eMessaging gateway to GPs part of the west side story

Melbourne's Western Health is gearing up to enter phase two of a project to securely deliver notifications from its hospital systems directly into GP desktop practice management software through an SMD-compliant eMessaging Gateway.

Western Health's executive director of ICT, Jason Whakaari, told the eHealth Interoperability Conference in Sydney recently that the organisation had worked with secure messaging vendor HealthLink and health IT firm Alcidion to extract information from Western Health's BOSSnet digital medical record and deliver it directly into GP desktop systems.

Western Health, which includes the Williamstown, Footscray and Sunshine hospitals, worked with its two Medicare Locals – South Western Melbourne (SWMML) and Macedon Ranges and North Western Melbourne (MRNWMML) – to hook up general practices as part of a pilot that first began in December 2013.

The ongoing project involves 22 practices comprising 162 GPs, or 20 per cent of GPs in the catchment, who are able to receive basic admissions, discharge and transfer notifications directly into their systems, as well as notifications of deceased patients and receipt of referrals. The GP systems are a mixture of predominantly MedicalDirector with some instances of Zedmed, Best Practice and Medtech.

While the majority of notifications are still going out to the other GPs in the region by fax, the project is achieving an average of 11 per cent of notifications sent electronically, with the bulk involving notifications of outpatient appointments, admissions, discharges and receipt of referral.

The next phase is to add more clinically relevant documents, including discharge summaries, outpatient summaries and medications summaries, Mr Whakaari said.

“It’s nice to have the admission, discharge and transfer information going out but from the GP feedback that we get, they say they’re interested in medication summaries more than anything else,” he said. “If they had to choose something to get quickly, they’d choose medication summaries.”

The existing pilot has been extended to include the scoping out of the next phase, which if successful will then be opened up to all GPs in the area, he said. For the less tech savvy practices, the Medicare Locals have been helping to organise all of the required digital certificates and back-end work that the hospitals aren't keen on dealing with.

“The next component of it is that we’ll look at exploring options for managing inbound referrals from GP to the acute,” he said. “When I say look at options, it could be gateways, because currently we scan in our referrals that we receive in paper form through the fax. So we could automate that, or we could also do something where we open up our booking system so that the GPs can book [electronically], much like the UK experiment. We’re going to look at that soon after we hit phase two.”

While HealthLink was chosen as the messaging vendor for the pilot, Western Health will go out to tender again for a full roll-out if phase two is successful. Mr Whakaari said he hoped that the SMX consortium – in which the major vendors have achieved interoperability with each other but have not yet progressed into the wild – would be successful.

“What we’d love to see of course from a health service perspective is the SMX up and running,” he said. “Hopefully that’s something that gets up and we’d certainly be interested in leading the innovation charge and supporting deployment if it was something that’s got some support.”

In addition to the eMessaging Gateway, Mr Whakaari covered four other areas where Western Health is leading the way. This includes laying down an infrastructure layer to allow for mobile and remote access to systems, the move from paper to digital with the roll-out of the BOSSnet digital medical record, the development of an Intelligent Patient Journey System in association with Alcidion and the allied implementation of an Access Glance bed management system with the same vendor, and the future implementation of the Vergence patient context switching system from Caradigm.

For mobility, Western Health is using the Oracle/Sun JCAPS integration engine that is supported by Victoria's Health Design Authority, ubiquitous WiFi in clinical and non-clinical areas, Citrix's Access Gateway for multi-user and remote access, two-factor authentication access and bring your own device.

The organisation is also taking a close look at the potential that the recent announcement by Microsoft that it will host its Azure cloud platform onshore can offer in the future. “We’ve never considered storage on the cloud in the past because of the inability to control governance if it’s not grounded within the Australian environment, but we’re having a good look at that.” Mr Whakaari said.

“We’re actually a Microsoft shop in the sense that in Victoria, we have a state Microsoft enterprise licence. You pay an annual fee and you can use whatever software that you like within the Microsoft environment. It works really well for us and we try to take advantage of that wherever we can.”

Mr Whakaari said the most significant eHealth development for Western Health in terms of getting away from paper had been the implementation of Core Medical Solution's BOSSnet digital medical record (DMR) scanning solution and its associated e-forms.

“What stood out for us over and above some of the other competitors when we did the tender was it had an ability to add additional functionalities,” he said. “So in addition to the scanning, we’ve got a range of e-forms; the clinicians can do direct entries into the e-forms. It can automate through HL7 direct entry from some systems that are capable in our environment and put the data straight in.

“Now we’ve progressed so that we’re producing discharge summaries and medication summaries out of that system.”

Mr Whakaari said it was fortunate that at the time of implementing the digital medical record, the organisation was also in the process of changing its pathology information system provider, meaning clinicians could do their results viewing from the new pathology provider from within the DMR.

For radiology, Western Health has a full Fujifilm suite, including an allied system called the intelligent Cardiovascular Information System (iCVIS), designed by South Australian firm Alcidion in association with Fujifilm. “I think we’re going to be the first health service in Australia to have a Fuji radiology PACS, a Fuji cardiology PACS, a Fuji radiology information system and a Fuji cardiology information system,” Mr Whakaari said.

Alcidion also designed the next innovation developed at Western Health, which is now being rolled out elsewhere – the intelligent Patient Journey System (iPJS). When added to the Access Glance bed management system also installed, clinicians and managers can all see where a patient is in both the clinical and patient flow sense.

iPJS was funded by a $1.5 million Department of Business and Innovation grant and is now live in six wards. It involves a set-up that resembles a commercial television in portrait view that hangs on the wall, alongside an iPad through which clinicians can do data entry.

“Each ward also has four iPad Mini retina display versions, which they take around the wards,” Mr Whakaari said. “If the doctor is coming in to do their rounds they’ll take the iPad with them to get some of the information.”

This information includes clinical assessments, notifications, internal referrals, queue monitoring and medication monitoring, and also tells the clinician if the patient is ready to be discharged and the planned discharge date, all in one app.

It also provides access to the iPM patient administration system from CSC, BOSSnet, the laboratory and pathology systems and the emergency department system, also from CSC.

“With the results, if you have a pathology or radiology or cardiology result, it’s got the drill down 'tapability' like an iPad tends to have,” he said. “So you can just tap on it and it will take you to a radiology image, for example, or pathology results. You can just drill down and drill back up, which is nice simplicity in the user front-end. That’s what clinicians really like about it.

“For their internal referrals, [it] runs a traffic light system in there as well, so if you have been referred to cardiology for some sort of test, it will have cardiology written there and it will be red, showing that they've got a referral booked but they haven’t been yet. If it’s got cardiology in orange, it means they’ve gone off to cardiology and if it’s cardiology in green, it means you can tap on it to drill down to check out the results that you actually need.

“They'll have the referral and their results and when you tap down into the results there is another traffic light infrastructure that tells you if it’s in normal range, when it’ll be green. If it’s some sort of outlier that the clinician should be more concerned about, then that would tend to be red. It's the same for all of the diagnostic referral areas – pathology, cardiology, radiology – it has that traffic light infrastructure around it.”

Alcidion built the iPJS based on its Maya platform, which also underpins the Access Glance bed management system being used to provide a view of the bed status of the entire hospital. Access Glance uses a drag-and-drop method that allows users to change bed occupancy around to assist with patient flow.

“Access Glance is very mobile,” Mr Whakaari said. “You’ll see nearly all of the clinical, executive and divisional directors walking around with the bed management views on their iPads, and the same with the bed management staff, the quality managers, the NUMs and any staff that help move the patients around.”

The final initiative that Mr Whakaari hopes to implement is patient context switching using a clinical workstation and associated software called Vergence, designed by Caradigm. In use at Macquarie University Hospital in Sydney, Vergence is able to link to a host of information systems so that once a change is made in one it flows directly into another without the data having to be re-entered.

It is a single sign-on, role-based application that allows for context management, he said.

“If you have five different screens open, for example, and you change the patient in one of the systems that you’re looking at, it will automatically change the same patient in the other screens you’ve got open. So if you’re looking at a PACS result and you change it from George to Jason, the other systems automatically filter through. We think that’s got great efficiency in clinical workflow, but it’s also got potential to reduce human error, retyping it in on the other systems.”

The system can work across as many vendor bridges as required, but Western Health is looking at five initially: patient administration, digital medical record, radiology, allied health and emergency department.

“We partly chose things that are core to our organisation and we also chose some that we know are really hard to do the development work with, so we'll get the vendor to do those,” he said. “We might also bring on some that are less mission-critical in the future. It also includes a single sign-on solution. A lot of people have that but we don’t in our environment.”

Next stop is electronic orders for pathology and radiology. Western Health is considering whether to roll-out limited CPOE through the existing digital medical record or to wait until funding becomes available to flip to a full electronic medical record.

It had hoped to get some funding through the most recent round of the Victorian ICT Innovation Fund – the beneficiaries of which were announced shortly after Mr Whakaari's presentation at the eHealth Interoperability Conference, with Western Health missing out – before deciding on whether to spend a smaller amount on CPOE through BOSSnet or a much larger amount on a full EMR.

“Either way we’re going to have quite a bit of board investment required if we do the flip, and if we don’t flip now, we certainly will flip at some stage in the future,” he said. “But it is a big investment and we’ve got to be realistic about that. The bigger the investment, the less likely it will get supported.”

Posted in Australian eHealth

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