Some thoughts on cooperation, standards and interoperability

In late August I attended a celebratory function in the Wellington Town Hall hosted by the New Zealand National Health IT Board. Along with three other vendors, Houston Medical had completed a ground‑breaking program in New Zealand called GP2GP. Similar initiatives have been tried elsewhere in the world but we believe, only if anecdotally, this is the first one that could be regarded as a success for the interchanging of information between different practice management systems that are under different ownership and management. As the project’s name implies, at present it is only working between general practices. But given the will there are no technical reasons that the mechanism cannot be extended to other parts of the healthcare sector if the relevant vendors are interested in developing the necessary protocols within their own software.

The scope of the functionality of the system can also be extended. The next initiative is to use the same ‘engine’ for ePrescribing, something that has already been demonstrated by Dr Ashwin Patel of MyPractice.

Medical software is an area where New Zealand can play its small size to a big advantage. It is easy to organise a meeting, nowhere is more than four hours away and there are now just four practice software vendors serving general practice. When Houston made its first tentative offering in 1989 we were number 32!

A poll from GPNZ identified the transfer of patient records from one doctor to another as the next most important outstanding software need. The National Health IT board took up the challenge and funded GPNZ, under Patients First, to project manage Houston Medical, Intrahealth, MedTech Global and MyPractice, and to make this wish come true. It was a cost recovery only budget with a total of around $750,000 split between all of us.

It was quickly found that because the four systems were so different, with completely different database structures it would be necessary to build an interface engine to generate the Clinical Document Architecture (CDA) message. This work, fortunately for us all, was carried out by an independent contractor, Peter Jordan under the supervision of Dr David Hay from the Auckland Health Alliance and Andre Bredenkamp from GPNZ. Over a 12 month period the vendors completed development, met for Connectathons, exchanged sample messages and found and squashed bugs. As funding was provided through a fixed price contract, the project was delivered on budget. Although the same could not be said for the delivery date, a six‑month project rapidly became 12! The vendors put aside their normal competitive behaviour, as we all realised we had something to learn and something to share and if it was not a success we were all the joint losers.

The transfer of the patient record from one general practice to another can be instigated from either end, but in my first example, Jenny the patient has arrived from Christchurch with her two children at a new practice and wishes to have their medical records transferred. Jenny enrols with the practice and then signs the record transfer request form, which is faxed or posted to her previous doctor. For obvious medico-legal reasons this request has to be approved and signed by the patient. On receipt of the request at the sending doctor’s practice, Jenny’s records are brought up on the screen and quickly reviewed. Any notes marked confidential to the doctor or the practice may be withheld but in most cases the ‘Send’ button in the practice software is clicked. HealthLink picks up the encoded patient record and transmits it to the receiving doctor. If the file is over 5MB, which is the maximum file size that presently can be transmitted between practices, the sender is advised to insert a CD and, unless a record is marked confidential, everything is sent or copied to the CD. 128 bit encryption is used and the CD can only be read by the appropriate receiving software. It would therefore not be possible for the patient to take the CD on holiday to India to use as a complete medical record! Confidentiality around encounter notes is maintained. Even when a medication is attached to a confidential record the medication is sent and the associated note can be omitted.

Jenny’s new practice will receive the transfer notes as a message in their HealthLink in-tray. The message is exchanged as a CDA HL7 V3 document. Because there must be no dispute as to what has been sent, this document also contains the complete patient record in human readable format. The receiving doctor may decide that a record of a runny nose when the 25-year-old patient was three is not really necessary and may decide not to import this particular encounter note.

As an aside, this optionality is currently a point of considerable controversy between doctors. One school of thought says that the doctor must import everything because that runny nose might be important in another context, and another is equally emphatic that they only want what they want. This debate is still to be resolved!

The receiving doctor can click the ‘Import All’ button, in which case allergies go to allergies, prescriptions go to prescriptions and medical notes go to medical notes. Pathology and radiology reports are also correctly filed.

If Jenny knew which practice she was going to before she left Christchurch then she could have signed the record transfer request form there. As long as she had enrolled in the new practice, everything would be waiting for her and her two children when she arrived.

Obviously these are early days, there will be enhancements and feedback to be actioned and there is much more to it than described above, but for $750,000, what a bargain! NEHTA are you listening? This is also a very important example of what you can do with standards.

For the technically minded and industry insiders, now comes a particular gripe and a plea to my competitors and colleagues in Australia. Since Houston Medical started supplying software in Australia in 1993, we have had a constant battle with standards, in particular with PIT, the ‘birth’ of which I am old enough to remember well.

Around 1996 I was with a Brisbane pathology lab and I asked if they could send lab results to a dermatology client in the HL7 format which we had been using in New Zealand for several years. They looked at me aghast and I quote: "Australian software would not be capable of receiving an HL7 message and we have devised something easier to implement called PIT."

And now, in 2011 doctors are still sending and receiving Referral, Status and Discharge (RSD) messages and even worse, having radiology results forced upon them in the PIT format, even though it is non‑standard and, in my opinion, should have been put out of its misery and buried years ago.

For those not acquainted with HL7, it is an international standard that was devised by Duke University in the United States in the late 80s for the secure transmission of health results from one facility to another. In New Zealand under the guidance of HealthLink, all messages between doctors and all pathology and all radiology results have been HL7 compliant since the mid-90s. Over the years HL7 has evolved from version 1 to version 2, and then through various iterations of version 2. New Zealand has moved to version 2.4 which allows the inclusion of an embedded PDF so images and letters can all be included. Version 3 is under consideration and is used in the GP2GP CDA message.

Australia, unfortunately is still struggling to mandate even version 2.3.1. The Royal College of Pathologists Australasia mandated the use of HL7 three years ago, but unfortunately the Royal Australian and New Zealand College of Radiologists still has to make a decision. The transference of Referral, Status and Discharge messages between doctors and hospitals cannot sensibly move ahead until the HL7 international standard is accepted across all health disciplines.

Therefore I close with a personal plea to the software vendors of Australia that need to implement the transfer of medical records from one practice or health service to another. If you really do want to embrace an eHealth record like the PCEHR, then standards are essential and the first move you should make is to ensure that all RSD messages between doctors and all reports from radiology and pathology are sent using the internationally accepted HL7 standard.

Derek Gower
Managing Director, Houston Medical
This email address is being protected from spambots. You need JavaScript enabled to view it.

Derek Gower is Managing Director of Houston Medical, which has offices and Hamilton, New Zealand and Sydney, Australia. He started off in farming and was a Nuffield scholar to the United Kingdom in 1972, having built the largest dairy farm operation in New Zealand at that time. A midlife crisis, share market crash and a change in lifestyle in 1987 saw him move into a small computer company in Hamilton where he helped develop the first software for physiotherapy to assist in claiming to the Accident Compensation Corporation (ACC). In the mid-90s he bought the entire company and grew it to be the one of the major suppliers of software to all medical professions in both countries including, but not limited to allied health, ophthalmology, endoscopy, cardiology, orthopaedics and day hospitals as well as general practice.

Posted in Australian eHealth


0 # No_To_Paper_Reports 2011-09-15 11:07
I have personally experienced problems with a lack of HL7 reports from ProMedicus (MIA radiology) who, for some reason, insist on using outdated technologies. The only way that we can move forward to truly paperless e-medicine is to have all vendors play-ball. These stumblings blocks to a seemless system are very annoying.
0 # Rodney Kurtzer 2011-09-27 19:49
I strongly concur with the comments of Derek Gower. I am one of the very few GP users of Houston VIP in Australia having used the program for some 11 years now. New Zealanders must look with awe at the money we have to burn in Australia when it comes to IT and Health. The issue of the transmission of results using any other form than HL7 highlights the stupidity that abounds in Australia. I have downloads from 2 Radiology providers and 2 Pathology providers and they all use seperate programs to download their results. Although the Pathology providers now transmit results in HL7format, neither laboritory can agree on using the same notation for results: for example one lab uses the notation for Gamma Glutamyl Transferase as GGT where as the other lab insists on the notation of Gamma GT and no amount of phone calls and discussion will get either to change! One of the major strengths of HL7 is the ability to graphically display a result with a single click of a button. For example in my present practice I now have 4 years of accumulated results for my Diabetic patients - this means for many I have accumated HbA1c results in HL7 format and displaying the HbA1c trend in graphical format over the last 4 years is a very powerful way of showing a patient their diabetic control. Try doing that with PIT. Similarly, serial PSA measurement plotted out give a very sensitive indicator for raising concern. Of course, now my division wants me to use another 3rd party to be able to communicate Electronic records between practices. I cannot understand why when I already have the services of world wide company who is well versed in doing this already transmitting Radiology results in HL7 format. I have also received Electronic Discharges from major hospitals using the same provider - sent straight to my mail inbox ready to file in the patients record. Still if we look at Australia's past history of "communication" we need only look to our past experiences with rail transport to understand that as a nation we practice "par excellence" making communication difficult.
For fee a fee of 10% of monies saved out of NEHTA $455 million dollars I would propose the following:
1. By 2013 all GP EMR must use a common coding system and that should probably be SNOMED. Similarly, at meetings of State Ministers of health, all health departments must agree to use SNOMED.
2. All electronic results must be transmitted in HL7 format - no PIT, no nothing else.
3. All GP EMR's must have an agreed and common demographic page that includes full name, DOB, address, Medicare no, PMS etc and this must be standard format - may be NEHTA could work on this.
4.Within each patients EMR must there must be a patient summary page that carries PMHx, Current Medications, Allergies, Current Medical Problems, Past Obstetric History - in an agreed format. Perhaps the RACGP might motivate themselves here and contribute.
5. The driving force for this change will be the much vaunted PCEHR. There is a lot of concern about who will maintain the accuracy of this record in a timely fashion. If the PCEHR was set up correctly then all a GP needs to do - say for a fee of $10 for the first entry and then say $4 for updates, is electronically upload the patient summary page from their desk top program, to the PCEHR - with the patients permission of course. Cash strapped, entrepreurial GP's would fall over themselves to get patients to take up the PCEHR and then abuse their software providers if their desk top EMR doesn't do the job! When ordering pathology or radiology investigations a cc of results could also be sent (with the patients permission) to the PCEHR if so desired.
6. Having enable "Practice EMR communication to the national PCEHR" there should now be little difficulty in allowing the electronic transmission of entire patient records between medical practices.
I calculated that I could probably save the government probably say $100 million dollars by takling this problem. Wonder if they will take me up. My fee of $10 million is very modest.

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