Pulse+IT - February 2007 by Pulse+IT Magazine

PULSE IT Ã

AUSTRALIA’S FIRST AND ONLY HEALTH IT MAGAZINE

ISSUE 3: FEBRUARY 2007

PRACTICE EFFICIENCY

www.pulsemagazine.com.au

Is your GP software threatened with extinction?

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An evolution in GP software

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Publisher Pulse Magazine PO Box 52 Coogee NSW 2034 ABN 19 923 710 562 www.pulsemagazine.com.au Editor Simon James 0402 149 859 simon.james@pulsemagazine.com.au

GUEST COLUMN: DR KENNETH ADLER PAGE 07

Art Director Scot Connolly Editorial Enquiries editor@pulsemagazine.com.au Advertising Enquiries ads@pulsemagazine.com.au About Pulse IT Pulse IT is produced by Pulse Magazine, the most innovative publisher in health. Over 10,000 copies of Pulse IT are distributed quarterly to doctors, practice staff and the IT professionals that support them.

PAGE 16 IT/IM SURVEY Geoffrey Sayer presents the results of the “Innovations for General Practice Survey”.

Contributors Dr Kenneth Adler, Linda Hein, Simon James, Louis Joseph, Jane London, Peter Machell, Dr Ian Reinecke, Geoffrey Sayer and Dr Daniel Silver. Non-Commercial Supporting Organisations • General Practice Computing Group (GPCG) • National E-Health Transition Authority (NEHTA) • National Primary Care Collaboratives (NPCC) Disclaimer The views contained herein (including letters to the editor) 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 2007 Pulse Magazine No part of this publication may be reproduced, stored electronically or transmitted in any form by any means without the prior written permission of the Publisher. Subscription Rates Please visit our website for more information about our subscription packages.

PAGE 38 MACINTOSH VIRTUALISATION Peter Machell details the sophisticated Mac software that should make you think twice before buying a Windows PC.

PAGE 40 DIGITAL CLINICAL PHOTOGRAPHY In the third article of his series, Dr Daniel Silver gets up close and personal with a detailed discussion of clinical macro photography.

SMS REMINDERS PAGE 26

SECURE MESSAGING PAGE 29

FAX SMARTER PAGE 34

LABEL PRINTING PAGE 36

REGULARS PAGE 06 STARTUP Editor Simon James introduces the ﬁrst edition of Pulse IT for 2007.

PAGE 12 GPCG Jane London asks us to consider technology and the environment.

PAGE 20 PRACTICE REVIEW Pulse IT checks in with the Goondiwindi Medical Centre.

PAGE 07 GUEST COLUMN US physician Dr Kenneth Adler reﬂects on his recent visit to Oz.

PAGE 13 PULSE IT SUBSCRIBER OFFER There’s been no better time to subscribe to Pulse IT, ﬁnd out why.

PAGE 24 INTERVIEW Pulse IT talks with Geoffrey Sayer of HealthLink.

PAGE 08 LETTERS TO THE EDITOR Feedback and comments about Pulse IT and the eHealth sector.

PAGE 14 NPCC Linda Hein details the NPCC’s new reports and support website.

PAGE 48 MARKET PLACE Australia’s most innovative and inﬂuential eHealth organisations.

PAGE 10 BITS & BYTES News about organisations operating in the eHealth sector.

PAGE 15 NEHTA Dr Ian Reinecke discusses NEHTA’s health identiﬁer privacy blueprint.

PAGE 50 SHUTDOWN Mr Fixit discusses early adoption and supplier inter-relationship.

PAGE 16 IT/IM SURVEY RESULTS Geoffrey Sayer presents the results of the “IT/IM Innovations for General Practice Survey”.

PAGE 29 SECURE MESSAGING Simon James takes a ﬁrst look at several secure electronic communication solutions.

PAGE 38 MACINTOSH VIRTUALISATION Peter Machell outlines the software solution set to take the Mac to the masses.

PAGE 19 IT/IM SURVEY REFLECTIONS Simon James and industry commentators reﬂect on the results of the IT/IM survey.

PAGE 34 FAX SMARTER Louis Joseph investigates alternative ways to send and receive faxes.

PAGE 40 DIGITAL CLINICAL PHOTOGRAPHY Dr Daniel Silver teaches the art of macro photography.

PAGE 26 SMS PATIENT REMINDERS Simon James takes a look at the use of SMS messages in medical practices.

PAGE 36 LABEL PRINTING Louis Joseph looks at dedicated label printers and their application in medical practices.

FEATURES

www.pulsemagazine.com.au

STARTUP

PULSE IT: 2007.1

Welcome to the third edition of Pulse IT, Australia’s ﬁrst and only health IT magazine. PULSE IT 2007 Welcome to the ﬁrst edition of Pulse IT for 2007, I trust you had a refreshing and enjoyable Christmas period! While the silly season raged around us, we spent most of our time bunkered down preparing for what promises to be a big year for Australian eHealth. We’ve emerged with a suite of complementary services to ensure that our readers have access to timely and relevant eHealth information, regardless of when and where they wish to devour it. Our revamped line-up includes: Pulse IT Magazine The Pulse IT Magazine is the backbone of our services. Thanks to a concerted effort from our writers, we have added an extra 8 pages to this edition while keeping advertising clutter to a minimum.

SUBSCRIPTIONS To ensure you keep receiving copies of Pulse IT and retain unrestricted access to our digital services, readers are encouraged to formalise their subscription prior to the launch of the May edition. As our teaser at the bottom of this page indicates, we have put together a great deal that makes Santa Claus look like a miser. More details about our subscription packages and our festive season promotion are available on pp13.

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With the continued support of our subscriber base, this is a trend we look forward to continuing into the future. Pulse IT eNewsletter We have commenced a fortnightly eNewsletter service to keep our readership informed of relevant eHealth happenings that occur between our quarterly printed magazines. Each edition will contain at least four articles, as well as other complementary content including FAQs and tips & tricks from selected software developers. Pulse IT Podcast Having gone through several months of planning, our podcasting service will be ofﬁcially launched on the 15th of February. As detailed in “Podcasting with iTunes” (Issue 1: August 2006, pp30), this medium presents us with many possibilities and I’m conﬁdent this service will be a great addition to the suite of Pulse IT products. Website All content from our printed magazines, eNewsletters and podcasts will be reproduced on our website. An article commenting feature has been added which should encourage supporting and alternate views to be discussed. Other enhancements are planned for the near future so be sure to check back regularly.

THIS EDITION As our cover suggests, most of the articles featured in this edition deal

with technologies that can help your practice run more efﬁciently. Speciﬁcally, we look at SMS patient reminders, paperless fax solutions, label printing, virtualisation and secure electronic communication. Geoffrey Sayer presents the results of the IT/IM Innovations for General Practice Survey and we check in with Matt Gilchrist at the Goondiwindi Medical Centre.

THANKS DANIEL! I’d like to take this opportunity to extend a special thank you to Dr Daniel Silver for his signiﬁcant, regular contributions to Pulse IT. To date, he has written an impressive 10,000 words about digital clinical photography and further assisted by providing the bulk of the excellent photos that have accompanied his articles. If you’ve missed his previous articles, I highly recommend you check them out at: www.pulsemagazine.com.au

LOOKING AHEAD In the next edition of Pulse IT we will give signiﬁcant coverage to the proposed Electronic Medicare Claiming initiative scheduled for rollout in “the second half of 2007”. We will also look at the latest release of Medicare Online Claiming and other payment systems available to medical practices. More “efﬁciency” articles will also be presented. Simon James, Editor simon.james@pulsemagazine.com.au

• Pulse IT Magazine • Pulse IT eNewsletter • Pulse IT Podcast • Pulse IT Website

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GUEST COLUMNIST

AN AMERICAN PHYSICIAN’S REFLECTIONS ON AUSTRALIAN E-HEALTH COMPARED TO THE USA Dr Kenneth Adler MD, MMM Currently only 9 to 24 percent of US physicians use clinical software, what we call an EHR1. This wide range in percent usage depends on whether you’re referring to very basic software or fully functional software that creates a paperless ofﬁce. Only 11 percent of US doctors currently prescribe medications electronically. We have no required software standards and precious little in the way of interoperability. By one account we have 319 EHR products and, unlike Australia, no single EHR product in the US accounts for more than 10% of market share. Our current national focus is on getting more physicians to use EHRs, not on getting systems to talk to one another. While we are starting to discuss interoperability issues, currently our efforts are in the early planning stages, with no government funding in sight. In the US, physicians purchase all their own hardware, software and network connectivity, with no rebates or incentives from the government to do so. We have a few isolated examples of insurance companies and integrated healthcare systems pitching in, but they remain the exception. We do have very sophisticated electronic billing and scheduling software (what we call practice management software) and essentially 100% of US physicians have this. It’s a necessity in our complex payment system with hundreds of different health insurance payers all having different rules and payment rates. Thus, most EHRs in the US require an electronic interface with the practice

DEFINITION: EHR We use the term imprecisely. In the US, the term EHR can mean simply the clinical software application used in a physician’s ofﬁce, a hospital clinical information system, or the theoretical interoperable collection of systems that provide all available health information on a patient.

management software being used. This is changing. The trend is now toward developing software that integrates the practice management and EHR software. A recent article in the journal Health Affairs entitled, “Health Care Spending and Use of Information Technology in OECD Countries,” stated that the US is at least 6 years behind Australia in terms of health information technology. This isn’t to say that there isn’t a lot of enthusiasm for EHRs in the US. Most of us who use them, love them, and are convinced that they are the key to improved quality and efﬁciency. Many of us have even improved our incomes using them, by eliminating or reducing certain costs like transcription, paper chart and form costs, medical records stafﬁng and staff overtime. We’ve also been able to increase our revenue through better coding and more accurate charge capture. EHRs hold enormous promise and the pace of adoption in the US appears to be accelerating. Starting July 1, 2007, the US government will offer a 1.5% bonus to physicians for performance reporting in our government funded insurance plan (also called Medicare.) Medicare, which covers only those who are 65 and older or disabled, accounts for nearly a quarter of US healthcare payments to physicians. If this bonus payment increases percentage-wise substantially in the future, and if the reporting requirements also increase, EHRs will likely become a necessity to qualify for this form of “pay for performance”. That certainly would help promote rapid EHR adoption (or widespread revolt.) In my short visit to Australia I was able to visit one GP surgery and talk to several GPs from different regions. I also interacted with a number of health information managers, and IT people from state departments of health and divisions of

general practice at the eHealth 2006 conference in Sydney. I was impressed by Australia’s widespread adoption of clinical software (at least in the GP sphere), your heavy use of e-prescribing and your current focus on achieving interoperability. NEHTA’s current approach of establishing standards first, and then pushing health information interchange certainly makes sense. I was left with the impression, though, that many GPs are not using clinical software nearly as effectively as they could (a problem we have in the US too) and was struck with the large discrepancy in usage between GPs and specialists. I wonder if most Australian physicians view this software as simply a tool to enhance their current workflows rather than a means to create new workflows that are more efficient and effective. One example is the GP who uses the software primarily for e-prescribing and perhaps to receive pathology results, yet maintains a paper chart for notes and correspondence. This seems inherently inefficient, perhaps more so than exclusively using paper. Also, this approach will make future complete electronic interoperability impossible. All in all I was excited by what I saw. It reinforced for me the notion that incentives drive behavior. In Australia, complex Medicare formulary requirements drove the widespread adoption of eprescribing. In the US, complex insurance schemes drove the widespread adoption of practice management software. Now both our countries need to figure out the right set of incentives and requirements to drive EHR interoperability without breaking the bank. Dr Kenneth Adler is a practicing family physician and the Medical Director of Information Technology for Arizona Community Physicians (ACP), a 96physician, predominantly primary care, physician-owned medical group, with 35 clinical sites in the metro Tucson area.

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INBOX

BROADBAND FOR HEALTH WOES I read with interest the article in the last issue of Pulse IT regarding the broadband for health rollout. Our experience has been quite different from that described, and it seems extremely difﬁcult to access this money. Our application for the second round of funding was submitted in April, and we have still yet to see any payment. We have enlisted the help of several people at our local division, and more recently, at the state based SA Divisions Inc, and despite all their kind help, we still are no closer to getting any payment. What ought to be a simple process is actually beyond some of the best experts in the industry!

INBOX member of ﬁve different boards and working groups trying to encourage broadband rollouts, I can do little other than to discourage people from applying for this scheme. It may have been much simpler if the money had been given to Divisions to deliver the services. Dr James Moxham Belair, SA Assisted in no small part by the falling cost and increased availability of high speed Internet in Australia, the Broadband for Health Program has been successful in connecting many practices to quality Internet services.

Further, our initial application for the grant last year, which was all supposed to have been ﬁnalised 18 months ago clearly wasn’t, as we received a bill last week from the ISP for extra costs.

Unfortunately for some, the costs of compliance with this scheme have ended up outweighing the unsubsidised market value of the underlying service. Having achieved its primary objective (for most), I’m pleased to note that the program will be terminated on 30 June 2007. — S.J.

The ISPs that we have discussed this with are also very disillusioned with the process, and say they have lost money setting up systems which were never used. Our practice has lost money buying services that were faster than we actually needed, being told it would Pulse+ IT be subsidised, and then receiving bills anyway.

We value your feedback so much we’re happy to reward you for it!

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Each edition, Pulse IT will give away a small token of our appreciation to a selected subscriber who writes in to share their views about Pulse IT or the application of technology in the health sector.

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I’m writing to thank you for publishing the article on podcasting in your August edition. I am not usually comfortable doing fancy things on computers but your article helped me to get up and running with podcasting in no time at all. The ABC mentions podcasting a lot, but until I saw your article I didn’t really understand what it was. I now download several different programs and listen to them on my Sunday walk using my daughter’s iPod - I’ll have to get one myself! PS - I can see why Louis Joseph [article author] likes the Yoga podcast, it’s great! Vanessa Kingston Woollahra, NSW I’m glad you are enjoying this new media format Vanessa. Be sure to visit our website and subscribe to the new Pulse IT podcast scheduled for launch by February 15th. — S.J.

LETTERS TO THE EDITOR

AUSTRALIA'S FIRST & ONLY HEALTH IT MAGAZINE

If someone from Broadband For Health can help us obtain this grant money it would be most appreciated, but in the meantime we are in the process of downgrading our broadband connection. As a

PODCASTING FOR ALL

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Subscribers who have a letter published in the May edition of Pulse IT are in the running to win an iPod Nano - the ideal device to tune in to the recently launched Pulse IT Podcast.

Letters of less than 300 words are preferred and can be sent using the details below: Mail: Pulse Magazine PO Box 52 Coogee NSW 2034 Australia Fax: 02 9475 0029 Email: editor@pulsemagazine.com.au Web: www.pulsemagazine.com.au Terms and conditions are available at the Pulse IT website.

INBOX DIGITAL PENS STRIKE A CHORD We received our ďŹ rst copy. What a great magazine. I will be keeping each copy as I am sure that I will reread some articles. The Wacom tablet is just what I need for a computer reluctant husband and doctor. He is a solo GP with 32 years in practice. Because of the change with the PBS yellow book he has to look at updating his skills. We had thought of a PDA which I see Best Practice have developed with their software. Food for thought which I would not have had if not for your magazine. Margaret Bodetti Ipswich, QLD As alluded to in my article on the â&#x20AC;&#x153;Wacom Interactive Displaysâ&#x20AC;? (Issue 2: November 2006, pp34), there is great potential for pen based input devices in the health sector. I believe that the hardware is in place, and look forward to seeing how software vendors will take advantage of this opportunity. â&#x20AC;&#x201D; S.J.

PULSE IT FEEDBACK: PART 1 Increasingly medicine involves the organisation, distribution, and sharing of information â&#x20AC;&#x201C; pathology imaging, drugs and drug reaction, specialist opinions, and genetic information. All this information has to be accessed and assimilated. Medicine is increasingly about this management of information. Your magazine meets this need to show

us the technologies available for this vital function. Congratulations on your ďŹ rst two editions and all the best for the future. Dr Ross Vining Director, Institute of Pathology and Medical Research, Westmead Hospital.

PULSE IT FEEDBACK: PART 2 Congratulations on the successful launch of Pulse IT. Iâ&#x20AC;&#x2122;ve found the articles in both editions to providing enough detail to make them useful but are presented in a way that makes the often difďŹ cult underlying concepts easy to understand. I look forward to seeing both the page count and frequency of Pulse IT increase when it is feasible for you to do so.

of this new publication which does an outstanding job of focused IT material for medical practices. The articles are cutting edge and clarify speciďŹ c and important areas of IT for health practice. I have travelled widely and seen journals and periodicals from around the world but on the topics that you have chosen, I have not seen an alternate periodical that covers the IT ďŹ eld with the quality found in Pulse IT. I believe this magazine to be a valuable addition to medical information and wish you every success with all future directions in this area. Dr. George R. Lewkovitz Bondi Junction. NSW

Dr Tony Andrew Cremorne Medical Practice

Iâ&#x20AC;&#x2122;d like to extend my sincere thanks to the dozens of people that have taken the time to write in and call to offer support for our ďŹ&#x201A;edgling publication.

You will be pleased to note that we have added eight pages to this edition yet maintained a low advertising ratio. To keep practices informed of health IT happenings between the quarterly printed editions, we have established a fortnightly eNewsletter with all content reproduced on our website. Our new podcast service may also be of interest to you. â&#x20AC;&#x201D; S.J.

Your encouragement and support during the establishment phase of Pulse IT has given us the conďŹ dence to aggressively pursue our goal of making Pulse IT the deďŹ nitive health IT resource for Australian specialists, general practitioners, practice staff and the IT professionals that support them.

PULSE IT FEEDBACK: PART 3

As always, I welcome and encourage any feedback that will help us to improve our offerings. â&#x20AC;&#x201D; S.J.

I write in congratulations on the excellent content of the ďŹ rst two issues of Pulse IT. I wish you well with the success

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BITS & BYTES

MEDILINK ADDS 2-WAY SMS FUNCTIONALITY

With the release of MedilinkXP 2006/R2, Medilink Solutions Pty Ltd have become the first Australian practice software vendor to release 2-way SMS and email appointment reminder functionality. While other products have the ability to send email and SMS appointment reminders, Medilink presently has the only solution on the Australian market that can process responses to such reminders without human interaction. SMS and email reminders can be sent from MedilinkXP to groups of patients or to an individual. The actual sending of the messages can occur ad hoc with staff interaction, or at pre-defined schedules e.g. 3 days prior to the appointment at 8pm. After receiving an SMS or email, the patient simply replies with “OK”, which changes the appointment status in the MedilinkXP appointment book to “confirmed”. Reports can then be generated to highlight patients that haven’t responded to the automated reminder. Traditional phone reminders can then be conducted if desired. 2-way appointment reminders extend the usefulness of traditional 1-way reminders. Medilink claims that greater staff efficiency, improved patient attendance and enhanced patient

care are all achievable with the latest version of MedilinkXP. As with its secure paperless communication, Medilink uses 2Hippo to provide its SMS services. Like all correspondence sent with 2Hippo, a detailed audit trail is generated when both SMS and email messages are sent.

Windows-compatible devices make wireless broadband access a reality for virtually everyone living within the Next G network area, Australia’s greatest 3G network.” Both modems are USB connectable, however the larger “relocatable” desktop modem requires an external power source.

2Hippo plans start at $3.95 per month. Medilink Pty Ltd www.medilink.com.au 2Hippo www.2hippo.com

TELSTRA EXPANDS WIRELESS BROADBAND OPTIONS Telstra have released two new wireless broadband modems that allow users to access their “Next G” network. BigPond Group Managing Director, Mr Justin Milne said that, “Together with the [PCMCIA] Mobile Card for laptops launched on October 6, the new

Telstra has not yet announced an “Express Card” solution, however many industry observers expect that they will utilise a forthcoming product from Maxon, the manufacturer of both of Telstra’s new modems. With the exception of the PowerBook range, Telstra has not yet delivered an Apple compatible Next G wireless broadband solution. At the time of writing, this is still the case, however a forthcoming software update from Telstra will allow these new modems to work with Apple computers. As with all wireless networks, the speed of the connection will vary greatly depending on a range of factors including distance from the network tower, proximity to other radio signals and the location and type of the building the user is located in. Telstra advertises a “G Fast” plan with download speeds up to 256Kbps and upload speeds up to 128kbps. Their “Super G Fast” plan is advertised with average download speeds of between 550-1500Kbps, bursting to 3.6Mbps, with upload speed bursting to 384Kbps. Telstra’s Next G network is capable of much greater theoretical speeds however, with progressive upgrades expected during the course of the year and beyond. Peak network performance is expected to be increased to an impressive14.4Mbps by the middle of this year. The mobile USB modem is priced at $299, the same price as the existing PCMCIA model. At $249, the desktop model is the cheapest in the range. Monthly mobile access plans start at $29.95 for 10 hours, with data usage plans ranging up to $199.95 for 3GB. Telstra Bigpond www.bigpond.com

PULSE + IT

BITS & BYTES

VOCERA ANNOUNCES SOFTWARE RELEASE 4.0

Vocera Communications has announced an update to the administration software that manages its wireless network communication system. Typically deployed in hospital and other businesses where efficient staff communication is essential, users of the Vocera system talk to each other using hands-free, voice activated “badges”. Typically worn around the neck of the user, these badges may best be described as “wireless network walkytalkies”. Julie Shimer, president and CEO, Vocera Communications has promised that “Software Release 4.0 will optimse system uptime, increase administrative efficiency, enhance system management, and expand the integration capabilities for our customers.” The refreshed software can now support up to 4,200 simultaneous users, up from the previous limit of 1,800. An improved administration permission structure has also been introduced. Vocera has implemented a new cluster architecture which reduces the downtime involved when switching from the primary server to a standby server from “minutes to seconds” according to a company press release. The new software has enhanced integration with external phone systems. Specifically, users can now dictate a phone number to call a contact outside of the hospital. “Touch tones”, can now also be sent which extends the usefulness of the badge during calls to organisations with automated response systems.

AGED CARE WEBSITE LAUNCHED

Senator Santo Santoro, Minister for Ageing has launched a new website to provide people with faster access to information about aged care services. The website includes several interactive resources including an “Aged Care Home Finder”, “Community Care Service Finder” and a “My Page” feature. “These features allow people to ﬁnd all the relevant details on approved homes and community care services in their local area,” Senator Santoro said. “Using the Aged Care Home Finder, people can save valuable time searching for the right home. Instead of travelling to several places to compare services, Internet users can now view and compare homes online and decide which best meets the needs of a particular person.”

for people with arthritis also have movie days and live theatre as part of their regular activities.” “With the click of a button people can view photographs of facilities as well as maps of their location that show the proximity to shops, parks and other important facilities.” The Community Care Service Finder also helps people search for services in their local area to support them staying at home, including personal nursing, home modiﬁcation, maintenance, and transport services. “The My Page feature allows users to store, update and share with family and friends material they have selected from the site. It also allows family members interstate or overseas to be a part of what is a very important decision,” Senator Santoro said. Aged Care Australia www.agedcareaustralia.gov.au

“For instance, people can ﬁnd out which homes providing specialised programs

Incoming call functionality has also been improved. For the ﬁrst time, people calling from outside of the hospital phone system can now dial direct to a badge, eliminating the need for the caller to dictate the recipients name after establishing a connection to the system. Vocera Communications www.vocera.com

PULSE + IT

GPCG

TRIPLE BOTTOM LINE Jane London

and/or recyclable products, using low phosphate cleaning products and so on.

It’s ofﬁcial: things are hotting up. With ‘global warming’ the new words on everyone’s lips it is time to focus on how you can make a difference, both at home and in the practice. Given the rate at which humans are depleting natural resources, discussions on the concept of sustainability and sustainable development are necessary within all public forums. After all, we can’t keep gorging resources at this rate and not expect to be left with the pantry bare. Sustainable development involves the merging of ﬁnancial, social and environmental policies and ideologies. This will ensure longevity of our resources and have positive economic elements. Many organisations have demonstrated that environmental policies make good business. It has been noted that such varied industries as electronics, paper and pulp, paint/coatings and

When taking into account computers and other pieces of information technology within the practice you can also apply the concept of triple bottom line to identify what your practice may be able to do.

FINANCIAL Utilising computers to move towards a more paperless system will reduce costs to the practice, not only in terms of paper, printing, mailing and storage, but also time effectiveness. With adequately trained staff, information is more easily retrieved and communicated resulting in added time for other activities (e.g. preventive care, patient education). Using remote accessible servers when attending at other locations will also reduce paper use, centralise data and improve time efﬁciency.

SOCIAL CAPITAL Effectively using computers within the practice may result in less error (e.g. prescribing), faster service – at reception and in the consultation – and greater customer satisfaction.

Service organisations, despite having a smaller ecological footprint, can still minimise their effect on the environment and make it pay off. printing have reported lower running costs and higher product quality as a result of implementing procedures and new techniques to minimise waste and pollution. Economic beneﬁt, however, is not limited to industry. Service organisations, despite having a smaller ecological footprint, can still minimise their effect on the environment and make it pay off. Drawing this triple bottom line (environment/ ﬁnancial/ social) in your practice may involve: installing rain and/or grey water tank, using recycled

PULSE + IT

Not trawling through piles of notes and ﬁles may also build team morale. Improved time efﬁciency may also enable other activities to improve patient health.

ENVIRONMENTAL Paper reduction is the most apparent beneﬁt of computer use, however the savvy practice may also want to take into account the life cycle assessment of the IT hardware used. This consideration is made before purchasing a computer, printer, fax or other piece of equipment.

Life cycle assessment looks at what consumables the item uses during its working life, what components it is constructed of and how these would be disposed of or recycled in an ecologically friendly way. Some companies (such as Xerox) have specific life cycle assessment policies whereby almost all parts are reclaimed by the company and reused at the end of a product’s useful life. Additions to a practice policy that outline green power choice, shutting down all computers each night, refilling inkjet cartridges, disposing of monitors via local council to minimise lead contaminants and reusing single sided, non-confidential paper are other ways to draw a triple bottom line under your computer use. The answer to how we could achieve some kind of ‘sustainable development’ is still a contentious issue, which provokes a range of responses. Yet whilst the mechanics are open to debate, the underlying principles are quite clear. In some way we must grow the economy in an environmentally and socially responsible way in order to develop a workable relationship with the surrounds in which we live.

CONTACT Should you wish to know any more details you can contact Jane London at the Royal Australian College of General Practitioners. Jane London works in the Quality Care Unit of the RACGP coordinating ongoing GPCG activities.

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

PULSE IT HAS NEVER SOUNDED BETTER Until the 31st of March, every new Pulse IT subscriber will receive a free iPod Shufﬂe.

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At only $165, this bundle represents excellent value. For more details, please visit our website.

www.pulsemagazine.com.au

NPCC

NPCC LAUNCHES REPORTS AND SUPPORT WEBSITE Linda Hein The reporting support website guides practices through the reports, including a simple introduction to the NPCC reports, where to start, how to run the reports and interpret the results, and provides a link directly to the main NPCC website containing information and presentations from all of the Collaboratives’ workshops. The National Primary Care Collaborative (NPCC) team has worked successfully with suppliers of leading Australian clinical software to make the Coronary Heart Disease (CHD) and Diabetes related NPCC reports available to the wider Australian general practice community.

The now widespread availability of the NPCC reports presents an opportunity for Australian general practices, with the support of their divisions and general practice networks, to develop robust diabetes and CHD registers and dramatically improve the veracity of practice data.

A reporting support website has been developed by the NPCC to help practices understand and use these reports. The NPCC reporting process offers practices a unique insight into the mechanisms of care delivery at work within their practice and reveals opportunities to enhance earning potential, streamline practice systems, and ultimately improve the quality of care of their patients.

The reports can provide more Australian practices with information about patient groups, practice performance and insights into the systems of care delivery within the practice, which most importantly enhances patient care.

The NPCC reports offer general practices a new perspective on their chronic disease patients by collecting a set of key clinical and ﬁnancial indicators from the electronic patient records within the software of severall software suppliers: • • • • • • •

Best Practice Communicare Genie Medical Director 3 Medtech32 Practix Zedmed

This type of information, until now, has not been readily available to practices not participating in the Collaboratives program, and is an invaluable tool for enhancing patient care and streamlining the practice systems. In addition, this information also provides the opportunity to enhance practice earning through the improved practice systems.

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Their availability also continues the Collaboratives’ linkage with Australian health priorities, divisional network strategies and strategies of other general practice support organisations. Julian Flint, Health Informatics Coordinator at Adelaide Western General Practice Network (and former NPCC Data and Information Manager), said the Collaboratives has not only been the best thing for Information Management in terms of the quality and accuracy of patient data, practices are actually using that data to make decisions in terms of patient care. “Before the NPCC there were no clinical software programs that could search for information on the scale required for the Collaboratives”, he said. “The Collaboratives pushed forward software search capabilities, as well as GP and practice appreciation of quality data, and it’s fantastic to see these search tools now available to the majority of general practices around Australia as well as the practices participating in the Collaboratives program.”

The 3-year, $17.3 million Commonwealth funded Collaboratives program has already assisted over 500 participating general practices from around Australia improve health outcomes for patients with chronic disease by introducing better systems of care and enhancing overall business efﬁciency. For more information on the program and the reporting support resource, please visit the NPCC website. Linda Hein is the Communications Ofﬁcer for the National Primary Care Collaboratives.

EXAMPLE FROM THE WEBSITE The NPCC reports produce powerful information which is immediately useful in your practice. Example 1: A simple statistic like the percentage (%) of diabetic patients with an HbA1c <7% might trigger an examination of many aspects of your practice including: • Are we recording this information properly? • Is our recall system working? • Do the GPs in this practice have a consistent understanding of when a new HbA1c test is required? • Is our delivery of diabetes care sufﬁciently methodical or do gaps exist in our systems? • How much income are we missing from diabetes PIP payments? • Are we setting ourselves up for a high future workload with acute diabetic patients by missing opportunities to intervene early?

NPCC www.npcc.com.au NPCC Reporting Support Website www.npcc.com.au/Reports/home.htm Adelaide Western GP Network www.awgpn.org.au

NEHTA

PRIVACY BLUEPRINT FOR UNIQUE HEALTHCARE IDENTIFIERS Dr Ian Reinecke

information. The IHI will only be used to identify individuals for the purposes of healthcare; and individuals will not be required to produce an IHI to receive healthcare.

The effectiveness of Australia’s healthcare system relies on the ability to uniquely and accurately identify individuals. Healthcare requires the constant collection, exchange and transmission of health information. This is usually in the context of information about a single patient being exchanged between multiple healthcare providers. Therefore it is critical for patient safety and privacy that this information exchange occurs reliably and securely. The Council of Australian Governments has committed Australia to a single, national approach to identifying individuals and healthcare providers for the purposes of health communications. This approach, being developed by NEHTA, is known as the Unique Healthcare Identification (UHI) Service. The UHI Service will involve the allocation, issuing and maintenance of unique identifiers for individuals (known as the Individual Healthcare Identifier or IHI) and healthcare providers (the Healthcare Provider Identifier or HPI). As important health information about patients is shared between clinicians, it must be absolutely clear which patient the particular information relates to. The current practice of identifying patients - often by simply using their name and address - is not safe enough. Identifying individuals by a unique number offers significantly greater protection for this

The transmission of patient information must ensure reliable delivery to the right healthcare practitioner. Identifying every one of the 400,000+ healthcare providers in Australia by a unique number offers significantly greater reliability than using practitioner names and addresses. From the outset, NEHTA has recognised that privacy is an issue of great concern to Australians – particularly in the health sector. Whilst NEHTA must manage the risks of a particularly complex legislative and regulatory environment we must also recognise that privacy perceptions of the Australian community play a major role in ensuring the success of e-health systems. As confidence and trust build upon a strong privacy foundation, the UHI Service will only be successful if it meets community expectations regarding privacy. NEHTA has recently released a Privacy Blueprint – Unique Healthcare Identifiers which sets out a systematic framework to consider privacy issues and poses a number of strategies to address them. The Privacy Blueprint aims to comprehensively identify the range of privacy issues that apply to a specific initiative, so that corresponding action steps may be subsequently undertaken to address those issues within the design, privacy impact assessment or implementation programs.

privacy compliance issues and promotes a coordinated approach to privacy management. This Privacy Blueprint also ensures that privacy is properly integrated into the UHI Service design and implementation, as well as being a critical mechanism for consultation on the UHI Service. The Privacy Blueprint outlines the nature and function of the UHI Service, and identiﬁes key participants in the proposed system as well as the information involved and how it will be used. A number of key privacy issues are then examined in detail, such as consent and notice, access, audit and secondary uses. These areas require consultation before the UHI Service can undergo a full privacy impact assessment or progress to implementation. The Privacy Blueprint aims to identify community concerns about these issues by using a series of speciﬁc questions within the discussion to elicit useful feedback. Such feedback will be incorporated into NEHTA’s ongoing management of privacy issues and will inform future consultation documents and privacy policy decisions. The Privacy Blueprint can be found at the NEHTA website. Dr Ian Reinecke is the CEO of the National E-Health Transition Authority (NEHTA).

NEHTA www.nehta.gov.au

Adopting a privacy blueprint process ensures that NEHTA proactively considers

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IT/IM INNOVATIONS SURVEY

WHAT IT/IM INNOVATIONS ARE GOING TO MAKE THE GREATEST DIFFERENCE TO GENERAL PRACTICE? Geoffrey Sayer PhD BACKGROUND There are many things that people suggest that Information Technology (IT) and Information Management (IM) can do to improve general practice. These improvements can be concerned with practice efficiencies, safer patient care, better patient outcomes, more sustainable business, more profitable business and cost effective delivery of treatments. A survey of the Pulse IT readership was conducted during November and December 2006 asking respondents the 5 most important innovations/ enhancements they believed would contribute the most to improving general practice. The survey was made available through a fax back 2-sided survey form and could also be completed on-line at the Pulse IT website.

their options. Approximately one quarter of the sample (24.5% and 23.0% respectively) chose “Sending electronic prescriptions to a hub to be pulled down by a pharmacist used by the patient” and “Timely and effective technical support” to round off the 5 most frequently selected options.

in these areas if advocacy and progress are to be made. However one must not forget that the end users are after applications that allow them to effectively, safely and efficiently care for their patients that are moving through different aspects of the health care system.

At the other end of the ranking 5% of respondents chose a not listed innovation which included “Better integration of voice recognition software” and “Secure Medical VPN”. Less than 5% of respondents chose the innovations of the “Ability to individually customise the look, feel and functionality of GP software” (4.3%), “Population health applications” (3.6%), “Hand held computers” (2.9%) and “Message acknowledgement systems for audit trails” (1.4%).

ACKNOWLEDGEMENTS

Communication innovations or enhancements (specialist reports, discharge summaries, referrals) would contribute the most to improving general practice… RESULTS The survey received 139 respondents that had completed the task of separately identifying 5 separate things. Communication innovations (Table 1) were the most frequent innovations/enhancements selected with nearly half of respondents (47.5%) selecting “Specialist reports received electronically” in their 5 options making it the most frequent option chosen. This was followed by approximately one third of the sample (35.3% and 34.5% respectively) choosing “Electronic discharge summaries” and “Ability to send referrals electronically from within the clinical software” as one of

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The characteristics of the respondents of the survey are presented in Table 2. A detailed analysis (with 95% confidence intervals and relative standard error of the estimates) is provided at the Pulse IT website.

CONCLUSION It appears that the most significant improvements the respondents believe to make a difference to General Practice are related to the sharing of information from different healthcare sectors. It is possible that standards and the building blocks that will assist this are not well understood by the majority of GPs and their staff, and that further education is required

The author and Pulse IT would like to acknowledge the help from the number of people who assisted in formulating the list of Innovations and enhancements for consideration. These included doctors and practice staff who participate in the GPCG discussion list and other software forums. We also like to thank the support of a number of the Divisions of General Practice who assisted in promoting the survey as well. Geoffrey Sayer (PhD) is currently employed by HealthLink as Market Development Manager. He has worked in the Health IT industry for the past 6 years in research and development; and as an epidemiologist and statistician in academia, the private sector and the public health system for the past 15 years. He pursues his own interests in research and development in general practice through consulting services and independent research.

Pulse IT Website www.pulsemagazine.com.au Detailed IT/IM Survey Analysis www.tinyurl.com/39k8kk GPCG Email Discussion List www.tinyurl.com/363krl

IT/IM INNOVATIONS SURVEY

Table 1: IT/IM Innovations for General Practice Survey – Most Important (N = 139) Innovation

Rank

Specialist reports received electronically

47.5

Electronic discharge summaries

35.3

Ability to send referrals electronically from within the clinical software

34.5

Sending electronic prescriptions to a hub to be pulled down by a pharmacist used by the patient

24.5

Timely and effective technical support

23.0

Widespread computerisation of Medical Specialist practices

20.1

Implementation of the open Electronic Health Record standard for transfer of records across systems

18.0

Electronic transport of diagnostic requests and monitoring of outstanding requests

17.3

Increasing the completeness of records for drug allergies, patient history and current medications

16.5

Centralized patient medical record

15.8

Viewing of diagnostic images from within the clinical software

15.1

Automated electronic version updates of software and content (e.g. PBS and PI changes)

14.4

Software developed under Open Source Software Principles

13.7

Training with current software products

13.7

Authority Notiﬁcation System from within the clinical software

12.9

More useful / relevant medication warnings, allergies and contraindications system

12.2

Patient held electronic health records

11.5

Implementation of treatment guidelines into software

11.5

Electronic generation and transport of “forms”

11.5

Better use of information gathered to fulﬁll Accreditation Requirements

10.8

Easier access to patient and practice information held in the database

10.1

Easier use of encryption

10.1

Implementation of SNOMED-CT (Nationally licensed medical terminology set) in clinical systems

9.4

Acceptance of an electronic signature by government agencies

9.4

Easier analysis of patient and practice information held in the database

8.6

Remote access to patient and practice databases

7.9

Single national patient identiﬁer

7.2

Better use of information gathered to fulﬁll CME Requirements

6.5

Other (e.g. Better integration of voice recognition software, secure medical VPN)

5.0

Ability to individually customise the look, feel and functionality of GP software

4.3

Population health applications

3.6

Hand held computers

2.9

Message acknowledgement systems for audit trails

1.4

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IT/IM INNOVATIONS SURVEY

Table 2: IT/IM Innovations for General Practice Survey - Respondent Characteristics Age

Median

125

50 yrs (20-77)

Gender

Males

52.9

Female

47.1

Which best describes your current occupation?

53.4

Specialist

8.4

Staff (GP)

30.5

Staff (Specialist)

0.8

IT/IM Support

0.8

Other

6.1

In what year did you ďŹ rst use a computer?

Median

Any purpose (home or in your practice)

131

1987

In your practice for any purpose

124

1995

In your practice to make part of the clinical record, including prescribing

115

1998

Do you write on paper in your practice?

Yes

60.6

39.4

Which patient management/clinical software do you currently use?

Best Practice

11.9

Genie

13.3

Medical Director

59.3

Medical Spectrum/Plexus/Practix

6.9

MedTech32

3.0

ZedMed

1.5

Other

4.1

Which practice management software (e.g. appointments, billing) do you currently use?

Best Practice

5.2

Blue Chip

1.5

Genie

12.7

Medical Spectrum/Plexus/Practix

6.0

MedTech32

3.0

PracSoft

44.8

4.5

ZedMed

2.2

Other

20.1

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IT/IM INNOVATIONS SURVEY

REFLECTIONS ON THE IT/IM SURVEY Simon James BIT, BComm CONNECTIVITY AND SPECIALIST COMPUTERISATION Will 2007 be “The Year of Secure Electronic Communication”? Given the lack of government incentive, and the historical inability of the profession to adopt unsubsidised technology, I expect this would be an overstatement. These results clearly indicate however, that there is widespread acknowledgment of the importance of more efficient communication between the various health sector participants. The acknowledgment by GPs of the importance of specialist computerisation is intrinsically linked to their desire to see the widespread adoption of secure electronic communication. Whether it is due to a lack of financial incentive or lack of perceived benefit, specialists are not adopting technology at the rate required to allow the full potential of secure electronic communication to be realised by the sector as a whole. In the absence of any large-scale government intervention, a concerted effort by GPs at the grass roots level will be required to affect this change. The AMA and AGPN (formerly ADGP) need to show strong leadership on this issue, regardless of where their traditional responsibilities lie.

SUPPORT With a background in software support, the high value placed on timely support by the survey participants came as no surprise. Contrasted with the low ranking of “the ability to customise software”, the majority of doctors appear quite happy to forgo “bells and whistles” providing their software is stable and effective support is provided in a timely fashion.

Several “off-survey” requests for less frequent and more reliable software updates support this notion, a sentiment that software developers seem to be acknowledging with many moving away from ﬁxed release dates.

AGEING POPULATION

When asked to comment on the survey results, Frank Pyﬁnch, a practising GP and founder of Best Practice said that “GPs are interested in providing the best quality of care for their patients in the most efﬁcient way possible. Population health is the domain of government, not of private General Practice.”

One thing that struck me early in the data management phase of the research was the age of the GP respondents. Perhaps pointing to wider workforce issues, only 8 GPs under the age of 40 responded to the survey. Given that stereotypically, younger members of the population are more comfortable and interested in technology, I found it interesting that over half of the GP respondents were eligible for Super entitlements!

Government has many options available to it to ensure standards are adopted by the industry. While vendor incentives are important, ultimately a high priority needs to be placed on the direct education of doctors and practice staff. Software developers have limited resources and respond best to customers demands as evidenced by the uptake of Online Claiming by both vendors, and in turn practices.

WHAT ABOUT STANDARDS?

BRING ON THE PIP!

Because of the scope of the survey, I expected the responding group to be primarily comprised of GPs with an interest in technology and its application in health. While I feel this assumption eventuated, there was little acknowledgement of the importance of standards and the current National E Health Transition Authority (NEHTA) initiatives (namely SNOMED-CT and the pursuit of a single national patient identiﬁer).

As alluded to in the November edition of Pulse IT, I encourage Medicare Australia to fast track a new PIP IT/IM incentive to provide practices with more ambitious secure messaging goal posts. Despite the financial and efficiency benefits that can result from secure messaging in its own right, financial incentives and a concerted effort by secure communications providers will be required to get both specialist and GP practices moving en masse.

Dr Ron Tomlins, Chair of the GPCG stated that “The low ranking given to standards and systems based issues that may underpin clinical efﬁciency and efﬁcacy is to be expected as most GPs are not IT-savvy and only interested in doing their primary job of delivering care.”

CONCLUSION

This is view is supported by Sydney GP Dr Robert Lewin who said that “Users aren’t interested in IT except where it directly impacts on practice performance.”

Despite the low response, this survey clearly highlights the innovations software developers and Government should be pursuing. As Geoffrey Sayer, the surveys designer puts succinctly, “End users are after applications that allow them to effectively, safely and efﬁciently care for their patients.” Simon James is the editor of Pulse IT.

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PRACTICE REVIEW

PRACTICE REVIEW: GOONDIWINDI MEDICAL CENTRE Simon James BIT, BComm

Located centrally, the Goondiwindi Medical Centre is the largest of the two general practices in the town. The medical centre was established when Dr Ian Thompson joined Dr Rowena Sheppard, Dr Bruce Dixon and Dr Kathryn Mainstone in 1998. Since the co-location of these two practices, the medical centre has grown steadily and now has nine doctors with a tenth scheduled to start in early February. The medical centre services an area 250km high and 350km wide, with half of the region’s 10,000 people living in the town. The practice has 15,000 active patients, which Practice Manager Matt Gilchrist attributes to the town’s large number of itinerant workers and the high volume of travellers passing through the area. The doctors are supported by four full time and one part time administration staff members. The practice currently has two registrars, with four practice nurses working 2.25 FTE also based in the medical centre. The practice is a teaching practice, taking students from the University of Below - Michelle scanning in Best Practice

Queensland and the other universities under the John Flynn Scholarship Scheme. In the past 12 months, a total of eighteen students have attended the practice including the winner of the inaugural RDAA Rural Student of the Year Award, Lydia Scott. Hailing from the University of Adelaide, Lydia was presented with this award in November 2006 in recognition of her work in setting up a Q Fever clinic in Mungindi, 170km west of Goondiwindi. Lydia established the clinic with the assistance of the doctors from the practice.

PRACTICE SOFTWARE Clinical The medical centre switched clinical software packages from Medical Director 2 (MD2) to Best Practice eight months ago. The decision to look for a new solution was made when it became apparent that HCN was scaling back development of MD2 in favor of the product’s newer sibling, Medical Director 3 (MD3). While Matt did evaluate MD3, he concluded that it was not suitable for his practice due to the additional underlying licensing requirements that his practice would need to meet. Due to the size of the medical centre’s database, Microsoft SQL Server would have been required to run MD3. While expensive in its own right, the practice would have actually been required to purchase a second copy of the database software for use on their backup server. To ensure compatibility, an additional copy of Microsoft Windows Server 2003 would have also been required to upgrade this same machine from Windows XP. Matt also cited concerns about the drifting MD3 release date, and

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claimed that HCN had not responded adequately to previous support requests or constructive product feedback. After evaluating several other solutions, the medical centre ultimately chose Best Practice. Matt indicated that they were impressed by the products client-server SQL underpinnings, the ability to run the product on a free underlying database system (MSDE), and the fact that the user interface was intuitive and easy for their staff to use. Matt also pointed to Best Practice’s strong documentation and vibrant online user community as important factors in his decision, stating that these resources have allowed him to manage the MD2 transition and ongoing maintenance of Best Practice with little outside assistance. Practice Management While Best Practice also has a practice management module, the medical centre has retained HCN’s Pracsoft for its billing and appointments. Matt indicated that the practice intends to migrate from Pracsoft to Best Practice Management when the Medicare Online Claiming functionality is ﬁnalised.

HARDWARE Server The Best Practice database is hosted on a 3-year-old, custom-built machine running Microsoft Windows Server 2003. This server is powered by dual 2.66 GHz Xeon processors and has 3 gigabytes of RAM installed. Storage is provided by an external SCSI drive enclosure containing four high-performance, 72 gigabyte drives spinning at 10,000 rpm. These disks are conﬁgured in a RAID 5 arrangement,

PRACTICE REVIEW which provides a good mix of performance and redundancy. While only a fraction of the space is used, the RAID has an effective capacity of around 216 gigabytes. This machine also acts as a terminal server, accepting both remote and local network connections. Backup Server The practice has a computer configured as a replacement server for instances where the primary server is out of service. Due primarily to the expense (over $1200), this computer doesn’t have a SCSI interface to allow it to connect to the primary server’s external RAID enclosure. The implications of this limitation were felt recently when the primary server’s SCSI interface card failed. Fortunately the card worked intermittently and the data was able to be transferred to temporary storage while a replacement card was sourced. The practice data is backed up and restored to the backup server on a weekly basis to test both the integrity of the database and the preparedness of the backup server. Client Computers Computers are installed in each of the 8 consultation rooms with one also installed in the practice’s treatment room. There are two computers positioned in the reception area, three in the back office, one in the practice manager’s office and one in the practice’s “skin clinic”. A computer is also installed adjacent to the practice sterilisation facility to allow the nurses to confirm patient Below - Dr Matthew Masel processing lab results.

demographics and match samples with the treating doctor. Some of these client computers are conﬁgured to use Terminal Services to connect to the practice server, while others are setup as conventional smart clients. Scanning The medical centre uses a Fujitsu 4110C document scanner that has performed reliably since being deployed several years ago. The practice has been paperless for six years and routinely scans up to 60 pages per day. Scanning is typically performed once a day, with documents imported into Best Practice via the bulk document import feature.

PRINTING The bulk of the printing in the practice is handled by HP1000 series machines. Other assorted printers including a HP LaserJet 4 that “won’t die“ are also utilised in the practice.

NETWORK The practice network operates at 100 Mbit over standard category-5 Ethernet cabling. A heavily secured wireless network is also available, though rarely used.

TOWN PROFILE: GOONDIWINDI The name Goondiwindi derives from a local Aboriginal word meaning “the resting place of the birds”. The town is situated on the Queensland side of the MacIntyre River, 350 kilometres south west of Brisbane. Just over 5,000 people call Goondiwindi home, with the town servicing the many trucks and other travellers who venture along the six highways that pass through or near

Internet Access The practice connects to the Internet via ADSL running at 8000/384Kbit. This service has only been connected for a short time, however Matt indicated that it didn’t perform noticeably faster than the 1500/256Kbit ADSL service it replaced (large downloads from some website being the exception). Remote Access The Goondiwindi Medical Centre was the ﬁrst practice to be granted permission from Queensland Health to make connections from the local hospital back to the clinic. Remote access can also be established from the local nursing home and the doctor’s homes. As is now commonplace, the remote access capability is achieved using Microsoft Terminal Services (RDP). While this access is encrypted by default, the practice has changed the default port

the town (Newell, Leichhardt, Gore, Cunningham, Barwon and Bruxner). Goondiwindi is a major centre for agricultural production with the district farming a diverse range of produce including cotton, grain, sorghum, corn, barley, wheat, chickpeas, beef, wool, lamb and pork. Goondiwindi has an active sporting community with participants able to get involved in Rugby Union, Rugby League, Cricket, Golf, Tennis, AFL, Netball and Swimming . The town boasts a large indoor gymnasium, and a large man made water park that can be used for water skiing, swimming and other recreational activities.

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PRACTICE REVIEW DIGITAL PHOTOGRAPHY As mentioned previously, the practice has a room dedicated to skin related medicine. The doctors have a range of photographic tools to choose from, including a Nikon Coolpix 4500, various Heine dermatascopes, and a dermlite which attaches to a 7.2 megapixel Sony DSC -W70. The practice also has several Pentax digital SLR cameras used primarily for macrophotography. The computer in this room has two monitors (a 17 inch and 20 inch wide screen) to allow for easier photo viewing and manipulation.

Above - The dual-monitor computer setup in the practice’s “skin clinic”.

in an attempt to strengthen the overall security of the system. Policies to enforce non-trivial passwords to both Microsoft Windows and Best Practice are also in place.

BACKUP AND REDUNDANCY Data Backup The practice maintains an aggressive backup regime, with copies of the PracSoft data taken ever hour. The Best Practice data and other documents are backed up at least four times a day, with the data copied to multiple practice computers. Once a week, DVDs are burnt and stored securely offsite. As the amount of data needing to be backed up is over 10 gigabytes, both a dual layer (8.5 Gb) and single layer (4.4 Gb) disk are used. Below - The practice’s diesel generator...

Backup Power A large APC Uninterruptible Power Supply (UPS) provides backup power to the practice server, external SCSI enclosure, phone system, network switch and Internet router. Smaller APC UPS devices are also installed on each client computer, a prevention measure that is being adopted by more practices in line with the falling price of UPS hardware and the increased realisation of the importance of reliable computer access. Both the server and client UPS devices allow up to 30 minutes of run time. In the event of an extended blackout, a large purpose built diesel generator is started, which can provide enough power to run the entire building. ...which gets its own ofﬁce!

After photos have been examined on screen, they are linked to the Best Practice patient record by the practitioner for future reference. Prior to this linking process, Microsoft Ofﬁce Picture Manager is used to crop photos to ensure the practice database isn’t bloated unnecessarily.

COMMUNICATION External Communication Like many modern practices, the Goondiwindi Medical Centre is infested with a plague of pathology and radiology downloading applications including MQLink, Fetch, Medical Objects, Promedicus and Argus. All results are downloaded in the preferred HL7 format. As a result, the practice was able to join the National Primary Care Collaboratives program with no additional IT setup required. Despite attempts to leverage the doctor-to-doctor communication capabilities in some of the aforementioned communication products, the vast majority of incoming and outgoing correspondence arrives and leaves on paper. Internal Communication The practice hosts its own email server behind the practice ﬁrewall, which allows communication within the practice to be conducted without encryption (as the unsecured messages aren’t exposed to the public Internet). Wildﬁre, a Jabba instant messaging server has been installed for quicker, less formal communication within the practice.

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PRACTICE REVIEW RECOMMENDATIONS As a self taught IT systems administrator, Practice Manager Matt Gilchrist demonstrated a good understanding of IT theory and its practical application in a medical centre. From an IT perspective, his practice has many strengths including: • • • •

Excellent power redundancy. Robust data redundancy. Remote access. Innovative internal communication techniques. • Client-server based practice software. • Comprehensive digital clinical photography facilities. As with all medical practices however, a few aspects of the IT system warrant review: External Storage As Matt evidenced ﬁrst hand during the recent hardware failure, SCSI hardware is not readily available, nor is it cheap. While the technology continues to rein supreme in terms of raw performance, Serial ATA storage technology is a better solution for the vast majority of medical practices. While only fractionally slower than SCSI solutions, Serial ATA disks, cables and interface cards are more readily available and signiﬁcantly cheaper. The external SCSI enclosure is a good solution in its own right, however the fact that the backup server doesn’t have

the ability to connect to it is a cause for concern. The practice should seek to replace their existing SCSI solution with a modern Serial ATA alternative. It would be cost effective to arrange this when the practice is ready to replace the ageing primary server. Once this setup is in place, in the event of a hardware failure on the primary server, the new external drive enclosure would simply be plugged into the backup server, allowing the practice to continue unaffected. Backup Given the large amount of data the practice needs to back up, the fact that DVDs aren’t burnt daily is understandable. Under the current arrangement however, in the unlikely event of a ﬁre, the practice stands to lose as much as a weeks worth of data. Deploying one or more external hard drives with either a USB2, Firewire or eSATA interface is a cost effective solution that would allow backups to be transported off-site each day. With the ever expanding capacity of modern hard drives, as much as 150 daily snapshots of the practice’s data could be stored on a single external drive unit (though it would be cheaper and provide more ﬂexibility to deploy multiple, smaller-capacity drives). To

ensure a permanent archive of the practice data is kept, DVDs should still be burnt at least once a week. While this would involve more DVDs, it would actually be more cost effective if the higher capacity dual layer DVDs were not used (due to their relatively high cost per megabyte). Remote Access While Matt has taken extra precautions to secure remote connections to the practice, when examined discretely, these techniques are not infallible. As such, the feasibility of “wrapping” their Terminal Services connections in either a VPN or SSH Tunnel should be investigated. Such additional measures can be deployed without additional software cost, and add little or no complexity for the end user when establishing or using the remote connection. While the likelihood of an unauthorised party penetrating the existing system is highly remote, adding either of these additional security layers would bring the practice’s remote access system in line with the highest available security standards. Simon James is the editor of Pulse IT. He invites medical practices interested in participating in a future practice review to contact him via email: simon.james@pulsemagazine.com.au

INTERVIEW

INTERVIEW: HEALTHLINK Pulse IT checks in with Geoffrey Sayer, HealthLink’s Market Development Manager.

PULSE IT: What is HealthLink? HealthLink is the leading provider of secure electronic health messaging services throughout Australia and New Zealand. We are in the business of eliminating paper as a form of communication in health care. The services provided by HealthLink integrate and enhance healthcare systems, improving efficiency, accuracy and patient outcomes with a higher order of patient privacy and confidentiality. For HealthLink, patient privacy and confidentiality is paramount in the sending of patient information to other health professionals. To protect the message in transit HealthLink uses PKI technology for its encryption. PKI ensures that only the intended recipient is able to open the confidential information, protecting the patient’s privacy and giving the sender piece of mind. HealthLink’s software enables all health professionals to become part of the largest electronic health information exchange network in Australia. The HealthLink Messaging System (HMS) is used by diagnostic companies, GPs, specialists, hospitals and allied health professionals. We do this by delivering software that integrates in with a practice’s system as well as integrating in with diagnostic and hospital systems. PULSE IT: What is a practice required to do to get up and running with HealthLink? It is relatively easy to get up and running with HealthLink. Practices can register online and a kit is then sent to the practice. The kit contains the software, integration guide for their clinical system and the PKI certificates that are used to sign and receive messages. It takes about 10-15 minutes to install the software.

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PULSE IT: Which practice software does HealthLink integrate with?

PULSE IT: What functionality of your software are these users typically using?

At the primary care end HealthLink integrates with a long list of practice software – Medical Director, Genie, Best Practice, IBA’s Practix and Spectrum, MedTech’s MedTech32 and Mercury, Profile, Houston, Incisive, My Practice and E-Merge. In a market where people are changing clinical systems or undergoing significant upgrades, practices are still able to keep their HealthLink system in place, with only some configuration of the new system at setup required.

It would be fair to say that nearly all HealthLink receivers are getting diagnostic results from pathology and imaging companies and have been doing so for a number of years. This is being supplemented with discharge summaries and an ever-increasing number of specialist reports.

PULSE IT: What market share has HealthLink achieved in Australia? The HealthLink provides the information exchange needs of GPs, specialists, diagnostic services and the hospital sector and is used on a daily basis by more than 4,000 healthcare organisations in Australia. HealthLink has more than 60% of GPs in Australia connected on its system and continues to grow. Historically, our share has been driven by the small to medium pathology and imaging providers. We provide great outsourcing models for these organisations and allow them to concentrate on what they are good at - providing diagnostic services. Going forward we are ever expanding in the area of discharge summaries from hospitals and establishing wider use of specialist communications. This has been possible and is moving rapidly because of the general consistency of coverage across all areas in Australia. Hospitals are taking advantage of our market share and fast tracking away from letters and fax outs. All aspects of the healthcare system want to eliminate paper which is further expanding the HealthLink network in terms of coverage and trafﬁc.

We have been involved in nearly all HealthConnect trials and continue to be so in a number of regions and states so other types of patient information is also been shared securely and appropriately through HealthLink. PULSE IT: As a communication platform, what advantages does HealthLink have over competing solutions? HealthLink designs its services to provide reliable end-to-end delivery of clinical information. The HealthLink system is readily expandable and easy to use particularly in a general practice environment. Simply our advantage over competing solutions is our experience and scalability; robustness in delivery of all message types; reliability of our service; and integration with such a disparate range of clinical systems. The strength of our system and our wide coverage has enabled us to secure business relationships with state and territory governments for the delivery of diagnostic reports and discharge summaries from the public sector. HealthLink has been around for a long time, has been responsive to the changing needs of the healthcare system and has a sound business model to be around for years to come. We are able to work with and deliver to all sectors of the healthcare system

INTERVIEW across all of Australia - something our competitors have not been able to do. PULSE IT: Outline the HealthLink pricing model. The HealthLink approach is that the sender pays for the message. To receive messages it costs nothing. This effectively means that GPs have not had to pay to become paperless. Specialists receiving diagnostic reports like GPs have not had to pay to receive these reports. However, Specialists are required to pay $30 per month per practitioner for the sending of reports to referring GPs. It is fair to say that the economics stacks up when one considers the complete cost of paper based reports and the elimination of scanning at the GP’s end plus, the added bonus of structured data and audit trails when the HL7 “Referrals and Discharge Summaries” message format is used. PULSE IT: How is support provided? The company provides a toll-free helpdesk service, which is available 12 hours per day across Australia. We believe that our fully supported service as part of the normal terms and condition gives our users conﬁdence that we will address their problems in a professional and responsive manner without any additional charges. There are also a considerable number of IT support providers across Australia who are familiar with HealthLink. These people have been servicing sites mostly as part of new installation of hardware and migration to different clinical systems. We are able to link sites up with these people who want assistance in their IT matters. PULSE IT: What provisions does HealthLink make for users of non-Microsoft operating systems? In addition to Microsoft sites HealthLink supports Mac users. We have been particularly apt at servicing GP and Specialist Mac sites for the bigger and smaller pathology players. Many specialists use Macs and have been able to send reports to their GPs through their installation of HealthLink as well.

PULSE IT: Does HealthLink develop clinical or practice management software? HealthLink is completely focused on messaging and does not get involved with developing clinical or practice management systems. It is a sound business strategy - sticking with what you do best. It allows us to concentrate in the servicing of existing sites and in the expansion of new sites. Expansion of product sets to get additional revenue without maintaining a high level of customer service can lead to loss of business focus. We believe that to do messaging properly it is important to ensure that standards are being consistently implemented across the large number of disparate clinical systems and multiple sectors of health. Because we are not competing with the vendors of the clinical systems we have a wider reach in terms of what clinical systems with which we are able to work. This is of greater beneﬁt to ensure a large network of practices is possible and a consistency or experience is achieved regardless of what clinical system a practice is using. PULSE IT: HealthLink has great success in New Zealand and has surpassed 95% market share. What challenges and opportunities exist for HealthLink in the Australian market? Australia’s track-record in health sector automation e-health has been substantially less than ideal. Relative to New Zealand, Australia is somewhat behind in the connectivity of the healthcare system, the volume of messaging and the use of HL7 standard messaging. We are fortunate in HealthLink that we have the New Zealand experiences while shaping the Australian business with an Australian based team that continues to grow. In the earlier days there were all sorts of challenges for HealthLink in New Zealand some similar and some different to the Australian market. In Australia, automation of pathology services has been the initial platform upon which a wide range of electronic services has been built. However, these have been built largely around

PIT messaging formats and a range of different communication applications by the different providers of pathology and imaging services. This has resulted in most GP practices now having five or more communication applications that are difficult to maintain and support for a practice. I believe that there will be a consolidation of the communication provider market because of internal and external business pressures in diagnostic and messaging companies. Practices are already demanding fewer communication applications on their systems. Only those providers who are able to compete by providing sustainable and complete solutions for both the senders and receivers of information will survive. Wider use of the HL7 messaging standards will be an important step for Australia for making significant improvements in sharing information. Implementing the existing core two HL7 messaging standards appropriately for “Pathology and Results” and “Referral and Discharge Summary” alone would automate 40-60% of all general practice messaging. What is disappointing is that these message standards have existed for a number years, however they are not properly implemented across all software and healthcare sectors. It is important that the end users are demanding of government bodies, clinical system suppliers and messaging suppliers to provide them the benefits of HL7 with the full clinical application loop. However we are not discouraged by history and embrace the future. HealthLink will continue to assist the healthcare system to realise the benefits of standards based messaging for improving practice efficiencies and patient care while maintaining security and trust in the sharing of health information. Pulse IT invites organisations and individuals interested in participating in a future interview to contact the editor. HealthLink www.healthlink.net

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FEATURES

SMS PATIENT REMINDERS Simon James BIT, BComm phone calls because it is less of an interruption”. In a medical practice setting, SMS technology is most commonly used to remind patients of future appointments. While there are other possibilities, this application will be the article’s focus.

SMS GATEWAYS

INTRODUCTION On the back of high levels of mobile phone penetration in this country, Short Message Service (SMS) messages have developed into a hugely popular communication method in Australia. Telstra claimed that over 33 million messages were handled by their network last New Years Eve, with an average of 50,000 per minute sent between 11pm and midnight! While for many, “SMS” conjures up thoughts of ear piercing beeps and captivated teenagers, the technology has had a history of innovative business uses. These have ranged from reminders to pay phone bills, to sophisticated electronic ticket solutions that utilise the graphical capabilities of modern mobile phones. The acceptance by Australian businesses of SMS technology has risen dramatically in recent years, with MessageNet, Australia’s largest business SMS gateway reporting volume increases of 58% from the 04/05 to 05/06. Tanya Aranov, MessageNet’s Marketing Manager claims that “There’s a far greater social acceptance in receiving SMS messages now and people are more responsive than they are with

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It would certainly be possible to send SMS appointment reminders to patients using a dedicated mobile phone, however this would become tedious very quickly. Enter the SMS gateway. An SMS gateway is a service that converts a computer-based communication to an SMS message for delivery to the recipient’s mobile phone. Typically this message originates as a simple email, however there are other options available to both end users and software developers. Because of the simple format of email messages, many practice software vendors have been able to incorporate SMS services with little effort by leveraging the existing email functionality in their products. By virtue of this fact, email based appointment reminder functionality is typically bundled along side SMS services with some solutions allowing the user to send both SMS and email reminders at the same time.

CHOOSING A GATEWAY Many software vendors have exclusive arrangements with an SMS provider which means the decision about which gateway to use may have already been made for you. Genie, Oasis, Practice2000 and Proﬁle are among the products that allow the

practice to decide which gateway to use, although all have a preferred provider set by default. Given that SMS gateway providers can only purchase their network access from a few top-tier telcos, costs tend to be fairly similar among the Australian based providers per message. Therefore, if your software allows you to choose a gateway, ensure you consider all set-up costs and support options before making a decision. Most gateways quote per message prices ranging from 16 cents to 25 cents depending on the volume purchased. Support and setup costs vary greatly, however some providers, including MessageNet, bundle these at no additional charge. While there are overseas operations that do have lower per message entry points, many insert advertising into the body of the SMS message and don’t use a localised timestamp. More signiﬁcantly however, overseas providers have lower transmission success rates that may lead to more phone call follow-ups being required.

SOFTWARE INTEGRATION The past two years have seen many practice software vendors add SMS integration to their products, or enhance the functionality of an existing solution. The extent of SMS integration in popular Australian practice software can be classiﬁed in 3 ways: a) No integration Under this scenario, the practice software does not make a provision for SMS patient reminders. While obviously not ideal, this doesn’t preclude practices using such software from exporting the

FEATURES relevant patient demographics and appointment details and processing these with a combination of external software (e.g. Excel then Outlook), or tools provided by the SMS gateway. Most SMS gateways rely on a specially constructed email address to indicate where the message should be sent. This would usually have the recipients mobile number followed by the ‘at’ symbol (@) and the SMS provider’s domain name. As such, for ad hoc messages, simple emails using the gateway’s prescribed address format may sufﬁce. b) Basic 2-Way Functionality There is variation between the ways practice software vendors have implemented SMS functionality, however the basic steps for sending SMS reminders are usually: 1. Selecting the patient or patients to send the reminder to. 2. Select whether the reminder will be sent via SMS, email or both. 3. Optionally personalise the body of the reminder message. 4. Optionally enter a password to authorise the reminder broadcast. 5. Send the reminders or schedule them to be sent at a later time. While many practices currently sending SMS reminders are not yet utilising the functionality, most SMS gateways allow the recipient of the SMS to send back a response via their mobile phone. Typically this is returned to the practice as an email and can be collected using an email client or the email module built into the practice software. Practices seeking to close the acknowledgement loop can manually process these incoming emails and change the appointment status to “conﬁrmed”. Depending on how aggressive the practice wants to be with its reminder system, traditional phone follow-ups can then be conducted for the patients who haven’t responded to the SMS. c) Enhanced 2-Way Integration This level of integration extends beyond the previous scenario with the software automatically updating the appointment status when a response is

received by the system from a patient, negating the need for staff to manually process replies. Achieved without relying on email to carry the appointment reminder, MedilinkXP (via the integration of 2Hippo) is the only Australian practice software solution currently offering this level of SMS functionality.

THE BENEFITS Less “No Shows” By definition, the main purpose of an appointment reminder is to ensure that the patient arrives when the practice expects them. By reducing “no shows”, both practice revenue and patient care can be maximised. Despite the lower costs and time involved, research1 has shown that SMS reminders are just as effective as traditional phone or postal reminders. Greater Efficiency And Cost Control Unlike traditional telephone reminders, SMS allows large batches of messages to be sent simultaneously. In much the same way as a mail-merge can be performed by combining a database with a form letter, SMS messages can be personalised using any relevant database field (although for simplicity, your software vendor may have restricted this). Because staff time involvement in the reminder process is minimised and SMS usage is easily tracked, detailed cost-benefit analysis can be performed which can assist practices to best target the use of the technology.

such that if a patient fails to turn up for an appointment, the doctor is deemed responsible for any medical issues arising that were not diagnosed and/or treated. So the more evidence that can be collected to demonstrate that medical practice made every reasonable attempt to contact the patient, the better.” Patient Good WIll Increased attendance rates by patients has obvious beneﬁts for practices, however patients also value the service as Ken Khoa Ho-Le, Managing Director of Abaki explains, “patients appreciate courtesy appointment reminders and doctors beneﬁt from less patient nonattendances.”

CONSIDERATIONS 1. Privacy Issues And Consent While confidentiality and privacy need to be given consideration, it should be noted that SMS does not introduce new privacy issues that don’t already exist with traditional communication systems. Like phone calls, faxes and letters, it is possible that an SMS message may be viewed by an unauthorized 3rd party. As such, practice staff need to have procedures in place that ensure SMS messages are only sent to patients who have consented to such communications. As shown in the screenshot below, Zedmed has included a consent checkbox field in their patient demographics screen to ensure that these procedures are enforced, a simple measure that other practice software solutions would benefit from.

An Audit Trail Is Created By removing most of the human interaction from the reminder process, comprehensive audit trails are created with little or no additional effort required by the practice staff. Managing Director of Mediﬂex, Phil Kirby explained that “When an SMS message is sent, MediFlex captures this information into the patient notes. This is to give the medical practice as much evidence as possible that they made an attempt to contact the patient.” He went on to to say that “Unfortunately, the medico-legal issues surrounding the doctor-patient relationship are

2. SMS Sent To The Wrong Number While a simple appointment reminder would typically only include the most basic of details, the possibility of SMS messages being sent to the wrong mobile number should be considered.

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FEATURES Extra care needs to be taken when recording the mobile phone number to minimise the chance of this scenario eventuating. 3. Message Length SMS messages are limited to 160 characters, however text can span multiple messages if the gateway is conďŹ gured to perform this operation. Be mindful however, that you will be billed for each 160 character block, so keeping your reminder messages as concise as possible is recommended.

CONCLUSION While busy practices tend to enjoy the odd â&#x20AC;&#x153;no showâ&#x20AC;&#x153;, most have long had measures in place to try to prevent their occurrence. With low setup and ongoing costs, practices can trial SMS patient reminder workďŹ&#x201A;ows with minimal time and ďŹ nancial investment. Unlike many efďŹ ciency initiatives, the beneďŹ ts to both the practice and its patients are likely to be both realised and measurable immediately.

2Hippo www.2hippo.com Abaki www.abaki.com Genie Solutions www.geniesolutions.com.au IntraHealth www.intrahealth.com.au Medilink

4. Timing The Reminders Research1 has suggested that sending reminders 2-4 days prior to the appointment is the optimal timeframe as it usually leaves enough time to schedule another appointment if the patient cancels, but is close enough to the appointment date that most patients wonâ&#x20AC;&#x2122;t forget about the reminder.

Compared to other communication methods, business usage of SMS has had a relatively short history in Australian medical practices. As practices and software developers identify other opportunities for the medium, tighter integration and greater practice efďŹ ciency are likely to result. Simon James is the editor of Pulse IT.

1 - Downer SR, Meara JG, Da Costa AC. Use of SMS text messaging to improve outpatient attendance. MJA; 183 (7): 366-368.

www.medilink.com.au MessageNet www.messagenet.com.au Oasis www.oasis-software.com.au Telstra www.telstra.com.au Zedmed www.zedmed.com.au

MEDILINKXP Integrated Paperless Solutions for Medical Practice

2-way

SMS/EMAIL PATIENT APPOINTMENT REMINDERS ANOTHER MEDILINKXP FIRST FOR MEDICAL PRACTICE!! Looking for a quick, easy and time-saving solution to patient appointment reminders? Look no further. MEDILINKXP can send reminders to your patientsâ&#x20AC;&#x2122; contacts for SMS and/or email, using the secure messaging services of 2Hippo, our Technology Partner for secure doctor-to-doctor and practice to patient communications. :KHQ WKH SDWLHQWV UHVSRQG ZLWK D VLPSOH Â´2.Âľ +LSSR UHFHLYHV WKH UHVSRQVH DQG GHOLYHUV WKH FRQĂ&#x20AC;UPDWLRQV VWUDLJKW LQWR \RXU MEDILINKXP $SSRLQWPHQW %RRN DV Â´&ÂľRQĂ&#x20AC;UPHG &RPSOHWHO\ DXWRPDWHG HOHFWURQLFDOO\ Like all functionality in MEDILINKXP VHQGLQJ $SSRLQWPHQW UHPLQGHUV LV HDV\ 6LPSO\ VHOHFW LQGLYLGXDO PDQXDO RU DXWRPDWHG batch, and your patients receive their SMS/Email reminders in no time at all, safely dispatched using 2Hippo secure messaging technology. 2Hippo also provides secure doctor-to-doctor messaging services for eReports, eLetters and eReferrals integrated into MEDILINKXP ZLWKRXW WKH QHHG IRU WKH SUDFWLFH WR LPSOHPHQW DQ HPDLO V\VWHP Why MedilinkXP SMS/Email Reminders? Ä&#x2020; Less Time Spent on Calls by Staff Ä&#x2020; Improved Attendance for Appointments Ä&#x2020; Improved Practice Cash-Flow Ä&#x2020; Efficiency reduces Costs Ä&#x2020; Patients Appreciate the Service Ä&#x2020; Patients have an electronic Reminder Ä&#x2020; Audit of Reminders Sent and Received Ä&#x2020; Two-Way Automation for Confirmations

FREE APPOINTMENT BOOK OFFER! Not already using an Appointment Book? Call Medilink and let us help you implement this valuable WLPH VDYLQJ V\VWHP Offer Valid until 31/03/07

Ä&#x2020; Integrated Medilink Solution with SMS Ä&#x2020; Use 2Hippo for eReports and eReferrals powered by 2Hippo www.2hippo.com

2Hippo SMS/Email included plans start from just $27 per month. Contact Medilink Solutions for more information on MedilinkXP SMS/Email Patient Appointment Reminders. Contact Neville Mander now on 0430 280 633 e: info@medilink.com.au t: 1800 623 633 w: www.medilink.com.au

FEATURES

AN INTRODUCTION TO SECURE ELECTRONIC COMMUNICATION Simon James BIT, BComm INTRODUCTION

DEFINITION

This article provides an overview of what is and will undoubtedly remain the most important eHealth technology for the remainder of the decade and beyond: Secure Electronic Communication.

In the true sense, “electronic communication” is so diverse a term that entrenched technologies including the telephone and fax machine could rightly be included under the banner. In the context of this article however, this term is reserved for discussion of computer based document/message transfer.

As would be expected, the importance of secure electronic communication within the health sector has long been pushed by eHealth vendors. Increasingly however, a growing number of doctors, practice staff, Divisions and other stake holders are starting to acknowledge the benefits that can result from more efficient and secure ways of communicating with their colleagues. As such, it came as no surprise to the author that no less than 9 of the 10 most popular responses to the “IT/IM Innovations for General Practice Survey” (Issue 3: February 2007, pp16), centred around improved communication and more effective access to patient records. This article outlines the benefits secure electronic communication solutions can bring to practices and highlights some of the historical and present day issues with the technology.

PULSE IT CRYSTAL BALL Given the importance of communication between health care providers, detailed coverage of secure messaging will be presented in every edition of Pulse IT for the remainder of 2007. We welcome any suggestions or editorial submissions that will assist us to promote awareness of this most crucial of eHealth innovations.

Extending this deﬁnition, “secure electronic communication” refers to computer based electronic messages that are protected in such a way that unauthorised recipients can’t intercept and interpret them.

THE BENEFITS The benefits most commonly promoted by vendors of secure electronic communication solutions include: Less Paper And Greater Efficiency It is obvious that reducing the amount of paper used in the health sector has environmental benefits, however improving document processing efficiency is usually the primary motivating factor for practices. In a typical medical practice, secure electronic communication solutions promise to reduce the time and expense involved with several routine tasks including: • • • • • •

Scanning Faxing Filing Shredding Printing Mail handling

Given that these tasks usually consume a large amount of practice staff time, the efﬁciency gains can be quite dramatic.

Better Security While the lack of security inherent in traditional paper based communication is well understood, this does not completely negate the underlying problems. Some of the well-known security issues with paper include the possibility of patient records and other correspondence being lost or stolen and the lack of practical backup solutions. Further, it is usually not possible to selectively restrict access to paper records to the appropriate staff members within the practice. With few feasible alternatives available historically, practices have had little choice but to utilise paper for the bulk of their correspondence and record storage. Now however, practices have a choice of several viable solutions that can significantly minimise the amount of paper and improve the security of routine correspondence with other health providers. Smarter Data Unlike documents that arrive at the practice in paper form, secure electronic messages can be specially formatted by the sender’s clinical software to allow specific pieces of information to be efficiently processed by the recipient’s clinical software. Not all electronic documents are ideally suited to this type of automatic processing (e.g. PDF, Microsoft Word and typical emails), however the health sector is fortunate to have a messaging format designed to allow disparate systems to send and receive clinical information effectively. This standard is called Health Level 7 (HL7) and is the foundation on which all

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FEATURES viable secure electronic messaging solutions are built. Given the importance of this standard, when ever possible, practices should elect to receive all electronic health correspondence in HL7 format. This option is usually offered alongside an inferior document type called Pathology Information Transfer (PIT). Because of technical limitations, PIT should be aggressively avoided by practices interested in realising the full potential of secure electronic communication.

Message Tracking And Audit Trails Secure electronic communication solutions track the progress of the message through all the various stages of the journey, something that is essentially impossible to do with paper based communication. While the implementation of message tracking varies between solutions, ultimately all systems rely on message acknowledgements to automatically create an audit trail. In the case of referral letters and specialist reports, this audit trail affords the sender of the correspondence better medico-

GETTING STARTED WITH SECURE ELECTRONIC COMMUNICATION The success of a secure electronic communication technology deployment is greatly effected by the actions of the health care organisations a practice routinely communicates with. As such, before deploying a solution, practices should: 1. Talk To Their Division Some Divisions have been quite instrumental in driving the adoption of secure electronic communication technology. Unfortunately others have not. Contact your Divison to see whether they have any plans to assist your area with a widespread rollout of one or more secure electronic communication solutions. 2. Talk To Other Specialists And GPs There are many examples where grass roots advocacy by GPs and specialists has been successful in driving the adoption of this technology. Practices should discuss the secure electronic communication plans of the practices that they routinely refer to, or receive referrals from. Realising the importance of the technology, some practitioners now include a brief paragraph at the end of all paper correspondence indicating their preferred secure electronic communication solution. To assist in promoting awareness of the technology generally, I encourage all practitioners with the capacity to send or receive doctor-to-doctor correspondence to adopt a similar approach.

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3. Talk To Your Hospital While the IT capability of hospitals varies greatly, practices should take the time to discuss whether discharge summaries and other hospital correspondence can be received electronically. Legacy hospital software systems tend to be far more ridged than the modern solutions used by medical centres, however an increasing number of hospitals are starting to add this capability. 4. Talk With Your Labs With few options available historically, many pathology and radiology organisations developed their own solutions for the secure electronic delivery of results. Having spent signiﬁcant amounts of money developing, deploying and supporting such solutions, many have resisted the advances of vendors and practices wanting them to move to more widely adopted solutions. Despite this, some groups now provide practices with several options including solutions that can also be used to send outgoing correspondence. 5. Discuss Your Needs With The Vendors Market consolidation will be required before secure electronic communication technology becomes widespread. Fortunately for the health sector, this is inevitable. As consumers in a highly competitive market, practices should discuss their needs with multiple vendors. The developer of the practice’s clinical software should also be contacted for their opinion.

legal protection and makes it easier to ensure that the patient is receiving the best possible care. PIP IT/IM Incentive The revised PIP IT/IM requirements that came into effect in November 2006 highlighted the importance of securing the electronic transmission of patient information and clinical data. The final requirement of Tier 1 simply states that “Encryption used for the electronic transfer of patient information and/or clinical data.” While this does not mean practices must send patient data via secure electronic means, it does require practices that choose to send patient information electronically to do so using an acceptable secure solution. Most practices should quickly realise the efficiency and economic benefits secure electronic messaging can deliver, however maintaining or achieving compliance with this government incentive will obviously result in additional financial gain. Patient Care With practitioners and practice staff spending less time processing paper, all

SECURE MESSAGING PROVIDERS 2Hippo www.2hippo.com ArgusConnect www.argusconnect.com.au CNS Health www.cnshealth.com.au eClinic www.eclinic.com.au HealthLink www.healthlink.net LRSupport (AllTalk) www.lrsupport.com.au Medical Objects www.medicalobjects.com.au Promedicus www.promedicus.com.au

No More “No Shows”!! Patients not showing up for their appointments is very common, and whilst efforts are usually in place to phone the patient a day in advance, this can be very time consuming and costly. Your staff may not have the time each day to contact patients, and in a busy practice, this task is often postponed or forgotten.

The solution to reducing “no shows” is to utilise MessageNet’s business-grade SMS gateway, enabling patients to be notified of their upcoming appointments at a click of a button. MessageNet provides you with the ability to send personalised and immediate SMS messages directly to your patients’ mobile phones from your PC. Patients can then send a message back, streamlining processes for your staff. Because tailored messages can be sent to a number of recipients at one time, your practice can stop wasting time and money ringing patients and leaving voicemail messages.

The advantages of using MessageNet SMS include: • Reduce “no-shows” – Remind patients of their upcoming appointments. • Save Time – Send messages to individuals or large groups at the same time, freeing staff to focus on more important tasks. • Personal – Messages are delivered to the patient’s mobile phone which can be accessed at any time. Messages can be personalised to include names, times and other specific details. • Cost effective – Reduce land line to mobile charges. • Opportunities – Utilise standard templates to send medication reminders or to notify doctors of their first appointment for the day. • Appreciation – Your customers will appreciate reminders and have the opportunity to reply without needing to call. Your practice will be viewed as progressive as you utilise current technology.

Getting Started Register for a free trial today, visit www.messagenet.com.au/trial About MessageNet With over 10 years experience, MessageNet is Australia’s most reliable provider of SMS communications in the business market. MessageNet offer the most sophisticated, feature rich and easy to use, 2-way SMS gateway service. Several practice management packages have integrated with MessageNet to offer SMS functionality. To find out more, call us on 1300 55 15 15.

Phone 1300 55 15 15 www.messagenet.com.au marketing@messagenet.com.au

FEATURES the previously stated beneﬁts of secure electronic communication should ultimately lead to improved patient care across the sector.

THE TECHNOLOGY A detailed discussion of the various secure messaging solutions available to Australian medical practices will be deferred to a future article, however in broad terms, secure electronic communication products are essentially software programs that encrypt and decrypt electronic messages to prevent them being viewed by unauthorised third parties during transmission. Secure electronic communication solutions are typically contrasted with traditional email due to their superﬁcial similarities. Email however, is a fundamentally insecure technology that should not be used for the transmission of any patient information (unless suitable additional security measures are taken). Many practices already have secure messaging solutions installed to facilitate the electronic retrieval of pathology and radiology results. Few may realise however, that in some cases these programs can be easily conﬁgured to allow referral letters, specialist reports and other documents to be transmitted directly from the practice’s clinical software package which may negate the need for the practice to install additional software.

RELATED PULSE IT ARTICLES Pulse IT has published several articles relating to secure electronic messaging. These articles are all publicly available at our website: www.pulsemagazine.com.au August 2006 • 2Hippo article • ArgusConnect interview • ArgusConnect video (Pulse IT DVD) Novemeber 2006 • Medical-Objects interview February 2007 • HealthLink interview

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ISSUES Despite the widely acknowledged benefits secure electronic communication solutions can deliver and the array of viable solutions on the market, widespread adoption of the technology has been underwhelming in the Australian health sector. While the outlook is improving, there are two major factors that continue to hamper the uptake of the technology: 1. Limited Specialist Computerisation 2. Limited Interoperability Limited Specialist Computerisation Compared to general practices, computer penetration in specialist practices is relatively low. This is due to various factors including a lack of government financial incentive and the absence of “Division-like” organisations with this goal on their agenda. Of the 33 possible innovations listed in the “IT/IM Innovations for General Practice Survey” (Issue 3: February 2007, pp16), “Widespread computerisation of Medical Specialist practices” ranked 6th. The fact that the vast majority of respondents to this survey were GPs, points to a realisation that the great potential benefits secure messaging technology can deliver are greatly diminished in the absence of widespread technology adoption by specialist practices. This can be contrasted with clinical software solutions, which can be successfully used by a practice regardless of how surrounding health providers are using their technology. Limited Interoperability With the exception of MedicalObjects (that can communicate with GPs using Argus), there is little or no interoperability between the competing secure messaging solutions on the market. To illustrate the effect this lack of interoperability has on the market, consider what the mobile telecommunications landscape would be like if it was not possible for Telstra customers to communicate with Optus customers and vice versa. Assuming

this impediment persisted, customers of each mobile phone carrier would be faced with three options: 1. Avoid the mobile phone system entirely and use an alternative technology (land line telephone, mail, email etc). 2. Purchase either an Optus or Telstra mobile phone and encourage friends, family and business associates to use the same carrier. 3. Purchase and use mobile phones from both companies. While the scenario presented above is simpliﬁed and would not be tolerated by the market, the options available to these imaginary telecommunication consumers translate directly to the current options available to practices who are considering the implementation of a secure electronic communication solution. That is, specialist and GP practices can either: 1. Not adopt secure communication technology and retain existing paper based workﬂows. 2. Select one of the available solutions and encourage the organisations and health care professionals with whom they routinely communicate to adopt the same solution. 3. Assess the intentions and current capabilities of the organisations with which they routinely communicate and deploy multiple solutions to facilitate to the highest possible number of secure transactions. None of these options are ideal, with each scenario’s obvious shortcomings highlighting the importance of standards-compliant, interoperable solutions.

CONCLUSION Despite the challenges, both GP and specialist practices should begin (or continue) working towards the ultimate goal of secure, electronic, paperless communication. The benefits are real and so significant that the initial time and financial investment involved in setting up a secure electronic communication workflow will be recouped many times over. The increased awareness and acceptance of secure messaging

FEATURES technology provides a real opportunity for secure messaging providers and clinical software developers alike. During the coming year, expect to see many clinical software developers place a greater emphasis on tight integration with secure messaging solutions as they continually seek to differentiate themselves in a maturing market. Tipping Point Small pockets of the health sector have been actively pursing secure messaging capability for many years, some with great success. Unfortunately however, the majority of the sector has grossly underachieved in this area. As with all communication technologies, the usefulness of the solution scales proportionally with the number of participants. Before the true potential of secure electronic messaging is realised, an “Al Gore style tipping point” needs to be reached, where the uptake of secure electronic messaging will become self-sustaining. While it is inevitable that this will occur at some point, for secure electronic

communication technology to reach critical mass in Australia’s health sector by the end of the decade, the following will need to occur:

the potential end users of secure electronic communication need to be better educated about the beneﬁts the technology can provide.

Government Intervention While an efﬁcient, unsubsidised market is ultimately desirable, in the short term, Government should not hesitate to intervene and do what ever is necessary to get practices to rapidly adopt secure messaging solutions.

In addition, decision makers at all bureaucratic levels of Government need to gain a better understanding of the underlying technology and organisational challenges faced by the end users of such technology to avoid repeating previous failures in this area.

Practices should have signiﬁcant ﬁnancial incentives to adopt secure electronic communication technology, which could be facilitated via minor extensions to the current IT/IM Practice Incentive Program requirements.

Grass Roots Advocacy And Organisational Support As is already happening, doctor-todoctor advocacy must occur and be supported by organisations including the Australian General Practice Network (formerly Divisions of General Practice), the Australian Medical Association and the various specialist and GP colleges.

Vendors who are able to demonstrate widespread adoption and usage of their solutions should also receive retrospective ﬁnancial bonuses, which would allow them to aggressively market and deploy their solutions. Education As occurred successfully with the rollout of Medicare Online (HIC Online),

These organisations need to go beyond their traditional charter boundaries and work together for the common good of the industry. Simon James is the editor of Pulse IT.

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FEATURES

SMARTER FAXING Louis Joseph BComm

HISTORY Precursors to modern fax machines predated the ﬁrst working telephones and were in use as early as the 1860s. One notable early adopter of fax technology was an ageing Charles Louis Napoleon Bonaparte (Napoleon III), the last Emperor of France. Fast-forward a hundred and ﬁfty years and fax machines are amongst the most widely adopted technologies in Australian medical practices. Despite convergence with photocopiers and scanners, underlying fax technology has changed little in the past few decades.

•

• For many years however, computerbased fax solutions have been available, promising to reduce the amount of paper used in the process, and more importantly reduce costs and increase efﬁciency. These computerbased solutions can be divided into two categories: 1. Internet Fax Solutions (aka eFax) 2. Modem Fax Solutions

ADVANTAGES Despite differences in the underlying technology used to transport computerbased faxes, both of these solutions promise to deliver the following beneﬁts: • Both clinicians and practice staff can send and receive faxes from any computer without having to relocate to a traditional fax machine. • Incoming faxes arrive electronically,

PULSE IT CRYSTAL BALL Look out for a detailed comparison of popular multifunction and computerbased fax solutions in a future edition of Pulse IT.

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•

negating the need for these to be scanned or ﬁled at a later date. Any printable document can be faxed directly from the computer, negating the need for documents to be printed, faxed and then stored or shredded. An audit trail of incoming and outgoing faxes can be automatically generated, which assists with cost control and reduces the chance of faxes going missing. Both incoming and outgoing faxes tend to arrive as higher quality images than those processed with traditional fax machines. “Spam” faxes can be ﬁltered and discarded without wasting paper and toner. A physical fax machine may not be required, reducing both upfront and ongoing costs.

INTERNET FAXING (EFAX) Like voice telephony, fax solutions that leverage the power of the Internet emerged several years ago, creating new possibilities for businesses that rely heavily on the fax machine as a communication device. These services essentially act as a bridge between the Internet and the traditional phone network, converting documents back and forward between the two formats as required. Sending When sending a fax via an Internet service, the user transports their “fax” to the service provider using any one of the following methods: 1. As an email or email attachment. 2. Via a web portal. 3. By “printing” to a special fax driver. 4. Using software provided by the Internet fax service.

Receiving With the exception of the printer driver approach, incoming faxes can be received using the same methods as when sending faxes. Practices would typically either have a staff member distribute incoming faxes to the relevant practitioner electronically, or store it in a holding folder ready for collection. Advantages In addition to the beneﬁts outlined earlier, Internet-based solutions offer other advantages over traditional fax solutions: • As faxes leave and enter the practice via the Internet, no dedicated fax line is required, which can save approximately $30 per month in line rental. • Fax rates are typically lower than the cost of traditional fax calls reducing ongoing costs. Security As with VOIP (Voice Over Internet Protocol), service quality and security need to be considered before using Internet-based fax solutions to send and receive sensitive patient information. The main problem with the popular Internet fax solutions is that the email leg of the fax journey is usually unencrypted. In line with best practice approaches to patient conﬁdentiality (and the current PIP IT/IM requirements), all patient information sent electronically needs to be encrypted. Note that this doesn’t just relate to outgoing faxes sent by the practice, but also those received by the practice via and Internet fax service. As indicated earlier, other options for both sending and receiving faxes using

FEATURES Internet fax services are available (most of which are more conducive to secure transmission), however the problems with email need to be stressed as it is the most widely used technique due to its convenience and ability to be integrated with third party software solutions. Another security related issue to consider is the fact that Internet fax solutions introduce an additional third party (potentially overseas) that could technically intercept fax transmissions. Practices considering Internet fax as an option should therefore enquire as to whether the provider offers secure solutions, and what guarantees they make about the integrity of their service and the conﬁdentiality of the faxes they process.

MODEM FAXING First introduced in 1985 by GammaLink, fax modems have long been used by organisations looking to streamline the receipt and sending of faxes. Unlike the previous scenario, this arrangement uses the dial-up modem in a computer in much the same way as a traditional fax machine i.e. a call is made to the recipient’s fax using the attached phone line. This functionality can also be shared with any other network-attached computer. As with Internet solutions, faxes can be forwarded to the modem-attached computer using a variety of methods

including fax “printer” drivers and purpose built software. While outside the scope of this article, many modern multifunction centres also offer similar functionality, negating the need for a computer to be attached directly to the fax line. Despite originating from a computer, the Internet is not used for any part of the transmission, which avoids the potential security problems associated with Internet fax solutions.

WHERE TO FROM HERE? While not without issues, I feel that computer-based fax solutions have matured to the point where many medical practices would benefit from deploying either a secure Internet or modem-based faxed solution (or a combination of both). Regardless of which option is chosen, practices should be able to reduce the amount of paper entering the practice, as well as minimising the amount of paper they themselves generate. More importantly, cost reductions and efficiency improvements should result. Despite the benefits computer faxing can provide, practices should continue to work towards the ultimate goal of secure electronic messaging. Now readily available, these solutions promise to maximise efficiency while providing the highest level of message security. Louis Joseph is an accountant with an interest in health IT.

INTERNET FAX SOLUTIONS 2Hippo www.2hippo.com eFax www.efax.com.au mBox www.mbox.com.au MessageNet www.messagenet.com.au Ozefax www.ozefax.com.au

MODEM FAX SOLUTIONS 4 Sight Fax www.4sightfax.com MacOS X 10.4 www.apple.com.au FaxTalk Messenger Pro www.faxtalk.com Windows XP www.microsoft.com MightyFax www.rkssoftware.com PageSender www.smileonmymac.com WinFax Pro www.symantec.com

Faster. Smarter. Stable. Ad-free. And more intuitive at your fingertips. The evolution of Australia’s fastest growing GP software continues as Best Practice Management now goes live with Best Practice Clinical. With companion software, Top Pocket – for your PDA – Best Practice gives you the unique, fully integrated whole-of-practice software suite you’ve been waiting for. Call, write or email for a FREE Demo CD of the lot. Best Practice Software PO Box 1911 Bundaberg QLD 4670 Ph 07 4153 1277 www.bpsoftware.com.au

FEATURES

DEDICATED LABEL PRINTERS Louis Joseph BComm

WHY? As their name suggests, dedicated label printers do one thing and one thing well: print labels! Given that all medical practices have printers capable of working with a range of media, the notion of a dedicated label printer may be strange to some, however many will attest to the convenience and efﬁciency such devices can bring to a practice. While windowed envelopes are another option, the scenario that dedicated label printers contrast best with is the printing of labels onto A4 sheets. This solution is ideal for large print runs, however most labels printed in medical centres are done in an ad hoc fashion, which invariably means label paper needs to be re-fed through the printer. In addition to monopolising the printer, manual re-feeding of label paper can cause paper jams and degradation of both the paper and printer. While most label printing software assists with the task, staff need to be mindful of which labels on the sheet have already been printed. This additional step adds complexity to what should be a simple procedure.

HARDWARE While there are more expensive options, label printers typically purchased by medical practices are based on “direct thermal” technology. This printing process applies heat directly to the labels themselves, causing a reaction that changes the appropriate parts

PULSE IT CRYSTAL BALL Look out for a detailed comparison of popular label printers and software solutions in a future edition of Pulse IT.

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of the label to black. This technology negates the need for ink or toner and means that the only consumable required is the labels themselves.

practices typically have widths of up to 60mm, with the length being determined by whether rolls of individual stickers or continuous label paper is used.

Direct thermal technology has matured over the past few years with improvements to both speed and resolution. Typical speeds are quoted at 40-60 labels per minute printing up to 300dpi, a resolution which is more than sufﬁcient for text and simple graphics. The sound level emitted during label printing has also improved, with currently shipping models producing far less noise than the models they replaced.

A variety of label sizes, colours and materials are available, including circular labels suitable for placement on the middle of CDs and DVDs.

SOFTWARE Printers from the leading manufacturers install software that integrates with popular Microsoft Ofﬁce software including Word, Excel and Outlook. The printers also ship with label software that allows for ﬁner control of the printing process. Using only the supplied printer driver and correct paper size settings, all practice software should be compatible with label printers, however some developers have chosen to tightly integrated label functionality to make the process easier.

THE LABELS As with all printers, the size of the labels a dedicated device can print to is limited by the width of its printing mechanism. Label printers suitable for medical

COSTS As with their laser and bubble jet cousins, label printer manufacturers appear to be following a loss leading strategy (i.e. selling the hardware as cheap as possible and attempting to make money on the consumables). Label printers suitable for most medical practices start just below $150, with models touting extra features (that are generally unnecessary) costing up to $400 and beyond. As the labels are the only consumable required to operate these devices, calculating and monitoring ongoing costs should be fairly straightforward. The table below gives examples of market prices for various label options. As expected, A4 sheets of labels sold in 100 sheet quantities are cheaper per label, however by a far smaller margin than I expected. This margin that would be reduced further if the cost of toner was incorporated into the price of the Avery A4 label sheets.

PRICE COMPARISON OF POPULAR LABELS Description

Size (mm)

Price

Quantity

Cost / Label

Dymo Large Address Labels

89 x 36

$29.95

520

5.76 cents

Dymo Standard Address Labels

89 x 28

$17.95

260

6.90 cents

Dymo Shipping Lables

101 x 54

$22.95

220

10.43 cents

Avery A4 Sheets (14 per page)

99 x 38

$55.96

1400

4.00 cents

FEATURES CONSIDERATIONS Because of the way the thermal printing technology works, care should be taken to prevent the labels from being subjected to high temperatures or long periods of exposure to direct sunlight. As I found out first hand, leaving labels in a car on a hot day can degrade the label, although in my case the labels were still useable with the text remaining visible against a slightly grayed background. Other reviews of direct thermal label printers suggest that the print on the labels is likely to fade over time, however I haven’t had the opportunity to see this eventuate first hand. In any case, practices are advised to discuss this possibility with the manufacturer of the label printer prior to using the device for tasks where the quality of the label needs to be maintained in the long term (e.g. archival storage, patient files etc).

CONCLUSION For practices that routinely print labels in an ad hoc fashion, a dedicated label printer is likely to complement and potentially replace traditional A4 labelling workflows. While laser and bubble jet printers can do everything a dedicated label printer can, I believe a dedicated label printer is a more efficient solution for most labelling tasks in typical medical practices. Though slightly more expensive per label than those sold in packs of A4 sheets, the efficiency gains staff will enjoy will far outweigh this cost and quickly offset the initial purchase price of the new printer.

MINI REVIEW: DYMO LABEL WRITER 400 A large mailing house handles the distribution of nearly all copies of Pulse IT, however we increasingly find ourselves posting copies to interested parties ad hoc. To assist with this more frequent of tasks, I fronted up to my local office supplies store and picked up a Dymo LabelWriter 400. The LabelWriter 400 is Dymo’s entry-level unit and can print up to an impressive 40 labels per minute. With a “time to first label” of only a few seconds, this device’s throughput should be more than adequate for most medical practices. The Dymo LabelWriter 400 is compatible with both Mac and Windows computers and connects via a USB cable. The device ships with a software CD that installs both a print driver and an application used for the creation of labels. While the supplied software appeared to be fully featured, I decided that it would suit my workflow better if I was able to print directly from my contact management system. In medical practices, the same is likely to be true. Fortunately, many practice software vendors include label printing functionality in their products. Practices that have a need to print labels of various sizes may be tempted by the LabelWriter Twin Turbo. This

transfer 40 labels a minute from the backing paper to the envelope as they roll out of the device, I believe this more expensive version can safely be ignored. All currently shipping Dymo LabelWriters have a 300dpi printing mechanism and yield impressive output. As the photo below indicates, labels can be designed to contain any combination of text and graphics, a feature that some practices use to include their logo on the return address label. Unlike laser and bubble jet printers that deposit toner or ink onto paper, the Dymo devices use a heat transfer process to mark the label. As a result, the only consumables required are the labels themselves. The printer shipped with a small roll of labels that I expect wouldn’t last long in a busy medical centre. Dymo retail a variety of labels and the device can accept sizes up to 60mm wide. CD/DVD labels are also available which can be used to neatly label backups. Currently, the only gripe I have with the Dymo LabelWriter is that it lacks a power switch and continually draws energy to illuminate a small blue light on the front the device. While perhaps not the biggest crime against the environment, this would have been a nice inclusion and puts a dampener on

Louis Joseph is an accountant with an interest in health IT.

Avery www.averyproducts.com.au Brother www.brother.com.au Dymo www.dymo.com.au Seiko Instruments www.siibusinessproducts.com

than the multiple units affords more redundancy and ﬂexibility. Dymo also retail a “Turbo” edition of the LabelWriter 400 that can print up to 55 labels per minute. Given receptionist couldn’t possibly

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FEATURES

MACINTOSH VIRTUALISATION

Peter Machell INTRODUCTION

THE PLAYERS

PERFORMANCE

Virtualisation or Virtual Machine technology allows you to run one operating system inside another, for example, Windows XP inside Mac OS X. There are many reasons why this is desirable, but most users simply want the ability to run their choice of operating system and still have access to software that runs on other systems.

While virtualisation products have existed for Windows and Linux operating systems for some time, Mac solutions only began appearing after Apple’s recent switch to the Intel processor platform.

Because of the beta status of VMWare Fusion, it would not be fair to compare the product with Parallel’s Mac offering at this point. I have instead compared the performance of running Windows natively, versus inside Parallels on the same computer.

Virtualisation technology is nothing new. Running a guest operating system inside a host has been possible for decades, but what’s been missing from the technology up until now is speed. With the recent release of virtualisation enhanced processors and sophisticated software, most speed problems are a thing of the past.

THE BENEFITS Portability The principle beneﬁts of virtualisation stem from its portability. An entire virtual machine exists as a single ﬁle on the host system’s disk drive. This makes backing the whole thing up fast and very easy, and means that the entire system can be transported to another host with very little downtime. Any system that can run the virtual machine software can serve as a host. Sandboxing And Rollback A virtual machine offers a great “sandbox” for trying out new software (or indeed development and support). Some are even using virtualisation to facilitate safer Internet browsing. If the system is compromised, you can restore to the last backup in a matter of seconds with no harm done to your host system. You can also maintain point-in-time snapshots of virtual machines and run multiple copies, simultaneously if you like.

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VMWare VMWare have long been the leaders in virtualisation and they have patented the snapshot ability, where a virtual machine can be backed up very quickly without interruption. This makes VMWare the choice for those wishing to run servers virtually. The release of VMWare for Intel Macs is called VMWare Fusion. It’s in early beta at the time of writing, and only available in debug mode, resulting in rather sluggish performance. Parallels Those wishing to run different or multiple operating systems on their desktop have a new choice in Parallels Desktop. This was the ﬁrst product to take advantage of new hardware virtualisation features in modern processors, and the ﬁrst to be offered for use on Intel based Mac systems.

I was surprised when benchmarking to discover that the Parallels virtual machine does some things, particularly disk and network access, even faster than Windows XP natively! As a result, most business applications will run considerably faster using Parallels on a Mac than they do on a Windows PC. Benchmark 1: System Level Tests I ﬁrst used Passmark software’s benchmarking tool to compare the performance of Windows running on Parallels with Windows running natively using BootCamp on the same Mac. The following graph highlights the stunning results:

PARALLELS VS NATIVE (BOOTCAMP) Network 409.7

209.5 Disk

Parallels Desktop for Mac allows you to run any PC operating system on a Mac, and does a particularly good job with Windows XP.

346.8

140.7 2D Graphics

316.6

408.6

Memory

This product has received widespread acclaim since it was first released as a public beta. Despite being shipped as a stable, finished product, development continues at a frenetic pace. Significant recent additions include the ability to create a virtual machine from an existing Windows installation and “Coherance”, the name given to a new feature that allows Windows applications to be run directly from the Mac OS X desktop.

297.5 311 CPU 205.85

439.85

Legend PARALLELS NATIVE (BOOTCAMP)

• HIGHER IS BETTER • Network speed was calculated using the average of small, medium and large FTP downloads.

FEATURES As you can see, both disk and network performance are nearly twice as good under Parallels. 2D graphics are a little better, memory a little worse. I’m not certain that the CPU comparison is accurate as I suspect Passmark may not be measuring the Mac’s dualcore processor properly when running virtualised. Benchmark 2: Medical Director 2 The next tests were done using a real database and Medical Director (2.88). All results listed show the average of ﬁve tests. As indicated in the following graph, MD2 runs better under Parallels than in Windows natively in each case.

MEDICAL DIRECTOR 2 PERFORMANCE Start MD 11

Open First Patient 5 6 Open Patient Average 2.3 2.9

Above - An MD2 ﬁle repair running on Parallels inside Mac OS X. This completed in a quarter of the time it took running natively in Windows on the same computer! The bars at the bottom left show processor usage - note the efﬁcient use of both cores of the CPU.

Legend PARALLELS NATIVE (BOOTCAMP)

• SHORTER IS BETTER • I also did a ﬁle repair but the numbers wouldn’t ﬁt on the chart; Parallels came in around 400% faster than Windows running natively!

CAVEATS There are a number of things that don’t work or run at full speed inside a virtual machine. The most notable of these is graphics ability. An installation of Windows running inside Parallels will only have access to a generic video card driver with 8 MB of memory, so gaming and 3D design are not yet supported. Parallels report that improvements to allow better utilisation of the video power of the Mac are coming soon. The Mac versions of Parallels and VMWare Fusion will only run on recent Macs with Intel processors. I recommend that at least 1GB of RAM be installed to provide adequate performance. As with all installations of Windows, you need to ensure that anti-virus software is installed within your virtual machine. You also need a licensed copy of Windows to remain legally compliant.

VIRTUALISATION ALTERNATIVES While virtualisation provides the most ﬂexibility, there are several other ways to run Windows on a Mac: Terminal Services (RDP) As with Windows and Linux, you can access a Windows Terminal Server from a Mac. This is a great solution for those wishing to use an alternative to Windows on a network of desktops. BootCamp BootCamp is an Apple solution that allows you to install Windows natively on your Mac. Unfortunately you need to reboot the computer to access it. CrossOver & WINE For the technically adventurous, CrossOver and WINE are solutions that work by allowing Windows programmes to run directly within a Mac or Linux operating system, without needing to install a copy of the Windows operating system!

CONCLUSION Parallels Desktop for Mac is the best alternative for a Mac user to run Windows-only applications. There is no downside to this and it’s highly recommended. VMWare offers a similar

experience for Linux users, and some versions of it are free. In my opinion, a Mac has long been the best choice for the majority of users, beginner through expert. Many have begrudgingly bought a Windows computer instead because their software developer only considers Windows. With the ease and speed of virtualisation there is no longer any reason not to have the elegance and reliability of a Mac computer on your desktop. Peter Machell is the systems administrator at Mobile Computing, a Brisbane company specialising in Health IT.

Parallels www.parallels.com VMWare www.vmware.com Apple Bootcamp www.apple.com/bootcamp CodeWeavers - CrossOver www.codeweavers.com

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DIGITAL CLINICAL PHOTOGRAPHY

DIGITAL PHOTOGRAPHY FOR BUSY CLINICIANS Part 3 - Getting Close Up - The Art Of Macro Photography

Dr Daniel Silver MBBS, Bmed Sc, DRCOG, FRACGP The first article in this series presented an argument to encourage doctors to buy digital cameras and to incorporate clinical photography into their clinical skills and routine practice. The second article provided some clues as to how to avoid buying a camera which wouldn’t take good closeup photographs. This third article was written to provide some basic but useful advice about how to use one’s newly purchased digital camera to take high quality clinical photographs of skin lesions. The laws of physics relating to optics conspire to make closeup photography a much more difficult exercise than most other photographic pursuits. The biggest problems associated with closeup photography are firstly getting adequate amounts of light from the object under scrutiny, and secondly, getting that small object in sharp focus. To understand these two critical issues and how they relate to taking good closeup photos one needs to be aware of some basic but important facts about how cameras, both digital and analogue/film, take pictures.

LIGHTEN UP! As one takes a photograph, light reflected from an object first passes through a series of adjustable glass lenses (plastic in cheaper cameras!) and then through a mechanical iris, the aperture of which can be quickly adjusted wider or narrower to allow more or less light into the camera. The light then enters the camera through a mechanical shutter which is opened for a determined amount of time. Depending upon the type of camera being used (digital or film-based/ analogue) the light finally strikes either an electronic light sensor or a traditional film with a coating of light sensitive silver

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halide crystals in one or more layers with associated pigments. In a digital camera the electronic light sensor’s individual light-sensitive electrical elements, or “pixels” measure exactly how much light and of which colour or frequency has landed on each of them and immediately transfers the huge amount of information to the camera’s electronic wizardry. This then converts the information into a picture which can be seen in the liquid crystal display (LCD) screen on the back of the camera very soon afterwards. In the light sensitive emulsion of a film, individual tiny crystals of silver halide in different layers of the film change irreversibly when they are struck by photons of light but the film must then be kept away from all extraneous light until it can be chemically treated (developed and fixed) so that it cannot degrade with loss of information. Aperture & Shutter Speed Exactly how much light enters the camera is controlled by the automatic functions of the camera’s internal computer which almost instantaneously adjusts the width of the mechanical iris in the camera’s lens (i.e. the aperture) and determines how long the shutter is kept open (i.e. the exposure time). The wider the iris is opened and the longer the shutter is kept open the more light can enter the camera to land on the light sensor or the film. If the light sensor in the camera detects a very low level of ambient light the camera’s computer may widen the iris aperture and/or keep the shutter open for longer in order to “capture” enough light to take an adequately illuminated image. Manually controllable digital cameras can be adjusted by photographers to override the automated features of the camera.

ISO Yet another factor relating to cameras, light and photographic images is the “ISO” rating which is a measure of the intrinsic sensitivity of the electronic light sensor or of the film to light. A low ISO rating indicates a low sensitivity to light whereas a high ISO indicates a high light sensitivity. In a traditional film or “analogue” camera a “fast” or very light-sensitive film has a high ISO rating and is made with a thin coating of emulsion containing comparatively large crystals of silver halide which can individually capture many light photons and therefore will react to relatively low levels of light. However the tradeoff is that these large crystals create visibly grainy photos. By contrast, “slower” films with lower ISO ratings are made with emulsions containing very tiny silver halide crystals each of which can only react to much smaller numbers of light photons and therefore to respond at all there must be a high level of ambient light. However photographs made with this type of film are highly detailed and have no visible grain. Unlike film which is made with a specific and unchangable sensitivity to light, a digital camera electronic light sensor can be adjusted to be more or less sensitive to light. While this functionality can be used to great advantage it is not without some tradeoff! Due to the limitations of currently availabe technology, increasing a light sensors’ sensitivity to light when there’s not much ambient light available results in the increased prominence of the internal “electronic noise” occurring within the sensor. This can result in the appearance of grain or mottling, especially within darker areas of pictures and it is similar to the grain found in pictures taken with film cameras using low ISO film. This

DIGITAL CLINICAL PHOTOGRAPHY problem of grain is worse if the light sensor’s individual pixels are especially small as is the case with many small and highly portable digital cameras which usually have quite small sensors crammed with many megapixels because manufacturers think that consumers will be attracted to cameras with even more megapixels, a new phenomenon known as the “megapixel race”! While these cameras may well create highly detailed images in bright light, images taken in low-light settings will be very grainy and of low quality. By contrast those expensive, heavy and bulky digital single-lens reﬂex cameras have quite large light sensors with large individual light-sensitive pixels which which create pictures with virtually no graininess in all but the darkest circumstances (as described in the previous article). So the take-home message which must be repeated yet again is “more megapixels isn’t necessarily better - caveat emptor”!

flash units are usually totally useless for closeup photography because most cameras cannot adequately restrict the amount of light released by the flash units during closeup photography. As a result, if one tries to use a camera’s inbuilt flash to adequately illuminate a skin lesion while the camera is held only a few centimetres from the skin’s surface, the resulting image will be totally white! Many digital cameras have a “hot-shoe” on their top surface and one might

assume that buying an external flash unit to sit on the hot-shoe would be the answer to this problem. Unfortunately this is commonly a useless strategy because one must buy a flash unit which can reduce its output sufficiently in response to feedback from the camera’s internal light sensor and most of the cheaper cameras do not offer this as an option. Those cameras which do have through-the-lens (TTL) monitoring for flash control are usually the expensive, heavy and bulky digital SLR cameras which have very protruberant lenses

Below - External ﬂash unit with through-the-lens (TTL) metering.

Ambient Light When one takes closeup pictures of very small things such as patients’ freckles or skin lesions, it is because they are so tiny that they cannot reﬂect very much light back to the camera. Therefore, even in a reasonably brightly lit room it’s highly likely that extra illumination will be needed to create adequately exposed closeup photos. If an additional source of light isn’t used, it’s likely that the camera’s shutter will be held open for far longer than 1/30 of a second, this being the critical level beyond which those inevitable minor movements of the camera while being hand-held or of one’s subject (remember, we’re discussing taking pictures of patients who move at least as much as we do!) will cause one’s photos to be blurred and useless. With more light on the subject the shutter speed will be faster and movement of the patient or of the camera will be less of an issue and so it is extremely important to have a very bright source of light shining on the patient to ensure that one’s photos are properly illuminated and not blurry because of hand movements. Flash Options Nearly every digital camera has a built-in ﬂash light. Unfortunately these

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DIGITAL CLINICAL PHOTOGRAPHY which can get in the way and cast a pronounced shadow on the closeup subject when the flash is fired! If one is to use an external flash which has the capacity to control its light output for closeup photography one must use an external bracket and hotshoe, which results in a cumbersome combination of camera, bracket and flash unit! One option is to use a dedicated “ring flash” unit with TTL metering. Ring flash units are usually quite expensive, often costing more than $500, but they are capable of providing excellent illumination. One minor problem with their use is that the light source which surrounds the front of the camera’s lens

HOW WHITE IS WHITE? Holding a very bright light with an incandescent globe close to patients will be uncomfortable for them, partly due to the high intensity of the visible light and partly due to the intense heat. By contrast, ﬂuorescent lights are much cooler but they emit a different shade or hue of white, with a more blue-green cast to it than the relatively warmer and redder light emitted by ordinary incandescent light globes. This difference in the “colour of white” becomes very obvious when one compares photos of skin taken under ﬂuorescent lights with photos taken under incandescent lights. In the former, the skin tones may look slightly yellow or green rather than bright pink or

so evenly illuminates the skin that all shadow and therefore any clues to the 3 dimensional nature of a skin lesion is lost. Nikon sell an interesting “ring light” which clips onto the front of some of its cameras to illuminate closeup objects for macrophotography. It differs from a ring ﬂash because it produces a constant output of very white light from a number of powerful white LEDs when it is switched on. Unfortunately it can only be used with a few speciﬁc Nikon Coolpix cameras but from the author’s personal experience using it with a Nikon Coolpix 4500 it works very well!

even red skin tones seen in the latter. Nearly all digital cameras can either automatically adapt to the type of light source and many will also allow users to manually set the “white balance” setting within the camera’s menu options according to the light source being used. This enables the camera’s electronics to adjust how the image is “created” so that skin colours are as natural as possible. However, even if one forgets to correctly set the camera’s internal white balance setting for the light source used to illuminate patients’ skin lesions, it is possible to make adjustments to the images after the pictures have been taken by using appropriate computer software. Of

Above - Ring ﬂash unit with through-the-lens (TTL) metering.

course, this takes extra time (which one just doesn’t have in the context of a busy day) and requires more than a bit of familarity with the software, not to mention having to buy the software in the ﬁrst place! It’s actually much easier and quicker to take the photos again with the correct white balance setting than to alter the photos with software once they’ve been taken. To summarise, it’s important to use a good bright light, keep it close enough to the patient to provide enough light for a well exposed picture (but not so close that it’s intolerable for the patient!) and ensure that the camera’s white balance setting is set correctly before the pictures are taken.

BCC on nose illuminated with incandescent light. The photo on the left was taken with the white balance set for incandescent light which results in correct skin tones. The photo on the right was taken with the white balance set for ﬂuorescent light which results in too much red and yellow.

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DIGITAL CLINICAL PHOTOGRAPHY BRIGHT BUT BLURRED! Next comes the issue of ensuring that the object being photographed is in sharp focus. Along with this issue comes another concept called “depth of field”. This term describes the range of distance from the camera in which everything is in sharp focus including the object of interest in the photograph, perhaps some things closer to the camera than the object of interest and perhaps also things which are behind the object. Think of it this way: try to imagine looking at a line of dominoes standing on end, separated by 1cm and extending off into the distance directly away from you. Now imagine focussing on one particular domino one metre away from you. With a big depth of field perhaps all the dominoes both 10cm in front of the individual domino on which you’ve focused your camera’s optics and all the dominoes within 50cm behind that individual domino may well be in focus. By contrast with a small depth of field perhaps only one domino in front and 2 behind may be in focus and every other domino in front and behind of those few dominoes in focus will be blurry. The laws of optics also determine that the closer one gets to one’s object (and therefore larger the object appears in the image) the narrower the depth of field becomes. This means that one’s margin for error in focussing on a skin lesion can be very tiny and it accounts for why so many closeup photographs taken by inexperienced photographers are simply out of focus. It also explains why it’s possible for the very tip of a nodular lesion to be in sharp focus while the base of the lesion and surrounding skin may be completely out of focus! This can be disconcerting especially if the surrounding skin has features of interest. Similarly if one relies on the camera’s automatic focussing mechanism to take accurately focussed images one may be in for a few surprises. The author has commonly had to discard photos of an out of focus flat macule close beside a sharply focussed ruler all of 1-2 mm thick! So be careful exactly what your camera is “looking at” when it automatically focusses. In some cameras it’s possible to move the focussing area away from the

Top left - Small lens aperture (high f-stop setting) give long depth of field. Top right - Large lens aperture (low f-stop setting) produces narrow depth of field causing background and foreground to be blurred. Bottom - Well chosen depth of field allows enough of foreground and background to be in focus to add interest to the photo.

exact centre of the picture, either up or down or to one side in order to ensure that one can focus accurately. Alternatively, one may have to focus manually on one’s target assuming that the camera has a manual focus feature. One way to increase the depth of field is to narrow the aperture of the iris in the camera’s lens. Cheaper cameras often provide no manual control over the aperture, also known as the f-stop, which has a numerical value inversely proportional to the actual size of the aperture, i.e. the larger the f-stop number, the smaller is the aperture. With an infinitely small aperture the depth of field is theoretically infinite but clearly the smaller one makes the lens aperture (or the larger the f-stop) the less light actually gets into the camera. So to compensate for a tiny lens aperture required to increase

the depth of ﬁeld as much as possible one can extend the duration of the shutter opening. However the longer one keeps open the camera’s shutter the greater the risk that either the patient or the camera you’re holding will move thereby causing blurring of the picture! Faster shutter speeds minimize the risk of blurring caused by unwanted movement but reduces the amount of light. Increasing the camera’s ISO or light sensitivity setting can generate unwanted graininess in the picture. Increasing the brightness of the light shining on the patient’s skin can help but this is limited by the patient’s tolerance of the light and heat given off by the light source. So all these factors are interrelated and all conspire to make it hard to get a good closeup photograph! It is possible to use a tripod stand to support the camera so that it remains still throughout an exposure longer

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DIGITAL CLINICAL PHOTOGRAPHY than 1/30 of a second but it can take quite a bit of time to set up a tripod (extending the legs, attaching the camera and then positioning the tripod and camera sufficiently close to the patient) and still that won’t stop the patient from moving during a long exposure when extra light isn’t available. Overall tripods are cumbersome and just not worth the effort in almost all common clinical settings unless one is regularly taking pictures of exactly the same part of a patient’s anatomy (e.g. for iridology). Sudden tiny movements of one’s camera closer to or away from the patient or movements of the patient towards or away from the camera due to breathing, minor tremor or even one’s heartbeat can be enough to cause blurred pictures. Some cameras are rather slow at getting the focus and taking the picture (called shutter lag) and if the delay between one’s pressing the camera’s shutter button and the camera first establishing the correct focus and then finally taking the picture there may be quite a bit of movement of the camera relative to the patient’s skin lesion! One strategy the author uses to minimize errors of focus due to these extremely minor movements of the camera relative to the patient is to brace the camera against the patient. In this setting the end of the camera’s lens may only be a few centimetres from the patient’s skin and it is relatively easy to extend one or more fingers from one’s left hand while it also supports the camera’s lens or body. It takes a bit of practice to do this quickly, gently and without casting a shadow onto the patient’s skin lesion but it definitely helps to minimise movement between camera and patient. Patients will tolerate this level of physical intimacy for reasonable periods of time assuming one maintains a clinical demeanour! Because it’s all too easy to take hopelessly blurred closeup photos of patients’ skin lesions it’s extremely important that you always look at the photos before you ablate or excise the lesion you’ve just photographed or before the patient leaves your consulting room so that you can try to take the pictures again, this time in

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focus. It’s better to look at the photos on one’s computer monitor because the relatively small LCD screens on the back of most cameras are just too inaccurate to assess adequacy of focus even if one can zoom in a few times. If you don’t make it your policy to do this every time you may well end up extremely disappointed to discover that your photos were blurred and useless for the purpose of comparison at the same time as the patient returns some weeks or months later for review of a suspicious mole . The extra time you take to do this will be appreciated by your patient who will probably also enjoy looking at the photos you’ve taken!

EXACTLY WHERE WAS THAT SPOT I PHOTOGRAPHED LAST YEAR? Important as it is to document the appearance of individual skin lesions by taking closeup photographs, it is just as important to document exactly where on the body the lesions are (or were). “Context photos” taken which show exactly where on the face, body or limb a skin lesion is situated are a bit easier to take than closeup photos and are taken just far enough away from the patient so that one can easily see where the lesion is e.g. on the left cheek or on the lower back, etc. It is even more important to take context photos when the patient has multiple skin lesions such as dysplastic naevi which need to be followed up in the future. Some patients have a large number of these lesions and one may

first need to take an overall picture of a patient’s entire back for example. It may also be helpful then to zoom in a little bit closer to take some photos of perhaps four quadrants of the patient’s back. It can also be useful to draw numbered circles around specific and suspicious lesions using a marker pen (wipes off with alcohol swabs). Finally one might then take highly detailed closeup photos of each individual circled and numbrered skin lesion. This attention to detail will make it easy to recognize individual skin lesions and ensure that if one reviews the patient in the future there will be little difficulty recognizing which skin lesion is which and which of the many lesions has changed. This process obviously takes time especially when one has to also check that each photo is adequately exposed and is in sharp focus.

HOW BIG WAS THAT SPOT LAST MONTH? It is also extremely useful to take extra photos with a ruler placed close beside a skin lesion so that future review of

Above - closeup of nodular BCC but where on the patient is it? Below - (context photo), oh, that’s where!

DIGITAL CLINICAL PHOTOGRAPHY the lesion will clearly demonstrate if the lesion has enlarged. For complete accuracy it is worthwhile taking photos with a ruler in both vertical and horizontal planes relative to the skin lesion so that growth predominantly in one dimention can be measured. Finally, with the Medicare item numbers and fees for excision of skin cancers now dependent upon both the site and size of the lesion, and with pathologists often understating the size of a skin lesion because of elastic recoil causing lesions to miraculously shrink in size once removed (while at the same time the hole left in the skin following excision equally enlarges!) taking both context photos and photos with rulers beside the lesion will be adequate proof of oneâ&#x20AC;&#x2122;s claims should they ever be questioned by Medicare. Another principle is to use light and shade to enhance the three-

Above - Closeup of yet another nodular BCC but where is it? Below - (context photo), now itâ&#x20AC;&#x2122;s obvious!

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DIGITAL CLINICAL PHOTOGRAPHY dimensional appearance of lesions. Varying the position and the angle of the illuminating light on raised skin lesions will cast shadows which can enhance one’s perception of depth and improve the quality of the appearance of a skin lesion. However it’s also important to be aware that skin is sometimes a bit greasy and can reﬂect light so brightly that it can reduce the visible detail of a lesion. This may not be obvious when one is looking through the camera’s viewﬁnder but will be very

obvious when one examines the image immediately afterwards on the computer monitor and may force one to take the pictures again! You may also want to document the appearance of blanching which is so typical for a basal cell carcinoma when adjacent skin is stretched away from opposing sides of the lesion. It is possible, although somewhat clumsy, to use the ﬁngers of one’s left hand to stretch the skin away from opposing sides of a skin lesion at the same time

Below - A lesion taken with the author’s Heine dermatoscope and Nikon Coolpix 4500 camera.

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as the left hand braces the camera securely against the patient’s body. However, if this technique proves to be too awkward one may need to ask the patient to do the skin stretching! Finally, if you decide to purchase a dermatoscope speciﬁcally for the assessment of pigmented skin lesions you might also want to purchase a camera capable of connecting to a dermatoscope by means of an adaptor. Unfortunately there are not many cameras which can be

DIGITAL CLINICAL PHOTOGRAPHY at interpreting what one sees with a dermatoscope but being able to preserve or document what one sees with photography can assist the learning process as it’s then possible to compare one’s dermatoscopy photos with those found in textbooks. Relying on one’s memory is just not good enough!

CONCLUSION

Above - The same lesion from the previous page shot using the author’s camera.

used for this purpose. As mentioned in the last issue, the author uses a Heine dermatoscope with a well and truly obsolete Nikon Coolpix 4500 camera which is used solely with the dermatoscope. This combination takes excellent dermatoscopic photographs and can zoom in quite a bit to further enhance the magniﬁcation provided by the dermatoscope. It is obviously beyond the scope of this article to discuss dermatoscopy in any depth. However if you already use a camera to document skin lesions and if you use or plan to use a dermatoscope then it is logical to consider going the “ﬁnal” step by documenting what you see in the dermatoscope using

digital photography! And it’s easier to take good quality dermatoscopic photos than other forms of closeup photos because the dermatoscopes provide excellent light with their built-in illumination and there is little risk of blurring due to unwanted movement because the dermatoscope is obviously resting on the patient’s skin! Dermatoscopes are ludicrously expensive and if one has to purchase another digital camera just to use with the dermatoscope that’s yet an extra expense. However these work tools are tax-deductible and in the long-term the extra expense is deﬁnitely worthwhile! It takes quite a bit of time to become competent

To sum up, if you have an appropriate camera, good lighting, and the patience to practice, it is possible to take wonderful and very useful photographs during consultations. While it may take a little while to become efficient at using this photographic technique it can be extremely beneficial to patient management and it is highly likely to improve patient satisfaction. The next article in this series will focus (sorry about the pun!) on how to get your photos onto your computer, what use you can make of your digital photos, how they can be improved if they have minor deficiencies and how to look after them. 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.

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SHUTDOWN

TWO’S A CROWD Mr Fixit

THE SETUP I look after several sites that have chosen to either primarily or exclusively use Mac systems. While Mac users typically reap many benefits from Apple’s high quality operating system, the niche penetration levels of the Macintosh conspire to prevent some technology from thriving on the platform (usually niche solutions themselves). My tale begins at a time when high capacity document scanning solutions had made little impact in the Land of Mac. After fruitless searching themselves, a practice asked me to procure a suitable document scanning solution for use in their exclusively Apple practice. There were many scanners that would have been suitable had the practice been using Windows, however none of the manufacturers developed Mac software. With few options to choose from, I identified a software product called ScanTango as the best way forward. ScanTango is a program written by a US based company, Mindwrap. It is essentially a combined scanner driver and document processing application designed to work with a range of Fujitsu document scanners. It has an impressive range of features, many of which are not included in Fujitsu’s own software. I’d had positive experiences with Fujitsu scanners over the years and was happy to find a Mac software solution that would give my client access to this hardware. After searching the web for testimonial about the product and not finding any reports of major issues, I contacted the ScanTango developer. He tipped me off about a new version of his software that would include support for a new model from Fujitsu, the Fi-5120c. Offering duplex scanning at up to 25 pages (50 sides) per minute, I learned that this scanner was essentially a refreshed

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version of the Fi-4120c, a model that I had deployed successfully in the past. Conﬁdent that I had found a workable solution, I called Fujitsu’s distributor and ordered a Fi-5120c which was soon to be released in Australia. When the scanner arrived, I checked back in with the developer of ScanTango and purchased the promised update (version 2) that included support for the Fi-5120c. Or so I thought...

THE DEBACLE Having purchased and installed the software, I plugged in the scanner, did a few test scans, trained the practice staff and was on my way. The staff were happy, the practice principle was happy, I was happy. 2 hours later, I had a call from the practice to say the software was intermittently throwing up communication error messages, requiring the scanner and software to be restarted to allow scanning to continue. Over the course of the next few months, the practice persisted with the “solution” while I tried to resolve the issue. Despite ScanTango updates, OS updates, scanner firmware patches, trials with identical scanners and different computers, and several lengthy discussions with Mindwrap and Fujitsu, I simply couldn’t get the solution to work as advertised. The major problem for the software developer was that with only a few hundred customers (based on my serial number), and presumably only a fraction of them using the new Fi-5120c, the number of people using the exact solution world wide could have only been a handful. Of these people at the time, I was the only person having this issue. Six months after I had initially deployed the “solution”, the developer contacted me to say that he had identified the root cause of the problem: The early first

revisions of the Fi-5120c had a hardware fault that rendered his software unstable. For reasons that I didn’t care to waste time thinking about, this hardware issue doesn’t cause problems when connected to a PC running Fujitu’s supplied Windows software. I was pleased that the problem had been isolated, however realised very quickly that this was of no help to my client. As Fujitsu didn’t advertise the product as being Mac compatible or supported, they were under no obligation to swap the scanner for a newer revision that did work reliably. Mindwrap had been successful in getting Fujitsu to assist customers in the US, but made little effort to pursue a similar arrangement in Australia. I did make my own enquiries with the local scanner distributor, but we both agreed I’d be better off unloading the existing scanner on eBay and repurchasing a newer revision. Having already wasted dozens of hours, I capitulated and requested a refund of the ScanTango software.

THE LESSONS The obvious problems associated with buying from a small international vendor aside, by purchasing the scanner and software when they were ﬁrst released to the market, I’d essentially signed up to beta test three technologies at once (i.e. the scanner, ScanTango and the combined solution). The main lesson to be learnt from my miserable experience however, relates to the relationship of accountability between hardware, software companies and support entities. The bottom line: If you purchase a product/service to support or add functionality to a 3rd party solution, you need to ensure that one or both of your suppliers will take ultimate responsibility for the total solution. To protect client conﬁdentiality, Mr Fixit’s identity remains hidden.

Take your practice in your pocket

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Top Pocket – Best Practice Software for PDAs. Best Practice continues the evolution in GP software. First the surgery. Then the front desk. And now the world! In your Top Pocket, wherever you go. Specifications: Minimum: 400 Mhz processor, 64 MB internal memory with approx 30MB free space for Top Pocket, Windows Mobile 2002. Recommended: 624 Mhz processor, 64 MB internal memory, SD or Compact Flash memory with approx 100MB free space for Top Pocket (see optional extras), Windows Mobile 2003 Second Edition or greater. Optional extras: 512MB (or greater) SD or Compact Flash memory card (for patient and drug databases. Note: Pocket PC must have SD or Compact Flash slot. Check with your manufacturer). External input devices Bluetooth keyboard, Bluetooth mouse (Note: Pocket PC must be Bluetooth enabled!)

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