Pulse+IT Magazine - August 2006 by Pulse+IT Magazine

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Australia’s First & Only Health IT Magazine

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Issue 1: August 2006

ARTICLES FOR

2Hippo Google Podcasting

Universal Power Supplies

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Backup Devices

Regulars Interview: Argus Connect Practice Review: Gundagai Medical Centre Question Time: IT Support Accreditation Epidemiology Shutdown

Columns The Hon. Mr Tony Abbott General Practice Computing Group Health Informatics Society Australia National E-Health Transition Authority

www.pulsemagazine.com.au GENIE

Attention: General Practitioners, Specialists and Practice Managers……

“You Can Laugh At Medicare and Accreditation Audits With This Simple To Use Software Program!” It’s never been easier to lower your medico-legal risk, make your practice audit proof and drastically reduce the amount of paper required to run your practice. You can get started in only 20 minutes time. Send and receive all your secure patient correspondence with one simple mouse click. Send messages with no printing, no scanning, no copying, no filing, no postage. Save money, save time. And every single message you send is fully auditable and easily tracked. Product Review By Rob King

new software program called 2Hippo allows one mouse click paper free communication between Doctors. Medical Practitioners can now send and receive instant secure messages straight to and from their desktop computers with one simple mouse click. It couldn’t be any easier.

Lower your medico legal risk

Every message sent via 2Hippo automatically generates its own unique barcode, so messages are fully auditable and easy as pie to track. Dealing with HIC or accreditation audits has never been simpler. And because there is zero chance of any messages going astray, using 2Hippo means reducing your Medico Legal risk as well. 2Hippo means you can rest easy, knowing you are protected from audits and legal action.

Send your messages with no paper

Best of all, messages can be sent and received with zero paper involved. No printing, no copying, no scanning, no filing and no postage. And messages can be sent and received in any format, including text and images, with no interference or loss of font’s and logos.

Keep your staff happy!

Your practice manager and your staff will love it! Free up their time and your time to spend on running your practice. Drastically reduce the day to day use of paper in your Medical Practice. Be home in time for dinner! Won’t that be great? No more looking for that missing letter or referral, you can instantly find all your patient correspondence sent via 2Hippo.

Focus on running your practice

2Hippo means you can spend your time focusing on running your practice and looking after your patients instead of worrying about petty admin tasks that seem to rob you of all your time and energy. Do the job you dreamed about in Medical school, instead of shuffling paper backwards and forwards.

8 things about 2Hippo you ll love

1. No annoying “pop – up” advertisements, ever. 2. You can install 2Hippo from the internet with one simple mouse click in only 20 minutes. 3. 2Hippo is simple to use – you or your staff won’t need weeks of training. 4. Messages automatically export in a range of

www.2Hippo.com.au

formats – (image and text, including HL7 and PIT) suited to your clinical records management software ready to import. 5. No disruption or interference to your Medical Practice at all. Install 2Hippo with one easy mouse click. No downtime at all. 6. 2Hippo tracks all referrals and reports for you. 7. 2Hippo offers you a free, 24 hour, 7 day support line. And we’re talking about real, fair dinkum support here, no 20 minute phone queues or lengthy delays. 8. 2Hippo will save you time and save you money.

What Doctors say about 2Hippo

2Hippo is brilliant, practical, bullet-proof, and fuss free. 2Hippo is easy to use, does not interfere with our other software, including clinical software, word processors, spreadsheets and graphics. The tracking and auditing process is outstanding. Knowing I have managed medico legal risk, automatically complied with accreditation and 2006 PIP requirements provides total peace of mind. 2Hippo is user friendly and easily installs from the Internet without needing specialised technical assistance. Perhaps the best feature is the minimal number of keystrokes required and the ease of use for those of us not technically minded .

Dr Wes Jame, Berwick, VIC

What kind of computer do I need? A Windows based PC with XP (SP2) and broadband internet access. (Talk to 2Hippo if you are using a Mac based system).

What if other Doctors you want to send to are NOT using 2Hippo?

Let’s imagine you want to send a message to a Medical colleague who is not currently using 2Hippo. It’s not a problem. All you need do is add your colleagues name to your personal 2Hippo address book, and your message will be sent automatically. You don’t need to do anything. How easy is that?

Send messages to anyone

And, 2Hippo will soon communicate with every other messaging program on the market. Imagine being able to send and receive secure messages

from any Doctor, no matter what messaging software they are using? With total transparency?

What 2Hippo means for GP s � � � � �

Make your practice audit proof Slash your medico legal risk Save time, save money - happy, efficient staff Drastically reduce the day to day use of paper Much, much more besides

What 2Hippo means for specialists

� Receive each and every referral instantly, straight to your desktop computer. � Never again reschedule an appointment when a patient books in for the wrong procedure. � Or when a patient fails to comply with medical instructions such as fasting � Much, much more besides…..

How you can use 2Hippo free

Just by downloading 2Hippo you get a free lifetime membership. This means you can send unlimited messages free of charge forever.

2Hippo subscription

Should you choose to subscribe to 2Hippo there are a number of plans available to suit your Medical Practice. You choose the plan that you want, and unlike other programs, there are no hidden charges or extra costs. Your subscription is all inclusive, and you can send unlimited messages. There is nothing more to pay, ever. No lock in contracts, no ‘per message fees’. What you see is what you get. To find out more on subscription go to www.2Hippo.com.au

Here s how you can get a free 30 day test drive of 2Hippo .

Here’s what to do if you would like a free 30 day test drive. There’s no risk and no obligation, and just by downloading 2Hippo you get a free lifetime membership. To get started you will need to visit the 2Hippo website, register your details and download 2Hippo. It’s easy and only takes 1 mouse click and 20 minutes. After all, there’s only one way to discover if 2Hippo is for you or not, and that’s to try it out for yourself.

Go to www.2Hippo.com.au or call: 1300 789 828 and press 8 to hear more about what 2Hippo can do for you.

or call

1300 789 828

and enter priority access code

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PULSE+IT Publisher Pulse Magazine 6/94A Spofforth Street Cremorne NSW 2090 ABN 19 923 710 562 www.pulsemagazine.com.au Publishing Editor Simon James 0402 149 859 simon.james@pulsemagazine.com.au Art Director Mark Duncan Editorial Enquiries editor@pulsemagazine.com.au

PRACTICE REVIEW: GUNDAGAI MEDICAL CENTRE PAGE 16

GUEST COLUMN PAGE 07 E-HEALTH: BENEFITING AUSTRALIANS The Hon. Mr Tony Abbott, Minister for Health and Ageing discusses the Australian Government’s e-health objectives.

Advertising Enquiries ads@pulsemagazine.com.au Subscription Enquiries subscribe@pulsemagazine.com.au About Pulse IT Pulse IT is produced by Pulse Magazine, the most innovative publisher in health. 10,000 copies of Pulse IT are distributed bi-monthly to medical centres and IT professionals across Australia. Contributors The Hon. Mr Tony Abbott, Dr David Brookman, Mr Nathan Coultard, Mr Nathan Hay, Mr Louis Joseph, Dr Tony Lembke, Mr Samuel Logan, Ms Jane London, Dr Brendan Lovelock, Dr Paul Mara, Dr Ian Reinecke and Dr Daniel Silver.

COVER STORY

Non-Commercial Supporting Organisations • General Practice Computing Group (GPCG) • Health Informatics Society Australia (HISA) • National E-Health Transition Authority (NEHTA)

PAGE 20 DIGITAL PHOTOGRAPHY FOR BUSY CLINICIANS In part one of our series on digital photography, Dr Daniel Silver explains why busy clinicians should take photos.

Disclaimer The views contained herein are not necessarily the views of Pulse Magazine or its staff. The content of any advertising or promotional material contained herein is not endorsed by the publisher. While every care has been taken in the preparation of this magazine, the publishers cannot be held responsible for the accuracy of the information herein, or any consequences arising from it. Pulse Magazine has no affiliation with any organisation, including but not limited to Health Services Australia, Sony or the Kimberley Aboriginal Medical Services Council that all publish printed articles under the title “Pulse”. Further, we have no affiliation with CMP (owner of “Medical Observer”), who are endeavouring to trademark “Pulse”. Copyright 2006 Pulse Magazine No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form by any means without the prior written permission of the Publisher. Subscription Rates (inc GST) 1 year: $99 Back issues: $22 Bulk rates: POA

Pulse+IT DVD pulse IT +

PAGE 10 PULSE DVD A brief wrap up of the contents of the accompanying Pulse IT DVD.

BITS & BYTES PAGE 08

NEHTA PAGE 13

2HIPPO PAGE 26

SHUTDOWN PAGE 42

FEATURES

REGULARS PAGE 06 STARTUP Editor Simon James introduces Pulse IT.

PAGE 16 PRACTICE REVIEW Pulse IT looks at the Gundagai Medical Centre’s IT setup.

PAGE 07 GUEST COLUMN The Hon. Mr Tony Abbott, Minister for Health and Ageing discusses the Australian Government’s e-health objectives.

PAGE 18 QUESTION TIME Pulse IT has a bunch of questions to ask your IT support person.

PAGE 08 BITS & BYTES News from IT companies operating in health. PAGE 10 PULSE IT DVD A brief wrap-up of the contents of the accompanying Pulse IT DVD. PAGE 11 GPCG Jane London discusses computer security in general practice. PAGE 12 HISA Dr Brendan Lovelock talks innovation and interoperability. PAGE 13 NEHTA Dr Ian Reinecke introduces the National E-Health Transition Authority. PAGE 14 INTERVIEW Pulse IT talks with Argus Connect CEO Mr Ross Davey.

PAGE 20 DIGITAL PHOTOGRAPHY FOR BUSY CLINICIANS In part one of our series on digital photography, Dr Daniel Silver explains why busy clinicians should take photos. PAGE 36 ACCREDITATION Dr Paul Mara discusses the implications of the new standards on medical records. PAGE 38 EPIDEMIOLOGY Dr David Brookman helps you prepare your data for accurate recalls and self-directed audit. PAGE 42 SHUTDOWN Mr Fixit challenges us to better position our servers for security and maintainability.

PAGE 24 BROADER BROADBAND Simon James thinks ADSL2+ gives long suffering “broadband” users something to cheer about. PAGE 26 2HIPPO Nathan Hay takes a first look at “intelligent messaging” provider 2Hippo. PAGE 28 GOOGLING GOOGLE Dr Tony Lembke looks beyond the search engine. PAGE 30 PODCASTING WITH ITUNES Mr Louis Joseph teaches the art of Podcasting. PAGE 32 UNIVERSAL POWER SUPPLIES Samuel Logan explains why every practice should have one. PAGE 34 BACKUP TECHNOLOGY Nathan Coultard outlines your backup device options.

GENIE

www.pulsemagazine.com.au

STARTUP

INTRODUCING... Pulse IT is Australia’s newest and most innovative health publication. This launch editorial outlines our vision for the Pulse IT magazine, DVD and website. Simon James BIT, BComm The promise of IT in health since the advent of the personal computer has been better patient management and practice efficiency. Despite the continual improvements to computing hardware and the software servicing the sector, the reality has been far less impressive for most medical centres. While there will always be external factors, better education amongst the users of health technology will play a significant role in shaping the future of health IT in Australia.

MAGAZINE

Pulse IT seeks to bring doctors, practice staff and IT professionals timely, relevant articles that we hope will improve their awareness and understanding of IT and its application in health. While there will be coverage of developments that will affect medical practices in the future, our primary focus will be on solutions that are already available. We will seek to include a diverse range of articles that will have wide appeal amongst the readership. While some articles will be of moderate technical complexity, the vast majority should be relevant and interesting to even the most computer shy person.

DVD

Each edition of Pulse IT will ship with a DVD containing software and other resources from innovative companies operating in the health arena. Typically the DVD will include demos, software updates and documentation allowing the user to increase their awareness of the great diversity of IT products available in health. Prior to Pulse IT, cost effective mass marketing opportunities for health IT providers have simply not existed. In unison with the magazine, it is our hope that the DVD will assist quality products to quickly gain exposure and penetration Australia wide, resulting in better outcomes for the health providers and in turn, their patients.

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The developers of the included software will be more than happy to assist with any enquiries you may have about their products, and will welcome suggestions for future inclusions.

WEBSITE

All articles published in the printed edition of Pulse IT will be made available online. Like the magazine, we intend to keep our website uncluttered, maintaining a strict focus on the content. Articles won’t be locked behind passwords or wedged between gratuitous advertising. Our website has been built on a highly flexible framework, and will allow us to incorporate cutting edge technologies and new content rapidly. Article Comments To facilitate discussion and debate, we have included a commenting feature at the end of each article so that supporting and alternate views can be voiced. Forums While the existing software vendor forums and email lists are the ideal place to discuss issues relating to your practice software, the Pulse IT forums will serve as a place for readers to discuss IT related topics that extend beyond the boundaries of their chosen package.

THANKS

I’d like to take this opportunity to extend a special thank you to all our launch edition writers and sponsors. Without their leap of faith, health IT may have never received the significant coverage it deserves. While we are proud of our first edition and have been humbled by the pre-launch interest, we can say with confidence that Pulse IT will continue to develop and become an useful and enduring part of the health IT landscape. Simon James, Editor simon.james@pulsemagazine.com.au

WHATS NEW FOR EDITION TWO?

The second edition of Pulse IT will arrive at medical centres at the start of October. Under the editorial guidance of a diverse advisory board, we plan to grow the magazine in both page count and scope. Magazine The following sections will be added: • Letters to the Editor. • A section answering technical questions from readers. • A section presenting tips and tricks from the readership. In addition, the Pulse IT news section “Bits & Bytes” will be expanded, and we expect to add more peak bodies to our already impressive list of contributors. DVD While maintaining a level playing field for the sponsors, the Pulse IT DVD will be revamped to include an “auto run” directory to make the content more accessible for less technically minded users.

FEEDBACK AND INPUT

We welcome feedback on all aspects of our publication including the editorial direction, design, website and the DVD. We invite doctors, practice staff and IT professionals who would like to contribute to Pulse IT in any capacity to get in touch. We are particularly interested to hear from medical centres with innovative or unique IT setups who are happy to share an insight into their IT systems with their colleagues. IT companies are invited to provide press material to the Editor for review using the details on page 4.

GUEST COLUMNIST

E-HEALTH:

BENEFITING AUSTRALIANS Our first guest article provides an overview of the Australian Government’s key objectives in meeting the challenges of delivering an efficient and accessible health IT plaftorm across Australia. The Hon. Mr Tony Abbott, Minister for Health & Ageing The Government’s e-health objectives are: first, to provide health professionals with the connectivity needed for swift access to information and financial transfers. Second, to ensure that patients can claim their rebate on line from their doctor’s surgery. Third, to ensure that private hospital patients can access information about rebates and particular “gap” payments for specific procedures and receive one consolidated bill. Fourth, and most important, to ensure that every significant health record is available in a digestible form to every patient and, with patient authorisation, to any treating health professional. Ultimately, better use of IT is about saving lives not just more convenience for patients and the people treating them, important though that is. An integrated health record could prevent some of

Territory where 7000 people have an electronic health record. If a person needed to visit a GP while away from home, the doctor could securely access his or her electronic record to help provide appropriate care. In the Eastern Goldfields district of Western Australia, doctors have secure online communications with pathology and radiology services, hospitals and the Royal Flying Doctor Service. The network lets GPs access essential patient information and test results. A GP in a remote practice can take a blood sample, send it to a city laboratory that afternoon, and see the pathology reports online the following morning. In Tasmania and South Australia, major public hospitals can notify a nominated GP electronically when a patient has been admitted or discharged.

In health IT, government’s best role is to make things possible rather than to make them happen. the estimated 3,500 avoidable deaths a year in hospitals due to inadequate record keeping and incomplete information. Online access could avoid repetitive radiology and pathology tests and save a significant part of the $3 billion a year spent on diagnostics. Electronic funds transfer from the Health Insurance Commission into people’s accounts could spare millions of patients the inconvenience of form-filling and trips to Medicare offices. Thousands of Australians are today benefiting from e-health through Government initiatives such as a trial in the Katherine region of the Northern

Broadband is driving e-health capability. More than 3,000 health care practices and nearly 4,000 pharmacies throughout Australia are now connected to business-grade broadband, thanks to the Commonwealth Government’s Broadband for Health program. The widespread use of prescribing software by medical practitioners means that 75 per cent of all original prescriptions are now computer generated. More and more, health providers and the public are turning to the Internet for health information. Since 2003, for example, three million Australians have used the Government’s HealthInsite

portal, which gives access to health information from approved information partners. It covers such important topics as diabetes, cancer, mental health and asthma. At present, around 4,500 Australians access HealthInsite every day. The National eHealth Transition Authority (NeHTA) is responsible for fast tracking e-health standards and developing the nationwide consistency that will allow clinical information to be shared by healthcare providers throughout Australia. In February this year, the Council of Australian Governments (COAG) committed $130 million to fund NeHTA’s work for the Individual Health Identifier, HealthCare Provider Identifier, and Medical Terminologies initiatives, for the next three years. In health IT, government’s best role is to make things possible rather than to make them happen. As minister, I will do everything I can to create a benign environment but it’s mostly up to the private market to develop the systems and the medical profession to use them if Australia’s health care is to remain second-to-none. Government can’t be the great provider but it should be the great facilitator, so the private sector can deliver e-health solutions. Pulse IT welcomes contibutions from people and organisations who influence the direction and use of IT in health.

QUICK CLICKS Health Insite www.healthinsite.gov.au NEHTA www.nehta.gov.au

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BITS & BYTES

BEST PRACTICE RELEASES “TOP POCKET”

MEDIPAK REBORN AS ZEDMED

Best Practice has upped the ante with the release of Top Pocket, a Pocket PC extension to its flagship product Best Practice.

Melbourne based Medipak has relaunched itself as Zedmed. With a lineage stretching back into the late 70’s, Zedmed has an established customer base with practices spread throughout Australia.

While not intended as a replacement for BP Remote (the Best Practice offsite logging solution), clinicians using Top Pocket on a compatible PDA can download patient files from Best Practice, view and add notes, refer to important demographics, and record prescription information and allergies. Interation checking and access to the BP Drug Database is also possible. Marketed as a “drop in replacement for MD2”, Best Practice has more than 1000 doctors spread over 200 sites using its flagship product with the same name. Despite being in business for less than two years, the company is enjoying an impressive growth rate of 5 sites per week, and expects to hit 500 sites by 2008-2009.

SIZE MATTERS AT DELL In early June, Dell refreshed its large monitor offerings, releasing the 2407FPW 24 inch widescreen. Compared to the 2405FPW which it replaces, the 2407FPW has few new features, testiment to the already excellent product (which coincedently is what Pulse IT was created on). A revised monitor stand, better contrast ratio and faster refresh rates are welcome changes. HDCP technology has been enabled in anticipation of new video encryption technology lurking on the horizon. While this technology is unlikely to have an impact in medical practices, it is a welcome addition as it ensures that this monitor’s resale value won’t be adversly effected in the future. With a native resolution of 1920x1200 pixels, this monitor allows nearly twice as much information to be displayed when compared to a typical 17 or 19 inch monitor. In a practice setting this means appointment screens can be larger, more clinical information can be shown without scrolling, and digital radiology “films” can be displayed in their full glory.

Lorraine Pyefinch, Director of Best Practice says that while most of their customers are converting from Medical Director 2, they are surprised by the number of newly established practices wanting an integrated, advertising free solution.

Like many Dell monitors, this model can be rotated 90 degrees on its robust stand. In the very least this is a good party trick, but may be the prefered orientation depending on available space and the task at hand.

Lorraine went on to say that enquiry is also strong from users of other clinical packages, however she admits that data conversion routines will need to be written before this market can be catered to fully.

At the time of writing, this monitor was retailing for $1499 from the Dell website. Readers should note that the price of Dell’s big ticket items fluctuates regularly, and price reductions on this monitor of 20% or more are not uncommon.

Best Practice www.bpsoftware.com.au

Dell also retails the 3007WFP, a 30 inch behemoth that could easily double as a drinks table at your next BBQ. In addition to the puchase price of $2,900, this monitor requires a high end graphics card (dual-link DVI) that will add aditional costs to most purchasers.

Pulse IT DVD A comprehensive training video and installable demonstration versions of Best Practice and Top Pocket are available on the Pulse IT DVD.

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Dell Australia www.dell.com.au

Sporting their new company colours at the Sydney GPCE, the team from Zedmed were hard to miss. Their booth was well attended throughout the weekend, giving the company a chance to demonstrate their flagship products, Zedmed Clinical and Zedmed Office. Zedmed www.zedmed.com.au

MD3 REGISTRATION RATE RISES Despite a slow start, Medical Director 3 (MD3) appears to be gaining traction in the market. MD3’s advertised user registration rate has risen to 39%, approximatelly three times the published figure just a few months ago. Notable improvements over its ageing sibling include a more robust SQL client-server database architecture, an integrated digital radiology viewer and free access to MD Reference, a web based library of clinical texts. Less advertising interference and a shared database (with PracSoft 3) are other improvements that will be welcomed by users. Current MD2 subscribers can upgrade for free. Medical Director 3 www.hcn.com.au/md3 Pulse IT October Edition Look out for a comprehensive review of the Filmless Imaging Technology in the next edition of Pulse IT.

BITS & BYTES

ONLINE WITH DOCSTOCK

GPCOMPLETE FLYS WITH FIREBIRD

DocStock, a purely online medical supplies store continues to carve a niche into the Australian market.

The Practice Management Software Company’s (PMSC) flagship product GPComplete, was launched in late May 2006 at the GPCE in Sydney.

Founder and Managing Director Matthew Smith, a former Marketing Manager for Welch Allyn says the main thing that differentiates his business is cost and convenience. At the time of writing, some items listed savings of up to 45% off the recommended retail price. “As DocStock doesn’t employ sales reps, have a fleet of company cars or maintain an expensive office or showroom, our operating costs are significantly lower than traditional distributors. That cost saving is then passed on and enjoyed by the customer. The convenience factor is the other key attraction for our customers. Our website allows them to view the product information, including pricing, see a quality photograph of the product and print or download a brochure. And all of this is available at any time of the day or night. If that still isn’t enough, they can always send us an email, or pick up the phone and ask questions”. Unlike other online stores, DocStock maintains an inventory in Australia. Often this means customers can have their products within 48 hours from the time of ordering. “Paying less for your goods doesn’t always mean having to wait a long time to receive them”, says Matthew. “We stock a large range of commonly ordered equipment, and can get many other lines at short notice. On top of that, being Australian-based helps to provide piece of mind that you are buying products that come with full warranty, suit the Australian power supply and conform to local regulatory and taxation requirements”. When DocStock opened its digital doors in late 2005, it exclusively sold Welch Allyn products. Over the past 9 months,

GPComplete uses Firebird for its underlying Database Management System (DBMS). Firebird is the open source version of Interbase, a DBMS that is popular with large organisations including Boeing, Nokia and the US Army. Closer to home, Firebird is used in solutions developed by Zedmed and ArgusConnect. When asked what benefits this provides a medical practice, Dr Nicholas Kemp, Director of PMSC explained that “Over the lifetime of the product, your software grows with your practice, without the threat of a nasty surprise in licensing fees once you hit the maximum threshold in size. Therefore the ‘performance throttling’ you will begin to see on other systems when 5 or more tasks are running at the same time won’t occur with ours.” He went on to outline the benefits of open source products more products from other suppliers have been added to expand the offering. Products now available include Diagnostic Sets, Stethoscopes, ECGs, Doctor’s bags, Dopplers, Lights, Thermometers, Patient Scales, Eye charts and Sutures, plus many more. DocStock had an excellent response at the GPCE in late May, selling out of several product lines. Matthew said that both his products and business model were well received by conference delegates. For more information, visit the DocStock website. DocStock www.docstock.com.au

generally. “Open source products are characterized by rapid response to user requirements. Development of the product is not constrained by commercial objectives but by the collective needs of the users of the product. Also because the source code is freely available for such products, bugs and security loopholes are identified by a far larger group of people, leading to their early identification and subsequent closure.” More details including a Flash video demonstration of GPComplete are available from the PMSC website. GPComplete www.pmsc.com.au Firebird www.firebirdsql.com Pulse IT DVD An installable demo of GPComplete is included on the accompanying Pulse IT DVD. More information about the DVD including installation instructions can be found on page 10 of this magazine.

GENIE RELEASES ORTHOPAEDIC MODULE In what they are claiming as a world first, Genie Solutions has added an orthopaedic module to their integrated clinical, billing and appointment system. The module was designed in consultation with a number of orthopaedic surgeons from some of their sixty existing orthopaedic practices. Built upon the existing Genie clinical record, the orthopaedic module adds a variety of scoring methods including Harris Hip, Oxford Hip, Oxford Knee, Lysholm Knee, HSS Knee, Ankle & Hindfoot, Midfoot, Hallux MTP-IP, Mayo Wrist and Constant Shoulder. These scores can be recorded pre-op and at regular post-op intervals for easy analysis. Since being the first company to implement HIC Online in 2002, Genie has grown rapidly and now boasts 750 sites, with over half being specialist clinics. Genie Solutions www.geniesolutions.com.au Pulse IT DVD A review of the Genie Orthopaedic Module will be included in the next edition of Pulse IT, but you can check it out now by installing the demonstration version included on the Pulse IT DVD.

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PULSE IT DVD

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Each edition of Pulse IT includes a DVD with a collection of resources from software companies working in the health sector. The following instructions compliment the documentation provided on the DVD. Don’t hesitate to contact the appropriate company using their details on page 41 if you need assistance. ARGUS

ArgusConnect have included an18 minute narrated video presentation of their product, “Argus”. Windows Window users can begin the presentation by opening the file named: Double-Click for Argus Presentation Mac Mac users can begin the presentation by opening the file named: mac_users_start_here.html This file should also work for other non-Microsoft operating systems. ArgusConnect Website Opening the “Argus_Website.html” file will direct you to the ArgusConnect website if you have an active Internet connection.

BEST PRACTICE

Best Practice have included: • Installable demonstration versions of “Best Practice” and “Top Pocket” with documentation. • A comprehensive training video. Demo Software and Documentation To install any of the included software or view the documentation: 1. Open the “Demo Software” folder. 2. Launch the “setup.exe” program and follow the prompts. Training Video To start the training video: 1. Open the “Training Video” folder. 2. Launch the program named “BPTutorial.exe”. Best Practice Website Opening the “BestPractice_ Website.html” file will direct you to the Best Practice website if you have an active Internet connection.

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GENIE

Genie Solutions have included: • Installable demonstration versions of their “Genie” software for both Windows and Mac systems. • The Genie manual as a PDF. • A PDF promotional flyer for their Orthopaedic Module. Demo Software To install Genie: 1. Open the “Demo Software” folder. 2. Open the appropriate folder for your computer i.e. Windows or Mac. 3. Launch the installer program and follow the prompts. Genie Solutions Website Opening the “Genie_Website.html” file will direct you to the Genie Solutions website if you have an active Internet connection.

GPCOMPLETE

GPComplete have included an installable demonstration version of their product. Documentation Please note that the installation instructions included in the “Documentation” folder have been superseded by a document available at: www.pmsc.com.au/GPCompleteDemo.pdf

Demo Software To install any of the included software or view the documentation: 1. Open the “Demo Software” folder. 2. Launch the setup.exe program and follow the prompts. Default login details for the administrator are: • Username: Admin (not case sensitive) • Password: abcde (case sensitive) When you login for the first time GPComplete will prompt you: 1. To change your current password and; 2. Ask you to enter a Staff-Key.

Sample Data You can insert the sample data by: 1. Logging in to GPComplete 2. Go to Help > Insert Demo Data Remove sample data by going to: Help > Delete Demo Data. This will not delete any information you have fed into the system. Note: Once Demo data is deleted it cannot be inserted back into the system. Help Help files can be accessed via the “Start Menu” at: Programs > GPComplete > Help Help can also be accessed from within GPComplete by going to: Help > Help Topics GPComplete Website Opening the “GPComplete_ Website.html” file will direct you to the GPComplete website if you have an active Internet connection.

MEDICAL OBJECTS

Medical Objects have included an information kit with links to their software and other resources. Some of the links require an active Internet connection as they reference files on the Medical Objects website, and others link to files on the Pulse IT DVD. Getting Started To launch the information kit, simply open the file named: start_here.html Medical Objects Website Opening the “MedicalObjects_ Website.html” file will direct you to the Medical Objects website if you have an active Internet connection.

COLUMNS: GPCG

COMPUTER SECURITY AND GENERAL PRACTICE Jane London Computer security in general practice is critical, ensuring business runs efficiently and to maintain the integrity of the electronic health records. The constantly evolving face of general practice makes it necessary to have an equally adaptable medium with which to organise patient and business information. The shift from paper based to IT savvy practices is under way meaning that decision support tools and other information from organisations operating in the national eHealth arena are of vital importance.

of technical issues can be completely avoided though. However we will discuss these in a future article.

ORGANISATIONAL ISSUES

Security Coordinator Who looks after your computer security? Chances are that if there is no coordinator, the oversight of the system will be lost. The coordinator doesn’t need to be the technical Jo(e) Fix-it, rather a member of the practice who understands the concepts and takes responsibility for the computer systems security. While it would be possible to assign the role of security coordinator

Policies And Procedures How is everything handled? Don’t store it in someone’s head, write it down! There should exist a manual that outlines the coordinators role, the disaster recovery plan, access control and other security aspects.

THE GPCG COMPUTER SECURITY SELF-ASSESSMENT GUIDELINE

This document has been designed with the practice, that is, its staff and GPs, in mind. That’s right - it is not a technical manual, but will help your practice put a series of computer security strategies in place. It covers organisation issues

In order to improve your practice, it isn’t necessary to have a thorough knowledge of IT systems, binary, gigabytes, RAM, firewalls and routers! One of the fundamental concerns of all medical practices in Australia is the preservation of privacy. Particularly when information is contained electronically on a server that is accessed by a number of different staff. And not to forget accessed remotely too. Security is also important because, if not maintained properly, can lead to a loss of patient clinical information, making medical care more difficult and prone to errors. In order to improve your practice, it isn’t necessary to have a thorough knowledge of IT systems, binary, gigabytes, RAM, firewalls and routers! What you do have to come to grips with is a better understanding of what the risks are, why they are important and what you need to do about them. This is why the IT systems are needed in the first place - and so they are the most valuable pieces of the puzzle. That’s not to say that a basic understanding

PULSE IT DVD

The GPCE Security Guidelines and Security Checklist are included on the accompanying DVD.

to two or more people, this isn’t recommended unless strictly defined sub-roles can be designated. Access Control Only certain people should see some types of information such as sensitive financial or clinical information. Delineate this and stick to it. Procedures need to be in place for occasions when an authorised person/s isn’t available, e.g. an invoice needs to be modified and reprinted but the Practice Manager is out for lunch. Disaster Recovery Plan It is Murphy’s first law “If something can go wrong, it will go wrong”. This plan will help your practice continue business as usual in terms of everything from making appointments and raising invoices through to providing clinical care. Consulting Room And Front Desk Security Screen visibility both at reception and within the consultation is a matter to be considered. It may be as simple as changing the position of your screen but there are other techniques, such as screen savers, that can be used.

outlined above as well as helping you understand some fundamental IT standard practice such as backing up data, viruses and virus protection, firewalls, network maintenance and secure electronic communication.

CONTACT

Should you wish to know any more details or get your hands on a copy of the guide, you can contact Jane London at the Royal Australian College of General Practitioners. It is also available at the GPCG website and on the accompanying PULSE DVD. Jane London works in the Quality Care Unit of the RACGP coordinating ongoing GPCG activities.

QUICK CLICKS

GPCG www.gpcg.org.au RACGP www.racgp.org.au Jane London jane.london@racgp.org.au

PULSE + IT

COLUMNS: HISA

INTEROPERABILITY AND INNOVATION IN AUSTRALIAN HEALTH CARE Dr Brendan Lovelock, PhD, AFAIM, MRACI, C Chem For many people, innovation carries the image of caffeine addled technologists huddled around computer workstations working deep into the night. However, this highly creative phase of technology development drives only a relatively small proportion of the innovation that impacts the Australian healthcare IT environment. In Australia, most of the innovation that will address the challenges facing our healthcare system will focus around how to select and implement existing technology in a necessarily conservative marketplace, an activity which relies on a different sort of creativity and skill. It is driven by the ability of healthcare institutions, technologists and vendors to communicate, educate and support individuals exploring the technology options available to them. Donald Berwick’s article, Disseminating Innovations in Healthcare (JAMA, 2003 Vol. 289, p1969) provides a good review of the forces impacting technology acceptance in healthcare. He describes a history of healthcare where the distribution of ideas can be dangerously slow. The largely cultural issues that impact this slow technology proliferation are focused around the perceived value of the technology, an individual’s predisposition to engage in change and the management/leadership within the group. The common thread running through all these factors is one of communication. It’s the ability for key decision makers to see and understand the technology and its impacts; to be able to discuss with others how these technologies are being implemented; and to physically observe the technology working, these are the most powerful drivers that influence technology adoption.

One program that is squarely focused on accelerating the diffusion of health IT through these principles is the Australian Interoperability program, which is supported by the Health Informatics Society of Australia and HL7 Australia. This program brings together the major Australian health information systems suppliers, along with the technologists and systems integrators, responsible for delivering the supporting communications infrastructures. The program’s objective is to construct fully interconnected health IT systems that can demonstrate to Australian healthcare decision makers the capacity for Australia to build and deploy these health information systems and to see the benefits that can be derived from them. It enables healthcare leaders to actually interact with the systems and better understand the value they generate. In particular, interoperability highlights the ability of these systems to create new health-critical information by combining data from many previously unlinked and disparate information sources. After months of planning, the interoperability team, comprising some of the leading Health IT experts in Australia, assembled at Telstra’s Innovation Centre in Sydney. Here they took the four scenarios that describe the patient experiences being demonstrated at this year’s interoperability event and established what was in effect, fully interconnected Health IT systems covering all the major information interactions that occur within Australian health facilities. This massive undertaking included all communications within single health institutions and across multiple health sites.

q The 2006 interoperability team with members from IBM, SUN, Cerner, Agfa, Medical Objects, McCauley Software, Trak Health, Kestral, Ocean Informatics, MacIssac Informatics and Meridian Health Informatics, at the Telstra Innovation Centre Sydney.

What does this mean for the diffusion of innovation? Well, it enables healthcare managers to physically see the benefits of what has often been a theoretical systems proposal for them. By doing so, it gives them the confidence that these systems work in an Australian health environment and that there are the support resources they need to build and maintain these systems. By gathering together healthcare managers who have similar objectives in deploying these systems, discussion and learning comes from their shared experiences. All these are key elements in accelerating the diffusion of innovation in healthcare. The interoperability program brings vendors and technologists together to critically look at the systems issues associated with interoperability. It provides a unique and safe environment where they can further develop their intersystem communications skills. In doing this we are building a stronger technology capacity in Australia and further developing the functionality and applicability of these products for Australian healthcare. Admittedly, the interoperability program has also involved many technologists huddled around workstations, and yes, there were large amounts of coffee consumed (thank you Telstra). However, the focus here is not new technology, but rather the strengthening of Australian healthcare’s ability to implement critically important and exciting, but existing, technology advancements. If you would like to see this demonstration in action, please come along to the Health Informatics Conference (HIC 2006) on at the Sydney Convention Centre (August 20th to 23rd). More information is available at the HIC website. Brendan Lovelock is the General Manager of the Health Informatics Society of Australia (HISA)

QUICK CLICKS

Health Informatics Conference (HIC) www.hic.org.au Health Informatics Society of Australia (HISA) www.hisa.org.au HL7 Australia www.hl7.org.au JAMA www.jama.ama-assn.org

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COLUMNS: NEHTA

DELIVERING AUSTRALIA’S E-HEALTH FOUNDATIONS Dr Ian Reinecke For some years now, there has been more promise from e-health than results on the ground. One of the reasons has been that the foundations of a linked, efficiently communicating healthcare system have not been put in place in a coordinated fashion on a national scale. The barriers to developing these building blocks have been many, which is why Australian Health Ministers agreed to give the task to an organisation designed and funded to do so. The National E-Health Transition Authority Limited (NEHTA) was established on July 5th, 2005 as a collaborative enterprise by the Australian Federal, State and Territory governments, to identify and develop the necessary foundations for e-health.

All while maintaining high standards of patient privacy and information security. The following outlines key aspects of NEHTA’s work, which is being undertaken in consultation with healthcare providers, consumers, the health IT industry and government agencies.

STANDARD CLINICAL INFORMATION

NEHTA has worked extensively with clinicians to specify the clinical data to appear in the electronic version of healthcare communications. Templates for trial are in the process of being developed with hospital discharge summaries and referrals being trialled in the near future.

With these building blocks in place, healthcare professionals will be well on the way to quickly and securely exchanging standard clinical information – information such as hospital discharge summaries, referrals and other priority health communications. These foundations will also ensure that information exchange can occur regardless of the software used by either the sending or receiving clinician. Ultimately, healthcare professionals will also be able to access any participating individual’s integrated health record.

STANDARD CLINICAL TERMS

The potential benefits of e-health systems across the national health sector are enormous and include:

NEHTA has evaluated various options to standardise the clinical terms used by systems within healthcare, and determined that SNOMED Clinical Terms (CT) should be adopted by e-health systems nationally. NEHTA has entered into an arrangement to make SNOMED CT available for use free of charge in health information software products used in Australia. Organisations who are interested in gaining free access to SNOMED CT for use in Australia should register their interest with NEHTA by emailing terminologies@nehta.gov.au.

• Improving the quality of healthcare services, allowing clinicians to more easily access accurate and complete information about their patients. • Streamlining the care of people with long term illness, who need to be looked after by many different health professionals, by enabling seamless handovers of care through for example electronic referrals and discharge summaries. • Improving clinical and administrative efficiency, by standardising certain types of healthcare information to be recorded in electronic systems; uniquely identifying patients, healthcare providers and medical products; and reforming the purchasing process for medical products.

The average encounter with a healthcare professional generates a large amount of clinical information - for example the diagnosis, treatment procedure and prescribed medication. The practitioner must choose from a huge number of ways and names to describe what they hear, see, prescribe or decide to do. When this information is sent to other practitioners – e.g. the pathologist, pharmacist, home nurse or specialist, each of whom may use different terms to describe the same thing – misunderstandings can occur.

NEHTA is working to extend SNOMED CT to suit the specific needs of the Australian healthcare environment and the practices of local health professionals.

IDENTIFYING HEALTHCARE PROVIDERS

clinical documents being sent to the wrong health practitioner, a means of identifying the 400,000 healthcare providers in Australia is being established by NEHTA. A national healthcare provider identification system will be rolled out from late 2007.

ACCURATELY IDENTIFYING INDIVIDUALS

Similarly, accurately identifying individual patients will significantly reduce the possibility of clinical information being assigned to the wrong patient. A national individual health identification system is currently under development by NEHTA, and a privacy assessment process has commenced. Healthcare identifiers for individuals are also anticipated to be available from late 2007.

PUBLIC HEALTH SUPPLY CHAIN

NEHTA has obtained the agreement of all Australian governments to a National Product Catalogue. This allows public health institutions in all States and Territories to obtain essential information about the medicines, medical devices and healthcare products they use, from the one electronic source. The National Product Catalogue will also hold information about non-medical products, such as office supplies and food items, becoming the source of purchasing information in the public health system.

SHARED ELECTRONIC HEALTH RECORDS

Ultimately, NEHTA’s work will lay the foundations for individuals to share selected health information with clinicians – wherever and whenever required, and in way that is secure and maintains privacy. Further information on NEHTA’s overall work program can be found at the NEHTA website. Ian Reinecke is the CEO of the National E-Health Transition Authority (NEHTA).

QUICK CLICKS NEHTA www.nehta.gov.au

To significantly reduce the possibility of

PULSE + IT

INTERVIEW

INTERVIEW: ARGUSCONNECT

In our inaugural interview Pulse IT checks in with Ross Davey, CEO of ArgusConnect. PULSE IT: What is Argus? Argus is a computer program that enables health service providers to securely exchange clinical documents via email. It operates on any doctor’s computer alongside existing medical software and provides additional features for the clinical environment such as security through the use of PKI encryption, the HL7 Standard for sending clinical data in an organised form and additional mechanisms that ensure recipients receive the document. Argus can provide doctors and other healthcare providers with access to pathology and imaging results, specialist letters, admission and discharge summaries, emergency department notifications and other related documents electronically and can import these documents into the patient notes. With Argus, a doctor can also transmit a pathology request, specialist referral, or compile and send a health summary to another doctor. Because Argus uses open, commonlyused internet technologies (e.g. email) other healthcare providers can implement Argus easily and cheaply. Also, doctors can choose whichever internet service provider they wish. PULSE IT: What is a practice required to do to get up and running with Argus? First, go to our web site and register your interest in Argus. This will get the ball rolling and we will contact you to determine how you would like to

PULSE IT DVD

An multimedia presentation from ArgusConnect is available on the Pulse IT DVD that accompanies this magazine.

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proceed and what facilities you have at present.

radiology practices or are private contractors.

Because ArgusConnect now provides both an interim email address and PKI keys as part of the install package, most practices will only need a computer with Internet connectivity to start to use Argus.

PULSE IT: What is the cost to a medical practice?

Client Site Requirements • PC with Windows 98, 2000 or XP, Linux or Apple Macintosh with OSX • GPs: Clinical software with pathology report receipt capability (PIT or HL7 format) • Specialists: as above or otherwise use MS Word for report typing • Pathology providers: Interface of lab system to ArgusEnterprise • Radiology Providers: Interface of lab system to ArgusX • Internet connectivity: dial-up or permanent connection with a speed of 28K up to broadband • Email address for the practice, dedicated to clinical messaging (i.e. different from doctors’ or practice personal email addresses) • HeSA PKI certificates for the practice PULSE IT: Can Argus be installed by a practice member, or is professional IT help required? Argus can be installed by a practice member and they could do this quite easily under the telephone guidance of our Help Desk staff. The entire installation and configuration normally only takes about 15 minutes from start to finish. However many practices choose to use an IT Professional because that person is frequently more able to understand the computer environment into which Argus is being installed. Also, around Australia there are more than 70 qualified ‘Certified Argus Installers’ who have undertaken formal ArgusConnect installation training, with more booked in for future training courses. Many practices avail themselves of the assistance provided by these people who work for Divisions, pathology or

Argus software licence is free to GPs and specialists. Support is also free to these medical practices. For other healthcare organisations such as pathology and radiology practices, hospitals and aged care facilities, Argus has a licence fee schedule that is linked to the size of the organisation. However even for these users there is an introductory low-volume fee-free licence offer available. All pricing is available for public viewing on our Web site. PULSE IT: How does Argus integrate with the practice’s clinical package? ArgusConnect has expended considerable effort in developing interfaces with most of the popular clinical software packages. This effort continues to be a large part of our development activity. We use a variety of methods of integrating depending on the capabilities of the various software applications; however most packages use a consistent means of receiving pathology, radiology and specialist reports, and Argus uses this method. The different software packages provide Argus with varying ways to capture their output reports and letters for sending to other healthcare providers. Currently packages that can export letters and reports to be sent by Argus are: • Zedmed • Genie • Medical Director • MedTech32 • Blue Chip • Best Practice Look for the ‘Argus Enabled’ logo on the software vendor’s publicity documentation. For specialists and allied health providers who simply use Microsoft Word to

INTERVIEW

compile reports, Argus provides an MSWord Template and interface so that reports can be sent directly from the Word menu. PULSE IT: Is Argus any different to other messaging software and if so, how? There are a number of differences that give Argus an edge over other messaging systems: • With Argus, doctors and other practitioners don’t have to sign up to a specific messaging service provider, which can restrict them to receiving documents only from that company’s clients. All users can choose their own ISP and can operate using dialup or broadband. • There is absolutely no cost for any user to send or receive messages, regardless of the type of practice or volume of messages. • There are no hidden secrets with Argus as Argus source code is open to any interested party. • Argus is managed by a not-for-profit company, ArgusConnect, and therefore is able focus on applying all funds to product development and service and not on a need to distribute profits to shareholders.

PULSE IT: How is Argus supported? Argus has a professional support team spearheaded by our telephone Help Desk. Most support for GP, specialist and other allied health practices is covered by remote Help Desk assistance. Many sites also have access to one of the 45 ‘Certified Argus Installers’ for assistance if the need is more complex or requires onsite assistance. For more complex issues, most sites also avail themselves of the option for ArgusConnect support staff to directly link to their computers using a secure online link. Larger and more complex sites enter into a comprehensive support agreement by which they pay a yearly fee to receive telephone, remote computer linkup, and on-site assistance. Standard support arrangements are available in business hours (8am to 5pm AEST) with after hours covered before and after these times by one Help Desk support staff member. PULSE IT: How many working sites does Argus have? ArgusConnect has current deployment projects happening in cooperation with

GP Divisions in Darwin, Alice Springs, Townsville, Toowoomba, Coffs Harbour, Bowral, Brighton, Mornington, Hobart, Burnie, Bendigo, and Adelaide North, with a further 8-10 ready to commence. Other deployment projects with organisations other than Divisions are taking place in Canberra, Nowra/South Coast NSW and Western Victoria. Four State Health Departments are using Argus for clinical data communication. Sites that are currently registered with our Help Desk include: • 150 GP practices • 32 specialist practices • 82 others (hospitals, community health centres, allied health etc) We are currently receiving about 60 registrations of interest per month. Pulse IT invites companies and individuals interested in participating in a future interview to contact the editor.

QUICK CLICKS ArgusConnect www.argusconnect.com.au

Calling Doctors and Medical Pr ofessionals Professionals 20 Day Everest Medical Trek

This trip designed specially with a medical orientation will take you trekking in Nepal s Everest region with world renowned High Altitude Medical specialist, Dr Jim Duff. As well as taking in the awesome views along the trails to Gokyo Lakes and the rich Buddhist culture found throughout the region, you will receive accreditation (QA & CPD points applied for). Dr Duff will set the scene for this specialised trek with a travel medicine slide lecture in the hotel on arrival in Kathmandu together with visits to the world famous CIWEC clinic, the Bir hospital and the Himalayan Rescue Association. In the mountains we will visit the Hillary Hospital and the rescue post at Machermo. During the trek Jim will highlight the medical conditions associated with high altitude - demonstrating the use of the Portable Altitude Chamber technology, developed by Jim, that is used for the treatment of mountain sickness. This superb (moderate grading) trek that is exclusive to World Expeditions combines the services of one of our longest serving leaders and author of Pocket First Aid and Wilderness Medicine, with high altitude, beautiful landscapes, culture and travel medicine. Cost: $3790 joining from Kathmandu Departure Dates: 2nd to 21st October 2006 and 1st to 20th October 2007

Call 1300 720 000 for detailed trip notes or visit www.worldexpeditions.com

PULSE + IT

PRACTICE REVIEW

PRACTICE REVIEW:

GUNDAGAI MEDICAL CENTRE In each edition of Pulse IT, we’ll take a look at a medical practice with an innovative or unique IT setup. We begin our tour at the Gundagai Medical Centre in rural NSW. THE PRACTICE

Gundagai is a pleasant rural town four hours from Sydney on the Hume Highway, and less than two hours from Canberra. The building that houses the medical centre in Gundagai started life as the town’s emporium, later housed a furniture shop and was reborn after extensive renovations as the town’s medical centre. The practice was established in 1982 and moved to the new premises in 2000. Opened by the then Health Minister Michael Wooldridge, the council owned building has five consultation rooms, a treatment room, procedures room, resource centre and meeting room, staff facilities and kitchen, and a pathology collection centre. The practice was designed from the ground up as a teaching centre for both medical students and GP Registrars. The practice is owned by husband and wife team Dr Paul Mara and Dr Virginia Wrice. Visiting specialists include a paediatrician and a cardiologist, and the practice is frequented by various allied health professionals including a podiatrist, physiotherapist, optometrist, psychologist and a diabetic educator.

COMPUTING HISTORY

Dr Mara, who completed a paper on Computer Science during his residence years in New Zealand has always had a keen interest in technology. His first computer purchase, a $12,500 IBM 286 portable was used primarily for word processing and writing computer programs. ‘Portable’ was a term used loosely in the early ‘80s, and this machine was literally the size of a suitcase despite having a tiny orange and black screen, and no hard drive! By the late ‘80s, Dr Mara had discovered the Mac platform and was drawn to them around the time when Microsoft started releasing the underwhelming early versions of Windows. The slick

16 PULSE + IT

graphical user interface, user friendly operating system and integrated networking justified the additional expense for Dr Mara. While this limited his choice of clinical applications, he recalls that the package he was using at the time from Jam Software was vastly superior to anything available on the relatively infant Windows operating system. When the practice relocated to the new premises in 2000, the computer system was changed to Genie, and runs the latest version presently. The practice has a history of innovation. To get broadband Internet to the new practice (which wasn’t available in the town at the time), Dr Mara took extreme measures and established an Internet Service Provider (ISP). As well as providing a much needed local access number for the town (at the time, most rural Internet users needed to pay STD rates to connect to their ISP), he was able to provide affordable Internet access to the surgery.

HARDWARE

The move to the new building saw an entire refresh of the practice computers. Since then, the practice has upgraded their systems in waves to ensure hardware is standardised across the practice. Computers The Genie installation is served by a Dual G4 Power Mac running MacOS X 10.3. This machine is completely dedicated to the task and typically has no direct human interaction. A pair of high performance hard drives are configured in a mirrored RAID arrangement for redundancy. At the time of writing, the machine recorded an uptime of 260 days, testament to the stability of MacOS X, Genie and the highly recommended measure of not using the practice server as a workstation.

The reception area, administration and consultation rooms are serviced by a fleet of eMacs also running MacOS X 10.3. Dr Mara said that while these machines have been reliable, they were starting to show their age. He indicated that he planned to refresh the whole line-up of desktop machines with Intel Macs once Genie releases an Intel native version. Begrudgingly it would seem, a Dell PC was purchased to facilitate HIC Online which wasn’t available on Macs at the time (although it has been for some time now). This remains in commission to support two Windows-only pathology programs. It also allows for remote access connections using Microsoft’s Remote Desktop Connection program, a technology for which there is no decent Mac equivalent at the host end. Dr Mara uses a late model G4 PowerBook for most of his computing, but also touts an ASUS laptop to run a few Windows-only applications. While he has tried emulation using Virtual PC, he described this experience as “painful”. Dr Mara had recently ordered a new MacBook Pro to replace both of his aforementioned laptops. Printers Each of the consultation rooms has a Kyocera FS-1010¹. These printers are configured with 3 paper trays (2 cassettes and a multipurpose tray), which minimises manual paper handling. While these printers don’t have top speeds that compare to current model laser printers, the time it takes for the first page to finish is still competitive and they have been very cost effective to run. The reception and back office administration computers are serviced by a reliable HP 4050² with 3 paper trays.

PRACTICE REVEIW

Scanning 2 years ago, a high capacity document scanner³ was hired to archive to PDF the 20 years worth of medical records the practice had accumulated. The hire of this device cost around $900, and the task consumed one month of a junior staff member’s time. The PDFs were linked to the electronic clinical records using Genie’s Image Pro module. A single click from the patient’s clinical screen opens this PDF, allowing the virtual paper file to be retrieved instantly. A Brother Multifunction Centre (MFC) was purchased for ongoing scanning and has performed well. Recently this device was superseded by a medium capacity document scanner�, however the MFC is still used for scanning pages from bound documents.

BACKUP AND REDUNDANCY

UPS A rack mounted Uninterruptible Power Supply (UPS) provides around 30 minutes of extra uptime to the main practice server and the networking equipment. RAID The aforementioned RAID mirror installed on the server is designed to provide data protection in the event of a physical drive failure. Backup A backup program called Retrospect consolidates important files from the various servers that Dr Mara runs. These backup files are transferred to a portable hard drive each night and taken offsite. Around 12GB of data are backed up each day onto the portable device, allowing for around 20 days of “roll back”. Each Saturday morning, a series of DVDs are burnt and stored securely offsite to ensure a permanent record is kept.

IT SUPPORT

Like many rural GPs, Dr Mara has supported his IT system with little outside assistance. While Divisional IT support

has not been in tune with his preferred platform or practice software, he has required little outside assistance citing few hardware problems and commendable software support from Genie.

GOOD, BAD, UGLY

Having highlighted most of the following himself, Dr Mara demonstrated an excellent grasp of the strengths and shortcomings of his IT system: Strengths • Standardised hardware purchasing makes software control easy and spare parts readily available when the computers begin to fail. • The predominantly Mac system should continue to provide a stable, easily maintainable platform into the future. • The absence of pathology and radiology software on the server is a highly recommended measure. • Preventative data protection measures have been taken, i.e. UPS and RAID. Recommendations • Ideally, the proprietary backup solution should be replaced with a system that allows the files to be restored without the use of the software. The Unix utilities built into MacOS X should be exploited to create backups that will ensure easy restoration for years to come. • On the release of an Intel Mac native version of Genie, the client computers should be replaced to improve the performance for the users. • When these new client computers are purchased, a new network switch should be installed to take advantage of their gigabit network cards. • While the high server uptime is impressive, it indicates that the operating system hasn’t had recent security patches installed. These should be downloaded and applied ASAP. Pulse IT invites medical practices interested in participating in a future practice review to contact the editor.

REFERENCES

QUICK CLICKS

2 - Current model HP 4350 www.hp.com.au

Parrallels Desktop www.parallels.com

3 - DR-3060, current model DR-3080II www.canon.com.au

CrossOver www.codeweavers.com

4 - Fijitsu FI-5120C www.fujitsu.com.au

WINE www.winehq.com

1 - Current model FS-1030 www.kyocera.com.au

Microsoft’s Mac Site www.microsoft.com/mac

WINDOWS ON MAC

While no self respecting Mac afficianado enjoys using Windows, the reality is that some Windows programs have no suitable equivalent on the MacOS. For over a decade there have been solutions to allow Windows to be run on Mac hardware, however since Apple switched its processor architecture to Intel, the concept has finally come of age. Remote Desktop Connection While not strictly running Windows on your Mac hardware, this program from Microsoft allows you to take control of a Windows computer, either on your local network or anywhere via the Internet. Emulation - Virtual PC Virtual PC, another Microsoft product, emulates Intel hardware on a PPC Mac, allowing Windows or other operating systems to be installed and run along side the MacOS. The process of “translating” the Windows software to the Mac hardware has a serious impact on performance, making it unsuitable for many tasks. Further, compatibility and support with all Windows programs isn’t assured, making this a less than ideal solution. Boot Camp While currently in public beta status, this software from Apple allows Windows to be installed on Intel Mac hardware. Once installed, the user has the option to boot into either Windows or MacOS. When running in Windows mode, software talks directly to the Mac (i.e. Intel) hardware meaning performace is equivalent to similarly configured “PC” hardware. Parallels Desktop This is a recently released commercial product that allows other operating systems to be run within the MacOS. Speeds that approach native performance in most tasks, and the ability to run both Mac and Windows programs at the same time make this the most appropriate solution for the majority of users. CrossOver and WINE CrossOver, a commercial implementation of WINE should be available by the time you read this. A technology that has long been available for Linux users, WINE allows selected Windows software to be run without Windows! This progress of this product will be watched with great interest by Mac users world wide.

PULSE + IT

QUESTION TIME

QUESTION TIME: YOUR IT SUPPORT PERSON They have no dress sense, talk a different language and probably aren’t bothered about either. Pulse IT has some questions for your IT support person. Business savvy IT support outfits long ago identified the health sector to be an attractive niche to operate in. Their clients have high earning potential, Government and advertising subsidised computing and relatively conservative system requirements. On the other side of the coin, IT support people (ITSP) face doctors reluctant to pay for outside help, low levels of IT literacy among practice staff and an environment where computers are a critical tool and downtime isn’t tolerated. Our first “Question Time” poses some questions for practices to ask their IT support person (ITSP). They have been narrated for clarification, and can act as a checklist to ensure that common traps are avoided. 1. What are the terms of our relationship? The contractual terms of the arrangement with your ITSP need to be clearly defined before a mouse has been clicked or a disk inserted. Typical support contracts will include an on-call retainer component, in addition to an ad hoc support rate. Whatever the arrangement, ensure that there is incentive for the ITSP to do their job well. Paying a fixed price per year is a simple way to achieve this, so long as specific minimum standards are agreed upon and enforced. Establishing an arrangement based on a purely ad hoc rate provides no incentive for the ITSP to work efficiently or objectively. 2. Do you have the appropriate insurance? While IT contracting is a relatively safe profession, all workers who enter your practice need to be covered by appropriate insurance policies. This may include public liability, professional indemnity and workers compensation.

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A breach of patient confidentiality, data loss or something as simple as a staff member tripping over the contractors bag can have far reaching and damaging effects on the practice. Consult a insurance professional if you are unclear as to what is required. 3. What are your after hours contact details and when can I call? Computer problems don’t adhere to business hours, and nor should IT support. Due to the reliance on IT systems in medical practices, after business hours is generally the only time major work can be performed. When negotiating the terms of the arrangement with your ITSP, ensure that a provision for after hours support is included. If this isn’t done beforehand, expect to pay penalty rates, fix the problem yourself or endure downtime. 4. In the event that we can’t contact you, who do we go to for help? For various reasons, IT support companies rarely grow larger than a handful of staff. The IT knowledge you are paying for is usually stored in the heads of a few key staff members, and they will not always be available when you need them. Talk to your ITSP about arrangements for such cases, and ask them to recommend an alternative operator for such emergencies. While this may rise a few eyebrows, your ITSP should have nothing to worry about if they are performing adequately. 5. How many staff do you have, and what are their rates? As well as having more people available to assist in the event of emergencies, larger IT support organisations will have staff with a range of qualifications, ability and charge out rates.

Having a senior technician installing minor software updates or wiring ethernet cables is not cost effective and shouldn’t be necessary. If the task appears to be simple, request a junior tech in the first instance. In the event that a problem is beyond the junior, they should still be able to rectify the problem with phone input from someone more knowledgable. 6. Do you retail the hardware or purchase on our behalf? While hardware margins are slim, some ITSP purchase and on sell computers, printers and other equipment to their clients to boost their revenue. Usually this results in equal and sometimes better prices for the practice. An important point needs to be made however: If an ITSP sells you hardware, they are directly responsible for the warrantee of the product, not the company they purchased it from. If for example you are invoiced by your ITSP for a Lexmark printer and it breaks within the warrantee period, it is their responsibility to follow the repair up with their supplier in a timely fashion. This is enshrined in the Trade Practice Act, so don’t wind up in a position where you are chasing an upstream supplier directly. 7. Will you install and support my clinical package? While some ITSP market themselves as “total solution providers”, the reality is that there are very few operators that can deliver on this promise. While most ITSP have a good grasp of networking, operating systems and hardware, very few will have the same level of knowledge when it comes to your clinical package. Your ITSP may have good intentions, but the reality is that some problems can only be resolved by the software vendor e.g. program bugs, 3rd party software integration etc. As you are probably

QUESTION TIME

already paying an annual support fee to cover such situations, don’t be persuaded to pay twice. The greatest assistance the ITSP can be in such situations is to apply their problem solving skills and communicate the situation to the software vendor. If your current software vendor isn’t fulfilling the terms of your arrangement, address this with them. 8. Does our software vendor have remote access? Many issues relating to practice software can be quickly resolved if the vendor has access to the users screen. While faxed screenshots, lengthy telephone conversations and emails can usually give the software vendor’s support team enough information to provide a resolution, allowing them remote access nearly always expedites the process. There are many secure ways to facilitate remote access, and there are many ways to expose your network and data to the world and its nasties. Be sure your ITSP is confident they know the difference! Ideally, the practice manager or practice principle will be able to issue the software vendor remote access details as required. After the problem has been resolved, the password should be changed to close the potential security hole. 9. Where is the documentation for our system? As an ITSP typically builds you IT system from already documented hardware and software, system wide documentation rarely materialises. While duplicated documentation is not required, instructions that connect the various parts of the system to your practice work flow should be written. If you don’t have one already, a section in the practice manual should be created to contain these notes. 10. Where is the job log for the work you just completed? While most ITSP will provide a basic overview of what work was carried out in their invoice, rarely is this enough to fully understand what has just happened. A detailed summary may not be of much use to you as a practice staff member, however your software vendor or indeed another ITSP may find this information extremely useful in resolving issues, particularly if they relate to work just carried out.

11. What’s the password for...? For the same reasons outlined above, any passwords that may be needed by other approved parties need to be easily accessible by authorised practice staff members. Usually this would be the practice manager and/or practice principle. There are secure ways of storing passwords within a computer system, so writing them in the practice manual or on a “hidden” scrap of paper isn’t appropriate. 12. What’s the strategy if: a) The server goes down? b) A client goes down? c) The Internet goes down? These three scenarios need documented action plans that can be initiated with little or no assistance from the ITSP. For this to work, the ITSP will need to be proactive and additional hardware, documentation and training may be required. This will add additional expense up front, but is money well spent and should minimise downtime and on site service visits. 13. Does our practice meet the IT requirements for the RACGP 3rd edition standards for accreditation? While few like the additional hoops accreditation has imposed on General Practice, the ones related to IT are very achievable and need to be addressed.

While this scenario is typically very stable and can save money, relying on another computer for printing has the potential to cripple your printing capability if the required computer is down. As a general rule, printers that need to be accessed from multiple machines should be purchased with a network card. Any laser printer that is suitable for use in a medical centre will have the option for a network card, so external print servers should be avoided. If this is not possible due to budgetary constraints, ensure that a written procedure is available to allow a non-technical person to connect and share the printer from another computer in the event of problems with the “host” computer. The cost of calling in your ITSP to perform these steps will erode the cost savings by omitting the network card in the first place. 16. You’ve just sold me an expensive Tape drive for backups, but my clinical data file is only 600MB? As outlined in the “Backup Technology” article on page 34, there are many different ways to perform backups. While tape drives DO have application in some cases, the vast majority of medical practices are suited to other options, which can be deployed cheaper and don’t suffer the downsides of tape. Keep in mind that just because they are commonly used in enterprise doesn’t make them immediately suitable for your important data.

The majority of ITSP won’t have heard of the RACGP and have little understanding of the practice accreditation process. If you’re ITSP is not aware of the Standards, don’t expect them to build your system to meet them.

As with every IT purchase, ensure you ITSP can provide cost/benefit justification.

14. Have you reviewed the General Practice Computing Group’s (GPCG) Security Guidelines?

As the article on page 32 details, UPS devices are a very cost effective way of protecting your server and the data it holds. Every practice should have at least one.

While the GPCG isn’t undertaking any new projects currently, the “Security Guidelines” is still a relevant and important document.

17. Why don’t we have a Universal Power Supply (UPS)?

In the next edition of Pulse IT we pose some questions to your practice software vendor.

This document is available on the Pulse IT DVD and from the GPCG website. 15. Why do I need to have another computer turned on to print? Modern operating systems make seemingly complex things easy. The ability to share a printer connected to a single computer with a whole network is one such example.

QUICK CLICKS GPCG www.gpcg.org.au RACGP www.racgp.org.au

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COVER STORY

DIGITAL PHOTOGRAPHY FOR BUSY CLINICIANS

In part one of our series on digital photography, we see why busy clinicians should include photos as part of their medical record. Dr Daniel Silver MBBS, Bmed Sc, DRCOG, FRACGP The rapid evolution of digital photography technology in the past decade has greatly changed the dynamics and efficiency of its use for the documentation of clinical information. Good quality digital cameras are now very affordable and can take high quality images useful in many different clinical settings. Unfortunately very few doctors currently use one in their daily work even though many have made the switch to computerized medical record systems which can now easily incorporate digital photographs. In addition, the increasing cost of medical litigation has placed greater burdens on clinicians to accurately document their dealings with patients in order to minimize future risks. There is now a very strong case to add photographic evidence of our clinical observations in certain circumstances in order to improve the quality of documentation for legal protection when things don’t quite go the way we wish. This article has been written to encourage readers to consider using digital photography to enhance the quality of care they provide as well as improving their medical records, and will argue that the benefits greatly outweigh the costs in time and financial outlay. Further articles planned for forthcoming editions of Pulse magazine will cover practical issues such as selecting a digital camera and accessories for clinical work, how to take excellent close-up photos, and how to make the best use of one’s digital photographs.

WHY SHOULD BUSY CLINICIANS USE PHOTOGRAPHY IN THEIR CLINICAL WORK?

The old adage that “a picture is worth a thousand words” is just as true in clinical medicine as in every other professional field. Much of the information we gain from patients is visual and in some fields of medicine such as dermatology, ophthalmology, radiology and cardiology visual clinical information is

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of vital importance for diagnosis and management. In general practice a significant proportion of consultations (about 15%) involve skin conditions or cutaneous manifestations of systemic disease. Skin cancers will affect 50% of Australians and a growing level of paranoia about skin cancers especially malignant melanomas propels many patients to their GPs, to dermatologists and to Skin Cancer clinics for “mole checks”. Most trauma will cause visible signs on the skin or visible deformities. What better way is there to accurately document visual information of diseases such as skin cancer than photographs? Clinical photographs are an excellent aide memoire when one wants to review a suspicious lesion in the future – our memories are very fallible and without photographs it’s virtually impossible to recall the exact appearance of a skin lesion or, worse still, of a number of skin q Crush injury at work.

lesions weeks or months after they were originally examined. Clinical photographs can be a wonderful teaching resource for junior colleagues who, without such resources, may take many years to gain sufficient experience to accurately diagnose skin lesions. Dermatology is one of the most neglected specialties in undergraduate medicine and most medical students have very few opportunities to see common rashes or skin cancers. Apart from a very few training positions for those doctors destined to become dermatologists, there is virtually no training about common skin problems for junior hospital doctors before they switch to vocational training positions and therefore most specialists excluding dermatologists have had virtually no experience with common skin conditions.

COVER STORY Training for general practice is still crying out for adequate resources specifically designed to improve diagnostic skills in dermatology even though every experienced GP knows that patients commonly present with rashes and skin lesions. So there is a need for more doctors to take clinical photographs in their daily work to help teach future generations of clinicians of all types. Good photographs can also provide excellent legal evidence and may provide sufficient support to minimize or eliminate the risk of successful medical litigation in many circumstances whereas the lack of photographs may undermine the chances of successfully defending a charge of negligence! Even psychiatrists may find value in documenting visual evidence of trauma or perhaps video evidence of patient behaviour for legal reports in the future.

WHY NOT CONTINUE USING CONVENTIONAL FILM CAMERAS? There is now little argument that digital photography has come of age. Digital cameras are now very affordable and can take excellent pictures with stunning detail and accurate colour saturation and contrast as the electronic light sensors are now produced with many millions of light-sensitive pixels. The automatic focus and control of exposure make it relatively easy for the least experienced to take sharp and well exposed pictures even with cheap digital cameras.

There are still many diehard traditionalists who demand the extremely high definition and colour accuracy of filmbased photography. However most people have now made the switch to digital photography because of the economy and convenience digital photography provides. One only has to walk into a photography shop to see how few film cameras are left on the shelves gathering cobwebs while the large array of digital cameras attracts the attention of most buyers. Newspapers all over the world now equip their photo journalists with digital cameras and paraphernalia and have reaped huge financial savings by eliminating developing and printing costs as well as being able to receive digital photographs as files over the Internet within minutes of the pictures being taken. Finally, camera manufacturers such as Nikon are one by one abandoning traditional film technology and even manufacturers of film are going bankrupt or diversifying into digital technology to survive as the use of film continues to dwindle.

p Squamous cell carcinoma, kept secret for 2 years!

DIGITAL VS FILM: THE ADVANTAGES

Firstly, the speed with which one can see images after they’ve been taken with a digital camera cannot be rivalled by any film technology, even Polaroid photography. Within a second of taking a digital photograph the image can be seen in a screen, admittedly rather small, on the back of the digital camera. Using this screen one can zoom in on the

image as well as scroll up and down and from side to side to see it in more detail. Images which are poorly focussed, illuminated or composed can be immediately deleted from the camera’s memory card and if necessary the photo can be taken again within a very short time before the opportunity is lost forever! In the case of film photography, it will be at the very least an hour‘s wait for the fully exposed roll of to be

PRINTING DIGITAL PHOTOGRAPHS

Digital photographs can be printed using various resources depending upon one’s specific needs: 1. Within the surgery one can use inkjet printers, even very low-priced units, to quickly print high-quality 15x10cm photos using glossy “photo“ papers. For infrequent use, this can be a relatively cheap exercise but may cost slightly more than having pictures taken with film printed out by a photo agency. Nevertheless doing it yourself gives you complete control over the quality of the final output and you may want to experiment till you get the quality you want. 2. Camera stores and chemists often provide printing services and will print out photos taken directly from a memory card or a CD containing the images. They generally charge competitive prices and will often print out your photos while you wait. However this process may well be less convenient than printing your photos yourself on your own printer when you want them and the quality of printing will vary significantly between operators. 3. Online printing services are simple to use – you merely upload your images from your computer to the online operator and your prints are sent to you by the post. This is probably the slowest but the cheapest way to do your photographic printing especially if you need to print large numbers of photos. If you only need to print a small number of photos this may prove to be the most expensive option!

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COVER STORY

developed and printed at the photo shop. However, the longest delay may well be the time it takes to take every picture on one’s roll roll of film. In the case of clinical photography it would be quite unusual to take an entire roll of film within one patient consultation. Usually a number of separate consultations over the course of several days or even weeks would be necessary before a roll of film is used up and can be sent off for developing and printing. By the time the pictures are back the skin lesion may have already been excised or the rash may well have resolved (hopefully) and if the pictures proved inadequate for some reason, the opportunity to take the pictures again will have been lost. Patients love to see the pictures of their skin lesions especially when they are in hard to see places such as on the back. Grotesque as some lesions can be, especially when the photos are taken close up, patients still have a morbid curiosity about the appearance of their skin lesions! Digital photography allows clinicians to show patients exactly what makes their lesions look suspicious thereby warranting biopsy or prompt removal. Using traditional film cameras creates delays which make this stimulating visual experience for patients impossible, at least within the initial consultation. Digital photographs can be stored or archived either directly within electronic medical records or externally but linked to specific fields within the medical record database. Both methods allow rapid and easy access to the images from within the patient record without having to do lengthy searches. One can easily make multiple copies of one’s digital photos onto CD or DVD to reduce the risk that they might be lost or destroyed. Digital photographs occupy virtually no room other than the hard drive within one’s computer or on an external hard drive. By contrast, prints made from films take up space in an album or a box and unless one is diligent in accurately filing them, printed photographs can be hard to find especially when there are large numbers to sift through. And if one has shifted one’s medical records to a computer it seems futile to have to keep a separate filing system for printed photographs when one can simply do it all (patient notes and patient images) on a computer system! Digital photographs can be examined on a computer screen and if they are of sufficient resolution one can zoom in to

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p Chronic leg ulcer. see greater detail. This just not possible with printed photographs unless a magnifying glass is used – what you see is what you get! Digital photographs cost almost nothing except one’s time. Once the camera and accessories have been purchased (they are tax-deductible if used primarily for clinical purposes) the photos cost nothing to take. Storing them on a computer’s hard drive costs hardly anything given the rapidly declining cost of hard drives and backing them up onto a CD or DVD is very cost-effective. Take one photo or take a hundred – the cost is essentially the same so there’s no disincentive to take as many as are needed. By contrast, every photograph taken with a film camera costs money, initially to buy the film, then more money to develop and print the photos and then even more money for storage of the printed photos and/or negatives in albums. Digital photographs are very easily incorporated into documents, slide shows or presentations for lectures, teaching aids or demonstrations for all educational scenarios whereas printed photographs taken with film need to be scanned before the images can be used for these sorts of purposes. Slides can be used for the traditional slide shows but it is far more tedious to load slide carousels than to look through pictures in an image browser on one’s

computer. Presentations with Microsoft Powerpoint or other presentation software such as Apple’s Keynote can be far more inventive, entertaining and useful than simple slide shows using film transparencies. Finally it can be very useful and extremely time effective to email clinical photographs to professional colleagues in order to obtain opinions. If the photos are digital they can easily be attached to emails without much bother but printed photographs from film first need to be scanned before they can be sent by email.

WHY ARE SO FEW DOCTORS USING DIGITAL CAMERAS IN THEIR DAILY WORK?

With all these advantages there must be some real or perceived disadvantages which deter clinicians from using digital technology or else this article would hardly be necessary. Obviously not everyone is comfortable with modern technology and it’s fairly obvious that to make the most of digital cameras and digital photographs one needs to use a computer! This issue is hard to get around but with time this problem will just disappear. New technology is always expensive when it’s introduced but fortunately the cost of digital cameras has plummeted in recent years while at the same

COVER STORY

time the quality of digital images and the features available on digital cameras have improved dramatically. Nevertheless, there is still an initial outlay needed to buy a digital camera and the essential accessories such as extra memory cards on which the images are stored before being transferred to a computer. Unfortunately the memory cards which come with the cameras are invariably of very low capacity. Unexpected costs arise when extra software is needed to manipulate and improve the images, and when one’s computer needs to be upgraded to cope with the demands of storing all the photos by installing a larger hard drive or by adding more memory (RAM) if the new software needs more memory than is already installed on the computer. One may also need to buy a new CD or DVD drive for backup purposes. However important the previous two factors are in causing people to defer their decision to buy a digital camera, the major obstacle facing most busy clinicians is time, or more specifically, the concern that it would take too much during a consultation time to take photographs and then to transfer the images to the computer and to do any subsequent processing of the images to link the photos to the clinical records. Well, it’s certainly true that a complete novice will take quite some time to become both proficient and efficient at taking good close-up photographs with any sort of camera and both interest and enthusiasm to devote this time are necessary to get up the learning curve. With a bit of practice, using a camera during a consultation doesn’t take much time, although patients often want

to spend some time looking at their own skin lesions! If the extra time taken converts a standard consultation to a prolonged consultation it is completely ethical and appropriate to charge a higher fee; patients accept this because they know their clinical needs have been dealt with in a very useful and entertaining way! The author typically takes about 3-4 minutes to take a few close up photographs of a questionable or interesting skin lesion, then transfer the images to the computer, link them to the patient’s medical record, label the images with the patient’s name and the date, and finally look at them on the computer, usually with the patient glowing with admiration at the new technology and somewhat horrified by the magnified appearance of their skin lesion. This may sound like a lot of extra time but surely it is time worth spending when dealing with skin cancers or lesions which one cannot definitely justify removing and therefore deserve followup in the near future. Obviously it’s best to practice with a newly acquired digital camera outside of the rigorous time constraints of the consulting room before trying it out at work. Even photographers with years of experience using film cameras discover that digital cameras are very different, in some important ways, from film cameras and this difference imposes a new approach to taking pictures. Nevertheless it usually doesn’t take very long to learn the basic functions of the camera and how to transfer images from the camera to the computer. And it ALWAYS helps to read the manual!

If you are a novice both to digital photography and to close-up or macro photography, you have a little bit more to learn but it’s not all that difficult. Macrophotography opens up a fascinating world on a very different scale and there are plenty of interesting subjects within every garden or shed just waiting to have their pictures taken at close range. The laws of optics imposes interesting and challenging constraints with macrophotography and it takes time to learn to take good quality close-up images of clinical subjects in a reliable and efficient way. Practice makes perfect but with a digital camera it costs you nothing to practice! The take home messages are that it can be a lot of fun using a digital camera, it isn’t particularly expensive, it doesn’t dramatically extend consultations, it can contribute significantly to quality patient care, it can reduce the risk of litigation AND patients actually love it when you take photographs of their skin lesions. The author is a busy rural GP based in Castlemaine, Central Victoria and has been using digital cameras since 1998 to assist his work which increasingly involves the management of skin cancers and other non-malignant skin lesions. His group practice, currently with 7 GPs, has had fully computerized medical records since 1992.

IN OUR NEXT EDITION... Look out for Daniel’s article on “choosing a digital camera for clinical work” in the next edition of Pulse IT.

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BROADER BROADBAND

While some people refer to Australia’s Internet connection options as “fraudband”, the new generation of ADSL goes some way towards addressing our standing as one of the world’s biggest Internet underachievers. Simon James BIT, BComm Based on the number of practices that have taken advantage of the Broadband for Health incentives, many medical practices have only recently upgraded from dial up modems or no Internet access at all. For these people, their new ADSL or cable connection may be welcome; however, there have been a few notable advances over the past year that offer some Australians better, equally affordable options. There is little doubt that the Internet will play an ever increasing role in the delivery of services and information to medical practices. Some of these services won’t be bandwidth intensive, however others will only become feasible when coupled with faster network capacity.

ADSL2+

While Telstra has recently upgraded the speed of its cable Internet offering, ADSL2+ is a technology with greater relevance for most readers particularly those outside of the capital cities. Download Speed The most obvious benefit of ADSL2+ is the dramatic download speed increase. Compared to the 1.5Mb/s limit of the initial ADSL offering, the 24Mb/s speeds quoted for ADSL2+ appears revolutionary. Be mindful however, that the providers of ADSL2+ are quite open about the fact that this is a theoretical maximum and the reality is less impressive. The variation in speed is directly related to two factors, both of which will be out of the Internet Service Provider’s (ISP) and your hands: 1. The distance the practice is located from the exchange. 2. The quality of the phone line. Based on vendor provided figures, the realistic speeds of ADSL2+ range from 6Mb/s to 20MB/s which is still impressive even at the bottom end of the scale.

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Upload Speed While the download speed is the figure most people are interested in when choosing an Internet plan, it is actually the upload speed that will be increasingly important for many future Internet services. As discussed later, maturing technologies including Internet telephony, remote access, and Internet based backup solutions all require fast speeds in both directions. Hardware Like its slower sibling, ADSL2+ makes use of standard copper phone lines. The increased speed is facilitated by a hardware upgrade at the telephone exchange, so no line work should need to be performed at your practice. Despite currently having an ADSL modem, you may need to purchase a new ADSL2+ model to take full advantage of the speed. Fortunately these are very affordable and easy to configure.

BENEFITS

Faster Internet access provides many benefits: Web Browsing and Email Perhaps this goes without saying, but having a faster Internet connection will make routine tasks like web browsing and email a smoother, more efficient process. In larger practices with multiple users accessing the Internet simultaneously, this improvement will be more pronounced. VOIP/Quality Of Service ADSL2+ modems typically have Quality Of Service (QOS) functions designed to improve Internet based phone calls. While I’m still not sold on Voice Over IP (VOIP) as a replacement for traditional phone systems, the combination of the increased network speed in both directions and QOS does make for better voice clarity. Podcasting Podcasting has been rapidly embraced by even non technical users, and is an ideal media format for time poor doctors. An avid podcast listener may download tens or hundreds of megabytes per day, so maximising the Internet capacity is important. Remote Access While the popular remote access software does perform well over slow connections, faster access allows for more fluid control and transfer of data. This will be appreciated by both your software vendor and IT support person, and will allow both of these parties to provide practice staff with more effective support when required. Video While it isn’t a stretch to suggest that most copyrighted video downloaded from the Internet is done so illegally (ask any teenager), there are an increasing number of organisations delivering or seeking to deliver video content legitimately via the Internet.

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Advances in compression techniques have helped make online video feasible, however real time, high quality video is only viable with a fast Internet connection. Companies looking to deploy IPTV (Internet Protocol Television) are claiming that a network capable of at least 2.5Mb/s will be required for the service to work reliably.

AVAILABILITY

Only a limited number of ISPs have the capability to offer ADSL2+. This is primarily due to the fact that Telstra, who provide their infrastructure to the bulk of Australia’s ISPs, are backing a competing technology that isn’t currently available. The largest problem with ADSL2+ stems from a reliance on new hardware being installed at telephone exchanges. As this work is being performed by companies with no government ownership (i.e. not Telstra), their roll-out is targeted based purely on commercial considerations. For practices in rural areas who may have only recently had ADSL enabled at their exchange, getting excited about any improved technology is not advised.

The most established provider is iiNet, who claim to have surpassed 100,000 ADSL2+ connections with current capacity for another 55,000. They have a large lead, however other popular ISPs including Optus and TPG are also competing for a piece of the action.

I’m frustrated by the broadband apathy displayed by providers, customers and Government. While ADSL2+ doesn’t compare to many of the cable options available in other countries, it is currently the best solution if your practice is in range of a compatible exchange.

PRICE

If you are a current ADSL user, there is little downside to upgrading. The price isn’t inflated and the benefits will be realised both immediately and into the future.

ADSL2+ plans suitable for most medical centres weigh in at around $50 per month, with setup costs ranging from nil to a few hundred dollars depending on the length of the contract and whether a new modem is purchased. As with traditional ADSL, an active phone line will be required, however this can be shared with an existing phone or fax.

Simon James is the editor of Pulse IT.

QUICK CLICKS

iiNet www.iinet.com.au

Many ISPs bundle VOIP services with their plans, allowing a standard phone to be plugged into the modem. As alluded to earlier, the quality varies greatly, but using this feature selectively (e.g. for appointment or payment reminders) may reduce your total communication costs.

Optus www.optus.com.au

CONCLUSION

Whirlpool - Australian Internet News www.whirlpool.net.au

Like many IT professionals who have seen the greener Internet pastures overseas,

Telstra www.telstra.com TPG www.tpg.com.au

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2HIPPO ENTERS THE SECURE COMMUNICATION MARKET

The secure electronic communication market has a variety of established players. We take a first look at the newest entrant, 2Hippo. Nathan Hay BIT, BComm INTRODUCTION

While secure messaging products are not scarce, this hasn’t deterred a company with perhaps the most unusual name in the Australian software industry.

Two key software components are installed: 1. The 2Hippo client software. 2. A “virtual printer” driver.

Developed, publicly tested and refined over the last two years, 2Hippo believes its “Intelligent Messaging” software extends beyond the current market offerings, and is now ready for widespread roll out.

The 2Hippo website is also an important part of the solution, and is used for various administration tasks including maintaining demographic details and managing the sophisticated privileges system.

GETTING STARTED

USING 2HIPPO

Getting started with 2Hippo is relatively straightforward and well documented by a narrated training video available online.

While outwardly the 2Hippo software looks very much like an email client, the differences becomes apparent when sending messages.

Requirements 2Hippo has fairly typical minimum requirements that most practices should be able to meet:

Unlike typically email software, messages are not generated from within the 2Hippo client. 2Hippo messages can be sent via any of the following methods:

• Windows XP Professional with service pack 2 and the latest Windows updates applied. • An active Internet connection (broadband is obviously better, although dialup modems will work). • Internet Explorer 5.5 or later.

1. Print using the 2Hippo virtual printer. 2. Use 2Hippo to send a PIT or HL7 generated by your clinical package. 3. 2Hippo Application Programming Interface (API) integration with your clinical package.

Due to the product’s reliance on Microsoft technology, Mac and Linux users are not currently accommodated. Rob King, Managing Director of 2Hippo explained that the framework is in place to expand his offering to other platforms, but will be guided by user demand. Installation The software is delivered via the Internet which is no surprise given the nature of the product. To perform an installation, users need to: 1. Register their details to establish an account. 2. Log in to the members area using these account details (which are verified to ensure the applicant is a member of the medical fraternity). 3. Click the “Download” button to commence the installation.

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Sending via Printing To send a document using this method, the user “prints” to the 2Hippo virtual printer, which in turn creates an electronic document (eDoc) and deposits it in the 2Hippo client software. Any program that facilitates printing can therefore be used to send documents with their formatting (including image content) preserved. A window with the addressing details appears, allowing you to specify the recipient and send the message. Using 2Hippo “intelligent templates”, this addressing step can be simplified, as the required details can be extracted from the printed document. Sending PIT or HL7 The second option allows for seamless integration with any program that can export correspondence to either PIT

or HL7. As with most secure messaging software, 2Hippo “polls” a designated folder and transfers the files to the intended recipient when detected. Advanced Practice Software Integration 2Hippo is providing access to its API to allow practice software developers to provide enhanced integration. By way of example, Rob King explained that “GPs could deliver referrals directly to a specialist appointment book, with an automated confirmation sent back to the GP for audit purposes when the patient presents”. Receiving Incoming messages can be viewed in the 2Hippo client software, or exported automatically for subsequent import into your clinical package. Selection and export criteria can be specified, allowing

BENEFITS OF SECURE MESSAGING

Security The most obvious benefit of secure messaging is that the confidentiality of the contents is protected during transmission. Cost Savings A busy medical centre may spend thousands of dollars a year on paper, envelopes, postage, phone and fax bills. Utilising Internet based delivery, the cost per message can be greatly reduced or eliminated. Speed of Delivery As with email, transmission of messages is almost instant allowing for rapid correspondence, regardless of where the parties are geographically located. Audit Trail Automated auditing, like that provided in 2Hippo, ensures every stage of the document transfer process can be tracked and reported on. Issues with transmission can be quickly identified and addressed.

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the incoming messages to be processed intelligently. Messages can be placed in different “drop boxes” depending on various criteria including the document type or the sending party.

Rob King anticipates the Divisions and practice software developers will embrace his company’s product, end user support will be primarily handled by 2Hippo staff.

Unless you elect to archive messages out of the 2Hippo environment, they are retained on 2Hippo’s servers. This enables the messages to be accessed from any Internet connected computer with the 2Hippo software installed.

An impressive series of training videos are available online, and cover all the key aspects of the program.

Address Book 2Hippo allows you to manage an address book of contacts. This contact list is stored online and can comprise both 2Hippo users, and people not currently using the product. Each 2Hippo user is responsible for maintaining their details online, and changes are immediately updated across all users “subscribing” to the contact. Reports 2Hippo’s integrated reporting uses a Wizard to define custom reports based on any eDoc field (e.g. sender, recipient, eDoc type, format and tracking status).

ENCRYPTION TECHNOLOGY

To maintain the security of the message during transmission, sophisticated encryption methods are used. 2Hippo uses 1024 bit encryption and handles this seamlessly and without the user needing to manually distribute public keys. In addition to these built in measures, users have the option to digitally sign their messages using their individual HESA certificate.

CHALLENGES FACING SECURE MESSAGING

As with clinical software generally, secure messaging products suffer from a lack of standards and compatibility between providers. Perhaps the thing that has hampered the uptake of secure messaging most is the reliance on the recipient having the same program as which the message was sent. In addition to the plague of pathology, radiology and transcription downloaders that infect modern medical practices, it is conceivable that a practice may require several secure messaging programs to communicate with their colleagues. 2Hippo seeks to reduce this impediment by undertaking to fax messages to recipients without the required client software. An email notification is sent to the recipient to alert them to the faxed message.

LOOKING TO THE FUTURE

2Hippo is currently finalising a service dubbed “Message Broker”. When released, users will be able to jettison

their existing downloading clients, yet still receive messages sent from their colleagues with these programs. In addition to the end user solution described in this article, 2Hippo has penned agreements to deliver data securely for other established businesses operating in the health sector. Of note is a collaboration that will see the underlying 2Hippo technology used to transport data for one of the leading transcription service operators.

CONCLUSION

2Hippo will face competition from many existing players in the market. Argus, Medical Objects, Health Link, Promedicus and several others are already competing in this space. Despite these challenges, the fractured market, modern technology framework and intention to “play nice” with competing products may give 2Hippo an edge. Nathan Hay is an IT consultant based in Melbourne.

QUICK CLICKS 2Hippo www.2hippo.com 2Hippo Training Videos training.2hippo.com

▼ 2Hippo’s Automatic Export Wizard locates and exports any document in a range of text and image formats. Pre-configured naming conventions can be used to simplify importing by the clinical package.

As a further security measure and to ensure reliability and performance, 2Hippo maintains private servers in a commercial grade data centre.

COST

2Hippo has various pricing schemes designed to cater for Specialists and GPs. High and low volume options are available, and a retrospective price guarantee ensures that you will pay the minimal amount. Free membership allows unlimited eDoc sending, and a full subscription allowing unlimited sending and receiving is available for $27 per month. A fully featured 30 day trial period is available at no charge. 2Hippo users are not bound by contracts, and the product is not hampered by advertising.

TRAINING AND SUPPORT

2Hippo offers support via phone, fax and a web based chat system. While

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GOOGLING GOOGLE While Google started life as a search engine, this quaint multi-billion dollar company has far more to offer. Our first article on Google takes a look at some of their other pursuits. Dr Tony Lembke MBBS, FRACGP, FRACRRM, DRACOG Chances are, when you go online, you start with a search. And most web users search with Google.

owners have 30% of the stock!) It would appear that their hypothesis has been proven correct.

Google began life in 1996 as a PhD project for two research students at Stanford - Larry Page and Sergey Brin. At the time, search engines were infamous for presenting irrelevant information. Pages were ranked according to how often they contained the particular “search term”. So, if we searched for “Einstein”, a page that discussed the family tree of a baker from Kyogle called Larry Einstein, which mentioned him umpteen dozen times, may well come up higher than an article about Albert Einstein, the patent clerk from Geneva.

Google now uses an estimated 100,000 linked Linux PCs to index the current crop of three billion web pages. They process more than 200 million search requests each day, handling each in less than half a second.

Page and Brin hypothesised that you can rank the relevance of a web page according to the number of other web pages that link to it. So, using their search engine, the most highly ranked page would be the one that contained the word “Einstein”, and that had the most other pages linking to it. Relevance could be increased further if each of the linking pages were weighted against the number of pages that linked in turn to them, and so on. A mathematically sophisticated “Fame-O-Rama”, according to New Scientist. (The specific technical details of their relevance protocol remain a guarded secret). They built a simple interface to present these results, and, rather carelessly, named it after the number googol. “Every Child’s Answer Book” had taught me that googol is the highest named number, being one followed by a hundred noughts. Google began operations in 1998 from a friend’s garage. This would appear to be traditional in California.

QED

The company was floated on the NASDAQ in August 2004. At the time of writing Google has a market value nearing US$120 Billion. (The two original

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GOOGLEPLEX

Google HQ (known as the Googleplex) is, apparently, a cool place to work - no doubt made cooler by the fact that many of the employees, initially paid with shares, have become “paper” millionaires. Google can search in 88 languages, including Pig Latin, Klingon, Elmer Fudd and Bork Bork Bork (as spoken by the Swedish Chef on the Muppets). The Google logo changes regularly to reflect current events and seasons. A World Cup inspired logo appeared at the start of the tournament, with the cartoon player appearing to be wearing the Italian stripe! Google maintains an archive of these special logos dating back to 1999, some of which are quite clever.

displayed on the appropriate search results page, sorted by how much they elected to pay per click (starting at 1c). After an activation fee (of $10), you pay only when a Google user clicks on your ad. AdSense are the little text ads that appear on many websites with the caption “Ads by Goooooogle”. Website owners who join AdSense receive payment for all visitors who click on one of the links in these ads. The actual ads displayed are selected automatically by the Google relevance engine, based on the page’s contents. So a page about your dog Snoopy would receive ads related to pet care, presumably.

BRANCHING OUT

Google engineers are encouraged to spend 20% of their time on other projects that interest them. Through this process, and through acquisitions, Google has expanded its operations into a number of different fields, including:

THE BUSINESS PLAN

Google Books (books.google.com) Google has started the scanning and digitising of the books contained in a number of the world’s leading libraries, including Harvard University Library and the Bodleian Library at Oxford. It plans to have completed 15 million volumes within a decade. You can search through the contents of books at books.google.com - the page reference and a small relevant excerpt from the text is displayed. Google claims that this is justifiable under the “Fair Use” provisions of the copyright act. A number of publishers disagree, and the courts will decide the matter in due course.

AdWords are the sponsored links displayed on the right hand side of a Google search results page. Advertisers can select the keywords relevant to their product or site, and their ads are then

Google Scholar (scholar.google.com) In November 2004, Google released Google Scholar, which indexes the full text of peer reviewed published literature across a range of publishing formats and fields. Results in Google Scholar are ranked by relevance based largely on the number of times the

April 1st is a particularly interesting day to check press releases from google.com. Last year saw the release of Google Gulp, a beverage that would optimise one’s use of the Google search engine by increasing the drinker’s intelligence through real-time analysis of the user’s DNA and carefully tailored adjustments to neurotransmitters in the brain. Google had revenue of US$6 billion last year, mainly through “keyword advertising”.

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scholarly works have been cited in other works.

productions, viewing them with your “Google Viewer”.

Google News (news.google.com) Google news was launched last month as a fully fledged google service. It “aggregates” news from more than 4500 services, is updated continuously, and can be customised to a user’s interests and preferences.

Google Calendar (calendar.google.com) This web based application provides a simple and free way to organise your schedule and share events with friends and colleagues. Google calendar can integrate with Outlook and iCal, and has the advantage of being accessible online at any time. Make an entry at work, and your home diary will automatically be up to date.

Google Mail (mail.google.com) Gmail is a free web mail service that provides a massive 2 GB of storage for each user. Store all your emails, and search them using the Google relevance engine. Google Earth (earth.google.com) A free application for Mac or Windows that enables you to view a satellite photo of any spot on earth, from any height, with relevant points of interest indicated. Fly from Nimbin to London in seconds, enjoying the view all the way, legally. Google Video (video.google.com) Google Video is the “world’s first open online video marketplace”, where you can search for, watch and buy a collection of TV shows, movies, music videos, documentaries, and personal

We are using Google Calendar at work to provide access to our on-call roster and reminder about particular meetings. We are using it at the Division so that members can integrate our CPD calendar into their own schedule. Google Answers (answers.google.com) If all this is too much, you can outsource your online research. Post your question, nominate how much you want to pay, and someone may tender to carry out the work for you. Answered questions remain available for all to read.

THE EMPIRE STRIKES BACK

Google’s success in becoming an indispensable part of each web user’s day has not gone unnoticed at

Redmond. Microsoft and Google are now competitors in a number of web services. Rumours have it that Google plans to launch a Google web browser and possibly a linux based Google Operating System. The rivalry reached the courts when a number of highly ranked employees left Microsoft and joined Google. We will be able to keep track of the action - with Google News on our Google Desktop through our Google Mail watching on the Google Video viewer. If the battlefield turns to Google Medicine, perhaps we will all be “acquired” and be able to retire as paper millionaires, drinking Google Gulp in the GooglePlex. Tony Lembke is a GP in Alstonville, NSW, and is a regular columnist on medical computing issues.

QUICK CLICKS Email Digest www.emaildigest.com MedicineAU www.medicineau.net.au

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PODCASTING WITH ITUNES Louis Joseph BComm PODCASTING

SUBSCRIBING

A podcast is essentiallly a series of files (usually audio or video) that are indexed to allow easy access by podcasting software. Each file is referred to as an “episode”, and can be downloaded either automatically by the software, or manually by the user when required.

While there are other options available, the three easiest ways to subscribe to a podcast with iTunes are:

Podcasting rose to popularity so quickly that some people may be unaware to what it refers. This article seeks to explain what podcasting is, how it can be used and how to do it with a product called iTunes.

Podcasts have never been restricted to audio, and video podcasts (annoyingly called “Vodcasts” by some) began proliferating even in the infant stages of the boom. In this article we will restrict our discussion to audio podcasts, however the instructions are equally valid for video and other formats.

The only thing that separates a podcast from a collection of sound files hosted on a website is the way they are indexed. A special contents file tracks information about the available audio files, allowing the user to get an idea of what the episode is about before downloading. When you subscribe to a podcast, you are essentially importing this file into iTunes.

1. Subscribe Using The Podcast Directory With thousands of different podcasts available, the podcast directory built into iTunes is a great place to start. To launch the directory from within iTunes, simply click on the purple podcast icon on the left of your screen, then on the “Podcast Directory” button at the bottom of the screen as shown below.

Thousands of regularly updated podcasts exist covering just about every imaginable topic. Despite the high quality of many podcasts, most are free to the listener. While there are dozens of programs that can be used to download and listen to podcasts, none are as popular as iTunes. Other than simplicity, iTunes has several advantages over other podcasting software. It is integrated with the worlds largest online music store, the largest podcast directory and the highest selling portable music player, i.e. the iPod.

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2. By Using An iTunes Enabled Web Link Accepting that iTunes dominates the medium, many podcast creators provide a special link on their website that opens their listing in the iTunes Podcast Directory. If you come by such a link when browsing the web, subscribing using it will save you having to search through the thousands of podcasts in the directory, or using the manual method outlined below. 3. Manually Enter The Address The podcast index file is referenced like any other web link. Typically the address will start with the domain of the website you are currently visiting, and end with “xml”, although other options are possible. If neither of the options outlined above are available or you have been sent the link from a friend etc, the most reliable way to manually subscribe to the podcast is:

ITUNES

iTunes is developed by Apple and ships with every Mac, however it has long been available for Windows. This article will be most useful if you have a copy of iTunes installed. If you haven’t already, I suggest you download a copy from the iTunes website (see “Quick Clicks”).

When a podcast is selected, an introduction screen opens with a description of the series, and a list of the available episodes. From this screen, it is possible to preview the episodes or add the podcast index to iTunes by clicking “Subscribe” as shown below.

1. From the “Advanced” menu, select “Subscribe to Podcast”

Podcasts are categorised, and can be sorted and searched based on many criteria. A chart of the most popular podcasts are displayed on the front screen, as are new and featured entries.

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2. Enter the podcast address and click “OK”.

DOWNLOADING

When you first subscribe to a podcast, iTunes will automatically download the most recent episode. After this, you can manually download other episodes by simply clicking on the “Get” button to the right of the episode name. Due to the large number of podcasts I subscribe to and the sometimes slow Internet connections I work from, I prefer to selectively choose which episodes to download based on the description given. The podcast settings I use are shown below.

Other people may prefer to set iTunes to check for new episodes on a regular basis and download them automatically. This is possible using the following settings.

MANAGING PODCASTS

As you subscribe to more podcasts, it becomes increasingly difficult to separate the episodes you have listened to from the ones you haven’t. By default, iTunes simply lists all downloaded episodes under the podcast title in the order they were released. While it is possible to display the play count for each episode, it becomes difficult and time consuming to manually sift through what may become a long list. Thankfully, iTunes has a feature called “Smart Playlists”. Smart playlists intelligently select audio files based on your specified criteria. While the possibilities are limitless, I’ve described the process of creating a smart playlist that will display all podcasts that haven’t been listened to: 1. From the “File” menu, select “New Smart Playlist”. 2. Configure the settings using the following graphic as a guide and click “OK”.

3. The new smart playlist will appear on the left. Name it “Unplayed Podcast” and you’re done.

iTunes automatically tracks the number of times tracks in your library are played. As a podcast completes, it will no longer have a play count of zero and will automatically be removed from the playlist. Note that the file isn’t deleted and can be accessed from the main podcast window at any time. To access the above preference panel simply click on the “Settings” button at the bottom right of the iTunes podcast window.

PLAYBACK

Podcasting improves over traditional broadcasts by allowing the content

to be played back directly on your computer or transfered to a portable music device. When combined with portable music players, podcasts allow you to take a Yoga class during a lunch break, get a market update between patients, or listen to the latest medical research on a chair lift at the snow. Apple’s iPod is by far the most popular portable music device on the market and integrates tightly with iTunes as you would expect. iPods come in various sizes and capacities to suit many applications, and there is a huge range of accessories to extend their functionality. Many other compaines also make portable music devices, and Microsoft has recently announced plans to release its own line of music players to compliment its own software and online music store efforts.

CONCLUSION

Podcasting went through an amazing boom in late 2005 and 2006, helped in no small part to iTunes. The word “podcast” was deemed to be so significant in 2005 that the New Oxford American Dictionary declared it the word of the year. Given the short history, the future of podcasting is difficult to predict. More paid podcasts are sure to emerge, however competition will ensure that this powerful medium remains largely free and accessible to the listener. While it’s unlikely that podcasting will replace any of the existing media channels, it is sure to firmly entrench itself as a powerful and popular compliment. Louis Joseph admits that he spends far too much time with his iPod.

QUICK CLICKS iTunes www.itunes.com New Oxford American Dictionary www.oup.com/us/noad/

THE AUTHOR’S PICKS

The following is a selection of the podcasts that the author subscribes to. You can check out these by searching for them in the iTunes podcast directory, or by entering the address manually as described on the previous page. • • • • • •

Alan Kohler Market Report Computer World Live Andrew Denton’s Enough Rope Inside Mac Pod Climber Yogamazing

Twice daily stock market news IT management coverage Excerpts from the ABC TV show Mac news and views Rockclimbing and mountaineering A weekly video yoga series

Search iTunes directory http://www.computerworld.com.au/podcast.mp3.xml http://www.abc.net.au/tv/enoughrope/podcast.xml Search iTunes directory http://www.podclimber.com/podcast.php http://feeds.feedburner.com/yogamazing

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UNIVERSAL POWER SUPPLIES

A Universal Power Supply can act as a first line of defence against data loss and downtime. They are affordable, easy to install and every practice should have at least one. Samuel Logan BIT, BComm Australian medical IT systems are varied, comprising of a dizzying array of hardware and software combinations. However there is one device that should be compulsory in all medical centres regardless of software or hardware preference; the humble Uninterrupted Power Supply (UPS).

WHAT

In its simplest form, a UPS is a battery that is plugged in between your mains power and your hardware (usually the server computer). In the event of a power failure, your server can continue running until the UPS battery is depleted. While this won’t allow your practice computers to run all day, it generally provides enough protection to ride out short power failures or safely shut down the computers.

WHY

UPS systems are designed to do one thing; provide a reliable, safe stream of power. UPS devices not only help in the event of complete power failure, but also protect against brownouts and power surges. In fact it is these events that can be more damaging to the hardware than total power failure i.e. blackouts. In the absence of a UPS, a power failure will almost guarantee data corruption or loss. Severity may range from losing the current letter being transcribed, up to massive database corruption requiring a backup to be instated. In some cases, the corruption may not be detected at the time of the outage, which can lead to more severe problems down the track, especially for practices that don’t store permanent backups.

PURCHASING

When purchasing a UPS, several questions need to be asked: • How many devices need to be protected? • How much power do these devices require to run? • How long do these devices run for during a power outage?

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In all cases, be conservative to allow for expansion and unrealistic manufacturer claims. With this information at hand, you can use one of the many web based UPS selection tools to choose an appropriate model (see “Quick Clicks”).

DEPLOYMENT

In a utopian setting, UPS devices would be deployed at each computer that either hosts or accesses data (generally all computers), however this is rare in practice. UPS devices are generally configured along side the practice software server, the justification being that this is where the important data the practice needs to protect resides. Additional UPS devices may be deployed on client machines and network hardware to allow the entire system to function briefly during a power outage. As there shouldn’t be any critical data stored on the client machines, the UPS devices assigned to protect them won’t need to be as large or expensive as the one protecting your server. Basic Configuration In consultation with the product manual,

even the most techno-illiterate practice staff member should be able to install and test a newly purchased UPS. After charging the UPS, all that needs to be done is: 1. Shut the server down. 2. Plug your server into the UPS. 3. Start the server up. Perhaps the only caveat to note is that many UPS devices have plugs for both battery backup and surge protection. These are not always clearly marked, so double check that you have used a battery-supported plug before starting your server. Advanced Configuration More sophisticated UPS devices can be connected to the server via a data cable (USB, serial or network) and paired with software that can tell the server to safely shut itself down in the event of extended blackout. This is ideal as your server is protected even when your clinic is closed and the UPS runs out of juice. Depending on your practice software, additional scripting may need to be performed to allow the UPS software

ONSITE

I had a call from a receptionist to tell me that one of their computers would no longer start. A new doctor with little computer experience had started recently, and it was his computer that was out of service. The receptionist said that the doctor never shut down the computer which I proposed may have been a contributing factor, but wasn’t totally convinced. The energy saving settings were setup correctly, so I didn’t have a problem with the computer being left on over night. After further investigation, I discovered that while the doctor wasn’t “shutting down” the computer, he was certainly turning it off - at the power point - religiously each day. While it’s not possible to say that the doctor’s end of day ritual was the cause of the hardware failure, it is the most likely explanation. The power supply and the hard drive on this machine had to be replaced before the machine could be recommissioned, at a cost of several hundred dollars and several days of inconvenience. In the very least, this incident provides an extreme example of why computers should be shut down on their own terms, something that can’t be guaranteed if a UPS isn’t installed.

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TYPES OF UPS DEVICES Offline (or Stand-by) An Offline UPS waits for the power level to drop below a threshold before engaging the battery, resulting in a tiny delay of power to the connected devices. While cheap, this slight delay makes this class of UPS the least ideal for deployment on a practice server, although could be used for network equipment and other less critical devices. Line Interactive This class of UPS continually conditions the power flowing to the protected device, supplementing the mains power with the internal battery when required. Given their affordable price and adequate features, line interactive UPS devices are the most widely deployed in medical practices. Online This class of UPS continually provides the connected devices with power from the internal battery, not directly from the mains power. As there is no need to switch from mains to battery power in the event of an outage, the unavoidable power drop other UPS classes exhibit is eliminated. Online UPS devices provide the highest level of power regulation and protection, but the complexity involved in the design make this class the most expensive to purchase and �� maintain.

to safely shut your database down. If the UPS software incorrectly closes the programs running on the server (i.e. by ‘force quitting’), the data corruption we are trying to avoid may eventuate. Your IT person in consultation with your practice software vendor should be able to assist if required.

Maintenance and Batteries Like all batteries, UPS cells deteriorate over time and should be checked at least once a month. While most devices have self testing functionality, nothing beats ‘flicking the switch’ (after a certified backup of your clinical data has been taken).

CONSIDERATIONS

More robust products allow old batteries to be replaced, saving you the cost of having to purchase a new unit, and the hassle of learning to configure and install new software. The more expensive models even allow this change to occur with the server and UPS running, a feature that will be necessary for large 24 hour medical centres.

While the benefits of UPS systems far outweigh any downsides, the following points should be given thought before purchasing: Noise If background noise in your consultation room is unacceptable, avoid the larger UPS devices that have audible cooling fans. Heat Keep the UPS (and server) in a well ventilated area and don’t inadvertently block the exhaust fans. Burning your surgery down may have adverse effects on the integrity of your data! Multiple Devices Protecting multiple devices with one UPS is quite possible, but the battery life will diminish in proportion to the extra power being drawn. Configuring automatic shutdown of multiple servers is also more complex. Printers Due to the large amounts of power used during laser printing, you should never attach a laser printer to a UPS. If you are averse to posting invoices and receipts, having a basic bubble jet printer available to connect to the UPS is the best option to get you through a blackout.

Don’t be tempted to stockpile batteries as they have a limited shelf life and may not perform well or at all when it comes time to install them. Purchasing a brand name UPS should ensure after sales support and parts are available when needed. Samuel Logan is an IT consultant specialising in medical and accounting practices.

QUICK CLICKS APC www.apc.com

Belkin www.belkin.com.au MGE www.mgeups.com.au Powerware www.powerware.com.au

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BACKUP TECHNOLOGY

The first article in our three part series on backups looks at the most basic element of the system: the backup device. Nathan Coultard INTRODUCTION

As Australia’s health providers slowly inch towards paperless workflows, secure storage and backup of data is increasingly more important. We start perhaps our most important series of articles with a look at popular hardware options with which to perform the backup of your practice data. These devices have similar if not identical pros and cons across all operating systems and practice software solutions. This series of articles will look exclusively at the backup of clinical data; the larger challenge of backing up entire computer systems is outside the scope of this series. The second article in the series will deal with the theory of backups, discussing frequency, organisational issues and auditing. The third and final article will detail specific examples with reference to five leading practice software vendors.

BACKUP UTOPIA

A utopian practice data backup strategy will: • Back up all digital practice data at least daily. • Allow regular “snapshots” to be created and stored permanently. • Not be labour intensive for staff. • Not be cost prohibitive either initially or going forward. • Allow easy restoration and auditing. As such, the device or devices that you choose to perform your backups should accommodate as many of these points as possible.

RESEARCH

Before purchasing a device to perform your backups, the following information needs to be collected: Size The amount of data (i.e. size in megabytes (MBs) or gigabytes (GBs)) that needs to be backed up should be

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considered first. There is obviously no point opting for a device that won’t fit your data. Speed of the Device The time a backup takes to perform is directly related to the amount of data to be copied and the speed of the device. While it is common to have backups run unattended over night (making the device speed irrelevant), this invariably means that in the event of theft or natural disaster, data loss will result. When planning a new backup solution, steps to reduce this exposure need to be made. Cost While the initial purchase price of a backup device is easily noted, be mindful of additional costs including installation, staff training, additional software and ongoing consumable costs (tapes, disks etc). The biggest ongoing cost by far will be staff time, especially if regular backup audits take place.

CD & DVD

CDs hold up to 700MB and standard DVDs can store 4.4GB. While the majority of practice databases will fit on a single DVD or CD, practices that store scanned images or other large files as part of their clinical record may exceed these limits. The speed of CD and DVD drives both for reading and writing data have continually improved. A full DVD can be burnt in under ten minutes using a modern burner with CDs taking less than five minutes. The cost of blank CDs and DVDs has long been below $0.50, making them the cheapest option for permanent storage. High quality internal DVD drives cost under $100, with external versions coming in at under $200. It would now be difficult to purchase a computer not capable of reading a

CD or DVD, making them an excellent choice in terms of compatibility. If your backup requirements exceed the 4.4GB a standard DVD will hold, you can simply burn multiple disks (or opt to use the uneconomical 8.5GB disks that are also available). While in use by early adopters already, the next generation of optical devices should begin to proliferate soon. Two competing technologies, Blue Ray and High Definition DVD (HD DVD) are vying to replace DVD as the standard video format. Like DVD, these disks will be able to be used as backup devices with far greater capacity.

HARD DRIVES

The two most common physical hard drive dimensions are 2.5 inch and 3.5 inch. The smaller variety can hold up to 160GB, with the larger format cable of holding a massive 750GB. There are also proprietary systems such as the ZIP, Jaz and Rev cartridge drives in circulation. In their own right they are good devices to perform backups, however the non-standard nature of these devices limits their compatibility and tends to doom them to obsolescence faster than generic solutions. Hard drives have the highest read and write speed of any storage device. Coupled with their large capacity, they are an ideal option if you have large amounts of data.

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IPODS?

As well as being the most popular portable music player in the world, the iPod can be used as a handy device to store data. At the core of the device is a 1.8 inch hard drive capable of holding up to 60GB. Because of their small size and the fact that you may carry it to and from the practice each day anyway, you may be tempted to use it as your primary backup device. There are many reasons why I believe this to be a bad idea, most stemming from the fact that clinical data stored on an iPod would be exposed to more dangers than data stored on a less trendy dedicated backup device. While it is fine to take your music to the gym, leave it in your car unattended or lend it to your kids, the same can not be said for clinical data. Coupled with the fact that the tiny iPod hard drives are notorious for failing prematurely, the chance of theft or loss or accidental damage is too great to make iPods a viable backup option. James Hutton External hard drives based on a 3.5 inch device typically sell for less than a dollar per megabyte making them a very cost effective solution. 2.5 inch solutions are more expensive per megabyte, but typically four times smaller than their larger brothers, making them ideal for transporting data off site. Because of their laptop heritage, 2.5 inch devices typically have higher shock resistance, and most can be powered from the data cable negating the need to transport power adapters. As well as the enclosed cases discussed above, hard drives can be mounted in caddies that slide into a drive bay (internal or external to the computer) , making connection easier and minimising costs when multiple drives are required. As the data backed up to a hard drive is unlikely to fill the drive, multiple backup sets should be stored until the drive reaches capacity. When this occurs, the oldest set can be replaced with the current backup e.g. a 300GB hard drive will allow for thirty days worth of “roll back” assuming a daily backup of 10GB. Having multiple hard drives would allow a far greater history to be kept, although ultimately a permanent record will need to be made at least each week, either to a series of DVDs or a tape.

NETWORK BACKUP SOLUTIONS

Local Network Network Attached Storage (NAS) refer to hard drives that are attached via a network as opposed to a traditional storage interface (USB, SCSI, FireWire, SATA etc). Once only targeted at larger businesses, NAS products have thrived at the bottom end of the market, and are now a simple and cost effective way of deploying a file server.

several hundred gigabytes can be stored on a single tape. Tape drives are relatively expensive to purchase, but the individual tapes are very cheap per megabyte. Most medical centres generally cycle through a series of tapes either weekly or monthly, and store a tape for a permanent record periodically (although rarely enough!).

For the purpose of performing backups, NAS devices are comparable to other hard drive solutions, although the backup will take longer to run and the device will be more difficult to configure. Due to the inclusion of the network interface and the lower sales volumes, NAS devices are more expensive than portable hard drives. Unless the device is being used for other applications in your practice, purchasing a NAS for the sole purpose of backup is probably not the best solution.

Due to the moving parts in both the drive and media, tape is relatively unreliable and the devices have fairly slow data transfer rates. Further, unlike DVDs and external hard drives, a backup stored on tape can generally only be restored on a single practice computer i.e. the computer with the tape drive. In the event that this device is out of service or has been superseded, the restoration of such data can be time consuming and potentially expensive.

Internet Services The adoption of broadband worldwide has allowed Internet based backup solutions to proliferate. These are popular in countries with cheap, reliable, fast Internet - Australian medical practices need not apply!

All the devices discussed have strengths and weaknesses, and it is my opinion that none are ideal for clinical data in isolation. If the total amount of data you need to backup is less than a DVD or CD, I recommend burning a new disk each day which create a cheap, permanent backup that can be restored from any computer. Given the rollback that individual DVDs or CDs allow for and the insignificant cost of the disks, there is little justification for using re-writable media.

The ever increasing size of practice software data files, privacy concerns (founded or otherwise) and the cost of transferring gigabytes of data across the Internet each month relegate this solution to the “future consideration” basket.

FLASH MEDIA

Small USB “thumb drives” can also be used for small document backup and transport. These drives are small enough to fit on a key ring and are very convenient for backing up documents quickly or for transferring data between computers when a network isn’t available. They are relatively expensive per megabyte and the capacity can’t match that of hard drives. Anecdotally they are not as reliable as the aforementioned media, so multiple thumb drives should be used if your practice chooses to use these devices for your backups. As always, permanent backups still need to be made, so a complimentary solution such as a DVD burner will also be required.

TAPE DRIVES

Tape has long been the backup medium of choice for large organisations needing to protect significant amounts of data. Depending on the device and the amount of compression applied,

RECOMMENDATIONS

If the data you need to backup exceeds the limit of a single DVD, consider the option of burning multiple disks or using a hard drive or tape device. Ideally the data will not be over written each night and multiple backup sets will develop over time. Even if hard drives or tapes are used daily, this doesn’t negate the need to burn a series of DVDs at least once a week, or alternatively store a tape permanently. While it may be a few years before the devices and media become cost effective, Blue Ray and HD DVD are destined to become a promising option to perform backups. Nathan Coultard is the Director of Techmed, an IT Support company based in Wagga Wagga, NSW.

IN OUR NEXT EDITION... The next article in this series looks at backup schedules, with the final article outlining best practice backup and restore procedures for five leading practice software packages.

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ACCREDITATION

ACCREDITATION AND ELECTRONIC MEDICAL RECORDS

Dr Paul Mara MBBS, FRACGP, FACRRM, Dip RACOG The release of the current (third edition) RACGP Standards for General Practices (Standards) imposes a number of additional requirements for medical records systems that many practices, both large and small, will find challenging and problematic. This series of articles seeks to provide a framework to support practices through the maze of standards criteria relating to medical records and particularly electronic records. Essentially the requirements of the Standards relating to medical records can be grouped into three main areas. These are: • Specific content requirements for electronic health records • Administrative requirements including those for maintaining security and privacy • Additional evidence based requirements used to assess compliance with the standards This first article discusses the structure of the standards in general and details the content based requirements.

STRUCTURE OF THE STANDARDS

The current Standards are divided into five sections, namely: 1. Practice Services 2. Rights and Needs of Patients 3. Safety, Quality Improvement and Education 4. Practice Management 5. Physical Factors Within each section are a number of Standards, Criteria and Indicators. • Standards are a broad description or statement of intent regarding key aspects of quality in the practice. • Criteria detail key components of the Standard. • Indicators provide a basis for measurement. The table on the following page provides an outline of the hierarchical structure of the standards and summarises all standards and criteria that require an assessment of medical records.

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SPECIFIC CONTENT REQUIREMENTS

Criterion 1.7.1 requires that all patients have an individual health record containing all clinical information held by the practice relating to that patient. Medical records systems may be almost entirely electronic, paper based or a hybrid. Increasingly practices are taking the plunge and moving totally electronic. Personal experiences with the change over vary but an individual written practice based strategy prior to implementation for the practice is a good idea to ensure all doctors and staff have consistent objectives, prevent loss of data and support a seamless transition.

allergies in the patient health summary (Criterion 1.7.2). The following are content requirements for health summaries: • Current problems • Past history • Allergies • Medications including drug, dose and frequency • Risk factors including smoking, alcohol and other drugs • Relevant family history • Relevant social history The optimum approach is to upgrade health summaries as each patient presents. Practice support and

... the current Standards now require that the practice is actively collecting details of the cultural background of patients ... Specific elements of the medical records include basic patient demographic information, health summaries, consultation or progress notes, referral documents and results of investigations or referrals.

DEMOGRAPHIC INFORMATION

As well as the name, age, gender and contact details the current Standards now require that the practice is actively collecting details of the cultural background of patients, including Aboriginal and Torres Strait Islander self identification and contact in case of an emergency.

HEALTH SUMMARIES

The current Standards now require that at least fifty percent (50%) of active patient records contain a health summary and ninety percent (90%) of these records contain a record of

administrative staff might ensure that demographic and contact details are current and each doctor should ensure that other details are current and complete. Depending on circumstances the patient may need another consultation to enable all information to be collected and this may be undertaken in conjunction with a patient care plan, aged health assessment or consultation with a practice nurse.

CONSULTATION NOTES

A record of every patient encounter including after hours consultations, home or other visits and telephone encounters should be kept. Some electronic medical records systems allow for off site recording and synchronisation of records but many do not have this facility. How the practice handles the recording of these consultations is an important issue for accreditation.

ACCREDITATION

Consultation notes should identify date and provider and include the following details for all patient encounters: • Reason for presentation • History of present illness including symptoms, onset, site, precipitating and relieving factors and time present • Systems review including significant negative findings • Relevant past history, social and family history if not already recorded • Examination findings including significant positive and negative findings • Problem list or diagnosis • Management plans including treatment prescribed, investigations ordered, referrals for specialists and other health providers, preventative and other health advice provided The Standards now also require evidence that problems raised in previous consultations are followed up and management plans reviewed.

REFERRAL LETTERS

Referral letters are one of the Achilles heels of electronic medical records systems. There is a growing use of templates that document all medication and previous history but unfortunately much of this information is either irrelevant because the current health

summary or medication list are not kept up to date. The end result can be a referral letter with significant amounts of garbage in and garbage out.

• Management including current medications • Significant past, social and family history

The Standards now also require evidence that problems raised in previous consultations are followed up and management plans reviewed. The referral letter, particularly for complicated problems, can be viewed as another opportunity to review the patient, their problems and context. Often the referral letter is the only way in which our colleagues can have a basis for viewing us professionally. Copies of all significant referrals are generally maintained in the electronic medical records system and these should include: • Reason for and expectation of the referral • History of presenting problem • Relevant positive and negative findings on examination • Results of investigations

SUMMARY

High quality, comprehensive medical records are crucial for maintaining patient care and improving risk management. As practices make the change from paper based or hybrid systems to electronic records systems they can take the opportunity to ensure that records are updated to reflect standards requirements for content, confidentiality, administration and security. Dr Paul Mara is a practising rural doctor and managing director of Quality Practice Accreditation Pty Ltd.

MEDICAL RECORDS AND RACGP STANDARDS Compliance Indicators 1.1.2

Telephone and electronic advice

1.1.3

Home and other visits

1.1.4

Care outside normal opening hours

1.3.1

Health promotion and preventive care

1.4.1

Evidence based practice

1.5.1

Continuity of care

1.5.2

Continuity of therapeutic relationship

1.5.4

System for follow up of tests and results

1.6.1

Engaging with other services

1.6.2

Referral documents

This table identifies key criteria relating to medical records and health information. These include content requirements for patient health records, requirements for the management of health information and criteria where the medical record is used as an indicator or assessment tool to ensure that criteria is met.

Content Of Patient Health Records 1.7.1

Patient health records

1.7.2

Health summaries

1.7.3

Consultation notes

Management Of Health Information 4.2.1

Confidentiality and privacy of health information

4.2.2

Information security

4.2.3

Transfer of patient health information

4.2.4

Retention and destruction of patient health information

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EPIDEMIOLOGY

APPLICATIONS OF DATA COLLECTED IN CLINICAL MANAGEMENT SYSTEMS Dr David Brookman MBBS, MHA, DipClinEpidem, FACRRM Your clinical practice system stores a lot of useful data and offers you the opportunity for applying clinical epidemiological methods for auditing the quality of care you provide, and in enclosed populations examining population epidemiology within a town. The capacity for population studies depends on the coverage of the population by the practice - the ideal being a single practice covering the entire town. If there is a small group of practices consider pooling your data but beware of duplications.

DATA QUALITY

Even in the best managed systems there will be data errors these should be checked for on a regular basis and eliminated as found. Typical errors are: • Duplication of person due to name misspelling. • Duplication of person due to birth date error. • Sex reversal or absence of classification. • Blending of persons due to same name (due to failure of checking before recording information).

The best way to eliminate medication errors is to prescribe generically unless you mark every prescription that brand substitution is not to be undertaken. Beware however, for pharmacists will tell patients that they cannot obtain the particular brand for X weeks and ask them if they can substitute without informing you. That this leads to medication errors is obvious but that is government policy as determined by the pharmacy lobby. The ideal practice system would allow you to prescribe whatever brand you like but record the generic name as well for auditing purposes but as far as I am aware no system offers this at present.

OVERCOMING DATA QUALITY PROBLEMS

Most of you will have well established clinical systems with a large collection of data and will find the prospect of fixing your data errors a bit overwhelming. There is always the problem of the currency of medications. Your system may record that a person has not had

I once recalled a young man for a PAP smear - fortunately he had a good sense of humour and declined on the grounds that it would be too painful. • Use of free text for recording: > Reason for prescribing. > Reason for encounter. > Disease classification. • Multiple medication names. • Failure to delete medications no longer used. • Failure to record chronic illness. • Failure to record family history.

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a medication prescribed for years, but they may be obtaining it from another source, or it may be an OTC medication hence simply eliminating all old prescriptions is not a suitable policy - the only solution is a medication review for each an every person who is chronically taking three or more medications every time they are seen.

Missing data can be filled on an ad hoc basis but this will not provide the assurance that the overall quality of data is improving. A planned review of the data and planned collection of missing information is the only solution. 1. Look at the population first: a. Marked deceased persons as such Generating a recall for the deceased is profoundly embarrassing. b. Ensure the sex is correct and recorded - I once recalled a young man for a PAP smear - fortunately he had a good sense of humour and declined the offer on the grounds that it would be too painful. c. Ensure the date of birth is correctly recorded - again recalling a 100 year old person for their measles immunisation is a bit inappropriate. d. Inactivate people who no longer attend the practice - develop your own policy but a person with a chronic illness who formerly attended monthly and has not been seen for six or more months is unlikely to reattend. The best way to conduct this is print out a list of all current patients and cross them off as they are reviewed - to save paper this could be as a spreadsheet on a laptop or palm/pocket PC. 2. Next look at the presence of clinical flag recording: a. Have allergies/adverse drug reactions been recorded or marked as none? b. Has the family history been recorded? c. Have previous surgical procedures been recorded? (This should be recorded separately from the general medical history but I have not seen a system which does this.) d. Have at risk persons been identified as such? (Aboriginal and Torres Strait Islanders, gestational diabetes, etc) e. Have all immunisations been recorded? (Your reception staff can ensure that the “blue book” accompanies all children when they visit). f. Have all mothers had an obstetric history recorded? (Ideally it should be possible to cross link children to their

EPIDEMIOLOGY mother using the internal database reference link - as yet I have not seen a system which offers this) g. Non use of the clinical encounter system provided - there are various systems provided docle, ICPC etc - none have I found to be sufficiently comprehensive as most of my work has been in rural areas of Australia where I have encountered problems not thought of by the urban, and/or non Australian creators of these systems - but the classification provided is indexed, and any free text you add is not hence you will need to become familiar with the idiosyncrasies of the system you are using and try to eliminate any free text classification. 3. Next look for incongruities: a. Medication with no indication - when I first audited one of the practices in which I worked I found 10% of people on insulin were not recorded as having diabetes. (Medical Director will allow you to readily identify these with the database search function - use find all patients on Insulin NOT diabetes). b. Apparent mismedication - diagnosis of asthma with beta blocker therapy, use of beta agonists with beta blocker therapy etc. c. Medications with no indications - a valid indication is “Prescribed by someone else for as yet unknown reason” to cover the hospital discharges and the specialists who have not yet learned to write a letter. d. Investigations with no indications - Beta HCG with no record of pregnancy concern, HbA1c with no diabetes, urine albumin/Creatinine ratio with no diabetes or renal disease etc.

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The initial review of the clinical data quality may take some time, do not expect to fix everything in a few weeks, and do not start until the demographic data are correct. Depending on the age of the practice there will be between 3000 and 6000 patient records per practitioner and you will need to become familiar with the capabilities of the system you are using. As I mentioned above, Medical Director version 2 offered a good database search function, but I found it easier to export the data to another database for analysis. Most of you will not have the software to do this so discuss with your software provider how you may conduct searches to look for the data errors I have listed above.

PRIVACY ISSUES

I have been unsuccessful in obtaining a rational answer on the issue of data privacy from various offices of privacy commissioners. The attitude taken by some University ethics committees is that the data cannot be used for self directed audit even if the purpose is to improve the quality of care offered, or to identify errors and omissions affecting the quality of treatment offered to the individual. The question revolves around who owns the information. I think there is little doubt that the medical practitioner owns the medical record, but the patient has the right to dispute the content. Where there is a medical practice company the company may own the record de facto if the practitioner has entered into a master servant relationship with that company and the practitioner agrees to use the clinical record system

provided (this applies to both paper and electronic records). Neither a company, nor an individual has the right to release the information in the record system that identifies any individual to a party external to the existing arrangement to provide clinical services. Thus the individual practitioners may come and go from a company but the records will be made available to the new practitioners as this is part of the agreed system of provision of care. The company or individual practitioner may not release the information to an auditor, the government, marketers, or staff of the division of general practice without the express (written) permission of the owner of the data or the patient (or their legal guardian). What this means is that effective audit can only be conducted “in house” as the sampling bias introduced by seeking written permission, and the necessarily small sample make any other form of audit useless - would you change a policy on the basis of a 0.1% sample of anything? The opportunity to improve the quality of care you provide is not just in your hands - it is only you who can provide the necessary audit of your services given the current constraints in Australia. Dr David Brookman has used Medical Director extensively to extract data for self directed clinical audit. He has a working knowledge of Profile and Genie.

IN OUR NEXT EDITION... Look out for David’s follow up article on recall systems in the next edition of Pulse IT.

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SHUTDOWN

POSITION, POSITION, POSITION As our undercover IT support guy reports, the location of your computer equipment is important for the security, longevity and maintenance of your computer hardware. Mr Fixit I’m not talking real estate here, or sex! What I’m referring to is the physical location of your IT equipment - the computer hardware that is increasingly more important to the running of your practice. It is a travesty that in many instances, the position of the vitals of your IT infrastructure is overlooked until the last minute when purchasing new hardware (or indeed during renovation or construction planning). Yet the location of your equipment can often have a bearing on its long term reliability, and in extremes on the very security and veracity of your data.

SECURITY

While the theft of any practice computer will cause inconvenience, the theft of your server will invariably cause widespread downtime and expose you to legal liability. Jim the Junky may not have much interest in Harriet’s haemorrhoids, but this information is easily retrievable from a stolen server given the lacklustre security inherent in most clinical software. If your data falls into the wrong hands, patient anguish, extortion and legal trouble are all possible. Wherever possible, your server needs to be kept behind a locked door “out the back”, or in the very least, locked down using a computer security cable. While I come across it on a weekly basis, having the server under the reception desk is perhaps the WORST place for a server due to its accessibility for a thief.

VENTILATION

Heat is the enemy of computer components. This is well known and yet so often overlooked. I am sure in the last decade that I have been involved in medical IT systems I have seen many examples where excess heat has caused monitors, printers and internal computer components to fail, resulting in expensive downtime and unnecessary frustration. As most people use desktop computers for their daily work, and don’t snuggle

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with them too often, many would be surprised by the heat they can generate. Try lying in bed with your favourite laptop (appropriately on your lap) surfing away for an hour or so. You will probably find that before long the computer is quite hot to the touch, and may actually shut itself down to prevent its internals from frying. Without adequate space around the computer, the exhaust fans can’t do their job and the important internal components will slowly roast until failure.

ACCESSIBILITY

As previously alluded to, the physical location of your hardware has a large bearing on how efficiently it can be maintained. I have seen instances of rack mounted computers placed so high on a wall that you literally need a ladder to swap Ethernet cables in and out of ports. I don’t carry a ladder or climbing harness in my service vehicle, and rarely have I come across medical centres that have them on hand either! Think about the position of your server. How easy can you or your IT person get to it if it goes down unexpectedly and needs attention?

ON SITE

I did a job at an inner city practice where space was admittedly at a premium. However in this practice the genius who put the whole catastrophe together decided to put the server to the rear of, and under one of the reception desks. I mean really underneath, to the point where you struggled to find the thing until it was pointed out to you. To make things worse, the monitor, keyboard and mouse were also nestled away in the gloom. It was just ridiculous. I asked the staff to think about moving the server to a new location where I could access it more easily. That was not seen as a high priority so guess what? It didn’t happen. I asked the staff to spring for the cost of setting up remote access so at least the server could be ‘looked

at’ from another machine. That wasn’t seen as a priority spend either. I asked the practice to buy a KVM switch so I could use the receptionist’s keyboard, monitor and mouse, again to no avail. Now I try as hard as I can to not be a techno-fascist, so of course I continued to work on (and complain about) this server, and I kid you not it was giving me the irrits! So one day while I was working in this subterranean world, the practice principal came into reception and inadvertently (I presume) stood on my hand. That was about as much as I could take. I told the doctor enough was enough and I would no longer work on the server where it was and until it was located elsewhere, they were flying solo. The doctor was unimpressed and thought I was being extreme. Pushed to defence I told her I was going to go into her room and remove all the chairs and the next consult she did would be with her and the patient sitting on the floor! She told me this was ridiculous, but I patiently (no pun intended) pointed out that I saw myself as a professional also and NO PROFESSIONAL would work under these appalling conditions. A couple of weeks later, I was called to the clinic to find a shiny new ventilated cupboard for the server with the monitor, mouse and keyboard setup neatly on the desk. Ahhhh Heaven! Although this was quite an extreme example, there is a serious side to it. Imagine if I had really been injured by the stilettos. There is a responsibility in OH&S terms to the contractors who work in your practice. A crushed hand can obviously be a serious injury to an IT guy. A fall from a chair balanced on a fridge to reach a patch panel or server could be devastating to the injured worker and your insurance premiums. Or imagine if I had sent a female co-worker touting a mini skirt to service the clinic; would she be expected to get on the floor to work on a machine? Slater and Gordon might have a field day with that! To protect client confidentiality, Mr Fixit’s identity remains hidden.

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