusMessages\Outgoing

  12. Click “Save” to complete the acknowledgement setup window.
  13. Click “Save” to close the “Configuration window”.

Best Practice is now configured to receive HL7 messages, and to output HL7 acknowledgement messages to be forwarded to the sender via Argus.

Zedmed - Specify The File Extension

Zedmed is preconfigured to check for incoming results and correspondence in the following folder:

C:\zedmed\download

By default however, this directory is only setup to import messages with certain file extensions (e.g. “.hl7” or .”pit”).

Before Zedmed can import HL7 messages sent from Best Practice (and several other clinical products), the user must configure Zedmed to acknowledge these additional file extensions. To do this:

  1. Navigate to the Zedmed Clinical home screen.
  2. From the “Tools” menu, select “Global Options”.
  3. Click on the “Communications” tab at the top of the window (see Figure 4).
  4. If “REF”, “ORU”, or “HL7” do not already exist in the list of “File Extensions to Import” on the left of the screen, use the “Add New” button to add these extensions to the list.
  5. Click “OK” to save settings and close the configuration screen.

9. Search The Argus User Directory

Having configured both Argus and the clinical software, the user now needs to locate the email addresses of the colleagues with whom they wish to correspond with. While it is possible that a colleague may have provided you with their Argus email previously, the likely scenario is that you will not even know which of your colleagues are presently using Argus.

Fortunately, ArgusConnect maintains a user directory that can be accessed via a web browser by all registered Argus users. To search for colleagues using Argus:

  1. Go to the ArgusConnect website: www.argusconnect.com.au
  2. From the left hand navigation panel on the home page, click “Argus Users Search”.
  3. In the “Site Identifier” section, click the “Browse” button.
  4. Navigate to, and select your “Site Identifier” file, which will have been issued by ArgusConnect. The file will usually be your site name followed by the “.bin” extension.
  5. Click the “Login” button, optionally ticking the “Remember me next time” checkbox.
  6. Perform a search using the criteria of your choosing.

10. Update The Argus Address Book

After identifying the colleagues that you are able to correspond with using Argus, you then need to add these colleagues to your local Argus Address Book. Whilst there are several ways to update your local Argus Address Book, the simplest way is to download the contact details from the centrally hosted Argus User Directory. To do this:

  1. Launch and login to Argus Messenger.
  2. From the “Show” menu, select “Address Book”.
  3. Select “Argus User Directory Entries” from the drop down list at the top of the screen.
  4. Click the “Add” button.
  5. Enter the name of colleague you wish to correspond with, and then click the “Search” button.
  6. Select your colleague/s from the list, and then click the “Add” button.
  7. Click the “Close” button.
  8. Exit Argus Messenger to complete the process.

11. Update Best Practice Address Book

Having located your colleague’s Argus email addresses, this information can now be added to the Best Practice contacts address book.

12. Inform your colleagues that you are able to send/receive correspondence via Argus.

Regardless of whether the colleagues that you wish to correspond with are already using Argus, it is a good idea to let them know about your plans to commence secure electronic communication with them. Taking this measure will not only give them a “heads-up” about your new communications capability, but will also allow them to add your Argus email address to their own address books.

Demonstration

Having now presented an overview of the steps required to configure both Best Practice and Zedmed to communicate using HL7 messages via Argus, this section demonstrates a practical application of the technology.

Meet The Doctors

Dr Garry Player is a GP who works at the Novar Street Clinic. His clinic runs Best Practice software.

Dr Derrick Zoolander is a Dermatologist who works at the Smithfield Consulting Suites. Dr Zoolander uses Zedmed.

The Scenario

Mr Sick Patient visits his GP, Dr Garry Player for a skin examination. Dr Player is concerned about several lesions, and instructs Mr Sick Patient to make an appointment to see Dermatologist, Dr Derrick Zoolander.

The electronic communication interactions relating to Dr Garry Player’s electronic referral letter to Dr Derrick Zoolander are outlined below:

1. Creating The Referral Letter

Having noted his observations in the patient record, Dr Garry Player opens his “Specialist Referral” letter template in Best Practice and writes the referral.

After saving the letter in the usual way, Dr Player clicks the “Export as HL7 file” button (circled in Figure 6 below). A HL7 file containing the referral letter is created, and deposited into the outgoing Argus folder:

C:\ArgusMessages\Outgoing

The letter and patient’s record are closed, and the consultation is concluded.

2. Sending The Referral Letter Via Argus

The next time Argus Agent runs on its predefined schedule, the HL7 referral letter will be imported into the Argus Messenger database. Argus Messenger will then attach the HL7 file to an email, encrypt this email and the attachment, and send it to the Novar Street Clinic’s email server.

This email server may be hosted within the practice, however more commonly the practice’s Internet Service Provider (ISP) will manage it.

Usually within seconds, the Novar Street Clinic’s email server will transmit the message to the recipient’s email server and deposit it into the Smithfield Consulting Suite’s Argus mailbox.

3. Receiving The Referral Letter

The message will reside on the Smithfield Consulting Suite’s email server until their copy of Argus Messenger next checks for encrypted correspondence. This will usually occur on a predefined schedule.

When Argus Messenger downloads the email, the HL7 attachment will be unencrypted and deposited into the into Zedmed’s incoming results/correspondence directory, i.e.:

C:\zedmed\download

4. Importing The Referral Letter Into Zedmed

Dr Derrick Zoolander imports the referral letter in the same way as pathology (i.e. from the “Results” menu, select “Import Laboratory Results”, or Ctrl + F6). Once the HL7 file has been imported into the Zedmed database, it will be removed from the above incoming directory.

Dr Zoolander will be presented with the Zedmed “Import Log”, flagging the arrival of the incoming referral letter and any new lab results.

After dismissing this log window, Dr Zoolander then clicks on the “Results Inbox” to review the letter (see Figure 7).

Using the demographic details contained in the HL7 file, an attempt to match the electronic referral letter to the appropriate patient file in the Zedmed database is made. If the patient doesn’t exist in the Zedmed database, or the demographics in the HL7 file don’t match the demographics in the database, the doctor can link the referral letter to the patient manually.

Once reviewed, the letter can be marked complete and removed from the Results Inbox, or marked pending if further action is required. The patient’s record can be accessed from this screen should further details need to be checked before this decision is made.

5. Viewing The Letter From The Patient File

Given that the electronic referral letter is likely to arrive days, weeks or even months before the patient presents at Dr Derrick Zoolander’s Dermatology clinic, it is likely that the letter will need to be reviewed at the beginning of the consultation. Typically this will be performed from within the patient record:

  1. Under the “Summary Views” pane on the left hand side, click on the “Results” tab to display the list of results and incoming letters.
  2. Right-click on the relevant referral letter, and select “View Results”.

The letter will be displayed in the window on the right hand side of the patient record screen.

What About The ACKs?

As indicated in the diagram on pp34, Argus has built-in message acknowledgement (ACK) functionality. The primary function of this “Transport Level” acknowledgement system, is to ensure that messages sent using Argus reach the recipient’s Argus installation.

While Transport ACKs are important, acknowledgement functionality also needs to be provided by the clinical software to eliminate the chance of messages being lost in the “hand over” between the messaging and clinical software. Two major factors prevented these “Application Level” acknowledgements from being demonstrated in this article:

  1. In the pre-release version of Zedmed that was provided to the author for the purposes of this article, HL7 acknowledgement messages (ACKs) were not generated when an incoming HL7 message was received.
  2. Whilst Best Practice does generate ACK messages, it does not track the receipt of ACKs sent by software in response to its outgoing messages.

In other words, even if Zedmed was able to generate ACKs, Best Practice would not do anything with them!

Fortunately, both Best Practice and Zedmed have indicated that these shortcomings will be addressed in future releases of their software.

Cost

The Argus software suite is provided free of charge to GPs and Specialists. This is made possible by the fact that ArgusConnect charges larger organisations, such as pathology and radiology providers, for the use of their software.

As alluded to earlier, the Argus product suite is highly customisable, allowing it to interface with a wide variety of clinical systems. Unfortunately however, this flexibility means that the correct configuration of the software is not always a straightforward process.

Fortunately, ArgusConnect offer to assist practices with the installation and configuration of Argus, and the configuration of their clinical software to work with Argus. This process usually takes place via telephone and/or remote access for a flat fee of $330 (reduced to $220 for prepayment).

Practices may also find that their Divison and various independent IT professionals are available to assist with the installation.

Once installed, ongoing support is provided free of charge by ArgusConnect.

As you would expect, neither Best Practice nor Zedmed levy a charge on their customers for using Argus.

Conclusions

This article has outlined the steps involved with configuring Best Practice and Zedmed to use Argus to send and receive secure electronic correspondence.

As highlighted by the brevity of the demonstration on pages 32-33, once configured, sending secure HL7 referral messages from Best Practice and receiving them with Zedmed is a very simple process.

Fortunately, the scenario presented in this article isn’t unique in the market, and the author encourages all practices to contact their clinical software vendors to discuss the secure messaging options available to them.

Posted in Australian eHealth

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