Pulse+IT - May 2007

PULSE IT Ã

AUSTRALIA’S FIRST AND ONLY HEALTH IT MAGAZINE

EASE INTO EASYCLAIM

ISSUE 4: MAY 2007

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

Today a number of organisations are selling electronic messaging solutions into the health sector. Unfortunately, in their haste, several are taking shortcuts resulting in significant risks for practices and patient care.

Typical shortcuts being taken include; • Not using the correct message acknowledgement process as set out in the Australian messaging standards (and thus being unable to ensure that a message is actually received by the intended recipient).

• Turning all forms of referrals and specialist letters into observation (lab report) messages and filing them away in the results section, effectively losing them in wrong section of the patient record.

• Neglecting to put in place end-to-end support arrangements with the medical software at either end of the messaging system.

There is a safe and sensible solution that deals with these issues correctly.

HealthLink is the electronic messaging system synonymous with quality and careful risk management. Don’t take risks with patient information; there is absolutely no need to!

Tel 1800 125 036 enquiries@healthlink.net Integration

Standards

www.healthlink.net Scalability

PULSE IT +

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

INTERVIEW: DR FRANK PYEFINCH PAGE 22

Art Director Nelson Saville Editorial Enquiries editor@pulsemagazine.com.au Advertising Enquiries ads@pulsemagazine.com.au

PAGE 6 STARTUP Editor Simon James introduces the fourth edition of Pulse+IT.

About Pulse+IT Pulse+IT is produced by Pulse Magazine, the most innovative publisher in health. Over 15,000 copies of Pulse+IT are distributed quarterly to doctors, practice staff and the IT professionals that support them.

Contributors Simon James, Dr Murkesh Haikerwal, Trevor Hendry, Jane London, Dr David More, Dr Ian Reinecke and Dr Daniel Silver.

Non-Commercial Supporting Organisations • Australian Medical Association (AMA) • General Practice Computing Group (GPCG) • National E-Health Transition Authority (NEHTA) Disclaimer The views contained herein are not necessarily the views of Pulse Magazine or its staff. The content of any advertising or promotional material contained herein is not endorsed by the publisher. While every care has been taken in the preparation of this magazine, the publishers cannot be held responsible for the accuracy of the information herein, or any consequences arising from it.

Pulse Magazine has no affiliation with any organisation, including but not limited to Health Services Australia, Sony or the Kimberley Aboriginal Medical Services Council that all publish printed articles under the title “Pulse”. Further, we have no affiliation with CMP (owner of “Medical Observer”), who are endeavouring to trademark “Pulse”.

Copyright 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 8 GUEST COLUMN: DR DAVID MORE Dr David More discusses the importance of patient information privacy.

PAGE 42 DIGITAL CLINICAL PHOTOGRAPHY Dr Daniel Silver concludes his four part series on digital clinical photography with a discussion about photo storage and organisation.

MEDICARE EASYCLAIM PAGE 24

SECURE MESSAGING PAGE 30

NEXT G BROADBAND PAGE 38

WIDGETS PAGE 50

REGULARS PAGE 06 STARTUP Editor Simon James introduces the fourth edition of Pulse+IT.

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

PAGE 08 GUEST COLUMN Dr David More discusses the importance of patient information privacy.

PAGE 16 GPCG Jane London provides guidance on electronic health resources.

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

PAGE 18 NEHTA Dr Ian Reinecke discusses NEHTA’s adoption of the HL7 family of standards.

PAGE 20 AMA Dr Mukesh Haikerwal encourages the health sector to make secure electronic communication a priority.

PAGE 22 INTERVIEW Pulse+IT talks with Dr Frank Pyefinch, founder of Best Practice.

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

FEATURES PAGE 24 EASE INTO MEDICARE EASYCLAIM Simon James introduces the new Medicare electronic claiming system, Easyclaim.

PAGE 28 MEDICARE EASYCLAIM INTEGRATION Simon James takes a look at the future of Medicare Easyclaim and discovers integrated solutions on the horizon.

PAGE 30 SECURE ELECTRONIC MESSAGING WITH HEALTHLINK Simon James demonstrates a working secure electronic messaging solution.

PAGE 38 NEXT G WIRELESS BROADBAND Simon James reports on Telstra’s Next G network, and BigPond’s wireless broadband solutions.

PAGE 42 DIGITAL CLINICAL PHOTOGRAPHY Dr Daniel Silver concludes his four part series on digital clinical photography with a discussion about photo storage and organisation.

PAGE 50 SHUTDOWN Trevor Hendry discusses the pleasures and perils of the Widget revolution.

www.pulsemagazine.com.au

STARTUP

PULSE IT: 2007.2 Welcome to the fourth edition of Pulse+IT, Australia’s first and only health IT magazine.

PULSE+IT EXPANDS

NEW WRITERS

Welcome to the fourth edition of Pulse+IT, Australia’s first and only health IT magazine.

I’d like to extend my thanks and warm welcome to first time contributors, Dr David More and Mr Trevor Hendry.

As a quarterly publication, technically we are only 9 months old, however we are feeling very much like we’ve aged at least a year since our launch!

I’d also like to welcome the AMA into the pages of Pulse+IT, and wish their outgoing President, Dr Murkesh Haikerwal all the best in his future endeavours, especially in his role as a member of Minister Tony Abbott’s EHealth Ministerial Advisory Group.

To prematurely celebrate our impending first birthday, we’ve increased our circulation by 50% to 15,000 copies. It is our hope that this expanded circulation will further increase awareness of the benefits technology can bring to Specialist and General Practice, and in turn, the health sector as a whole.

This aggressive and unprecedented expansion has been made possible by the continued support of our loyal advertisers. As such, I encourage all readers of Pulse+IT to take an active interest in what these organisations are contributing to the eHealth sector.

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 15th June to be eligible to receive a FREE iPod Shuffle.

More details about our subscription packages and the iPod promotion are available on pp13.

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THIS EDITION This edition contains not one, but two articles on the forthcoming Electronic Medicare Claiming, officially dubbed “Easyclaim”.

The first article presents an overview of the new system, and offers answers to many of the questions practices will have about Medicare Easyclaim.

The second article investigates future implementations of the system, with a focus on forthcoming practice software integration.

Dr David More discusses the challenges associated with health information privacy, and Jane London outlines ways for clinicians to effectively make use of the vast array of electronic health resources.

Pulse+IT checks in with Dr Frank Pyefinch, founder of Best Practice and Dr Daniel Silver concludes his comprehensive series on digital clinical photography, taking a look at ways to view and store your snaps.

Having spent 4 months using the solution, I report on Telstra’s Next G Network and BigPond’s wireless broadband offerings, while Trevor Hendry provides an insight into computerised Widgets.

Finally, a comprehensive technical demonstration of a secure electronic messaging solution is presented. This article is the first in a perpetual series aimed at providing practical examples of working secure messaging scenarios.

LOOKING AHEAD In the next edition of Pulse+IT we will examine the implementation of the Medicare Easyclaim system, and check on the progress of the forthcoming integrated solutions discussed in this edition.

This forthcoming edition will also contain a feature article designed to assist readers who are interested in setting up a website for their practice.

Simon James, Editor simon.james@pulsemagazine.com.au

Every Pulse+IT subscriber receives a

+ Ñ

To ensure a diversity of opinions is maintained in future editions of Pulse+IT, I’d like to take this opportunity to extend an invitation to individuals interested in contributing or collaborating on future articles to get in touch.

Dr Ian Reinecke discusses the Health Level Seven (HL7) standards, and Dr Mukesh Haikerwal comments on the importance of connecting health care providers.

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GUEST COLUMNIST

HEALTH INFORMATION PRIVACY: WHAT DO DOCTORS AND PATIENTS WANT AND NEED? Dr David G More MB, PhD, FACHI In the last few weeks we have had a number of reminders that management of the privacy of patient records remains a contentious and difficult area.

The first key reminder came in late February 2007 when Paul Feldman, co-chair of the American Health Information Community’s (AHIC) Confidentiality, Privacy and Security Workgroup, submitted his resignation to the interim National Coordinator for Health Information Technology at the Department of Health and Human Services (HHS).

AHIC (which has the same role as the Australian Health Information Council – also rather co-incidentally AHIC) is the peak health IT policy advisory board in the US and provides advice directly to the US Secretary for Health and Human Services (the equivalent of our Federal Health Minister).

In his resignation letter Feldman writes that the workgroup “has not made substantial progress toward the development of comprehensive privacy and security policies that must be at the core of a National Health Information Network (NHIN).”

Given this resignation comes after six meetings and many months of work, the degree of difficulty in reaching a consensus between parties is obvious.

The second reminder came with the April 2007 release of a survey conducted among UK GPs regarding the sharing of clinical records electronically with the UK NHS ‘Spine’ – which is a secure repository of shared electronic patient records which – under appropriate conditions – can be accessed to assist in patient management anywhere in the UK.

In summary the article in the UK Pulse magazine [not affiliated with Pulse+IT] survey found: • About one-third of physicians said they will allow full sharing of their patient records; • Four out of 10 physicians say they will opt out completely from the program and allow none of their records to be shared; • 80% of physicians surveyed still think that sharing electronic health records can threaten patients’ confidentiality, despite a government marketing campaign to promote the IT program; and • 67% of General Practitioners oppose the implied consent “opt out” model, which has formed the basis for the program to be rolled out.

If what is found in this survey is truly reflective of the views of practitioners, and I have no reason to assume it is not, then the implications for electronic sharing of health records by GPs is profound. What seems to be clear from these results is that a policy approach that makes practitioners feel secure and confident about the control of patient information, both for themselves and as agents for their patients, needs to be evolved.

A third reminder has come as recently as early May 2007 with multiple articles appearing in the E-Health Insider Primary Care - Issue No 116, 2 April 2007 reviewing the difficulties being faced by the UK Connecting for Health Program in getting acceptance for their ‘optout’ consent plans for electronic record sharing. More details can be found here: www.ehiprimarycare.com It seems to me there is one organisation and advocacy entity in the US that ‘gets

8 PULSE + IT

it” and that is the Patient Privacy Rights Foundation which is a tiny non-profit entity led by Deborah Peel, an Austin, Texas-based psychiatrist.

As reported on the US Modern Medicine website, her views are as follows: “Peel’s Patient Privacy Rights Foundation, meanwhile, has become a ubiquitous proponent for privacy controls in the growing debate over patient rights and healthcare data usage. On Tuesday, the Coalition for Patient Privacy, of which the foundation is a member and Peel serves as chairwoman, presented to a meeting of the HHS IT advisory panel, the American Health Information Community, an 11point list of basic privacy principles. The principles also incorporate the definition of privacy developed by the National Committee on Vital and Health Statistics and presented to HHS Secretary Mike Leavitt last year that states: “Health information privacy is an individual’s right to control the acquisition, uses, or disclosures of his or her identifiable health data.” The principles include using technology to allow patients the right to opt-in or opt-out of electronic systems, giving patients control over access, providing for complete audit trails and allowing patients to segment sensitive information.

In a letter to the AHIC over Peel’s name, she wrote, “Technology can create far stronger privacy protections and granular control over access to records than is possible in paper systems.”

She called on AHIC to “facilitate the creation of an electronic health system that patients will trust by using ‘smart’ technology to build ironclad privacy protections into system designs up front.” The full article can be found here: http://tinyurl.com/yuzodm

GUEST COLUMNIST The core points she makes, and what I think is getting to be the minimum acceptable position, are the following: 1. To have acceptable health information privacy rights it is necessary that the individual control the acquisition, uses, or disclosures of his or her identifiable health data.

2. The principles that need to be implemented include using technology to allow patients the right to opt-in or opt-out of electronic systems, giving patients control over access, providing for complete audit trails, and allowing patients to segment sensitive information.

3. That with proper planning aforethought it is possible to design systems that meet these standards. It is not the lack of capacity to design privacy compliant systems it is the lack of will to do so that is the problem.

4. Clinicians need to keep uppermost in their minds that individuals provide information to them, trusting it will not be abused. If that trust is not honoured, no electronic record sharing system will succeed I believe.

With this said, it is also true that if you explain the purpose behind, and the benefit to be derived from, health information sharing, and make it clear only authorised or de-identified information sharing will occur, the vast majority of the population are comfortable and content. As long as they are asked for consent beforehand, and can opt-out if they choose,

resistance melts away. This is especially the case among patients with chronic disease who receive treatment from a range of carers who need to be better co-ordinated than they are now by and large.

Also it needs to be said that the surreptitious sharing of patient information – even if de-identified – is a totally unsatisfactory practice and where it occurs it is to be condemned.

The bottom line here is that people like to be asked, and if asked will usually agree. If not asked annoyance soon emerges – think un-invited telemarketing calls!

Public perception of the security of their information is also very important in this regard. The rising incidence of identity theft in the country is lessening the confidence of the public in technology to protect financial information and most people see their medical record as a more private document than their bank statement.

I also believe it is not good enough to take the position that paper and electronic records should be treated identically from a policy, technical and privacy perspective. The goal of record protection may be the same but the methods of implementation are clearly different. You have to try hard to disclose the information in multiple paper records due to their cumbersome nature and size. Not so with electronic records where we have seen tens of

thousands of records disclosed with the loss of a single laptop or unencrypted DVD. It seems to me there needs to be much more acceptance on the part of both system designers and clinicians that maintenance of health information privacy is an ‘elephant in the room’ that can truly derail the best technical approaches to information sharing.

GPs, Specialists, Service Providers and Hospitals all need to keep this in mind as we move forward. Of course none of the above diminishes the need for awareness and action on the part of clinicians in their individual practices to also protect all internal records as well – be they paper or electronic. The hiccups with which I opened this article show what happens if you don’t. Once public trust is lost it will be very hard to regain. The bottom line of all this is that any e-health project that fails to get its approach to privacy right greatly increases its risk of failure - it is really that simple. What is needed is clear, so there is just no excuse!

Dr David More is an Independent Health Information Technology consultant and blogger who has been working in the e-Health domain for over twenty years.

He is concerned at the lack of clinician and patient focus in much of what is happening in e-Health in Australia.

Dr David More’s Health IT Blog www.aushealthit.blogspot.com

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BITS & BYTES

BEGINNING OF THE END FOR HARD DRIVE TECHNOLOGY? Manufacturers of Solid State Disks (SSD) are gearing up to reshape the laptop storage landscape.

Unlike traditional hard disks that use rotating magnetic platters to store data, emerging SSD devices are built using NAND Flash memory, a technology similar to the storage found in popular flash (thumb) drives.

With no moving parts, SSD consume significantly less power than traditional hard disk storage, which is an attractive characteristic for laptop users. SanDisk, the largest supplier of flash data storage claim that their SSD devices require as little as half the power of typical laptop hard drives. The lack of moving parts should also translate into greater reliability, however only real world testing will confirm whether manufacture claims of mean time before failure rates of 2 million hours are realistic.

Laptop users have enjoyed progressive increases in speed over the past few years with most laptops sold now sporting hard disks spinning at either

5,400 rpm or 7,200 rpm. Despite existing disk based technology providing adequate speed for tasks typically performed on laptops, SSD technology promises to deliver a significant jump in performance. With no mechanical movements, latency is eliminated resulting in significant speed improvements, particularly for small data transfers. Sustained data transfer speeds are claimed to be improved by as much as 50%.

SanDisk and Samsung are two vendors marketing their SSD products to laptop manufacturers, offering maximum capacities of 32GB and 64GB respectively. Both SanDisk and Samsung offer their SSD devices in 2.5inch and 1.8inch form factors, adhering to existing portable storage-size conventions, which should make it easier for both end users and manufacturers to deploy these solutions in the short term. Smaller devices and embedded solutions are likely to emerge in the near future to cater to the burgeoning sub-portable market.

Despite relatively low storage capacities, SSD devices are currently very expensive and are unlikely to appear in mainstream laptop lines for some time. Costs are likely to fall rapidly however, and industry observers expect SSD devices to constitute a significant proportion of portable storage by the end of the decade.

SanDisk www.sandisk.com Samsung www.samsung.com

SECURE MESSAGING CODE OF PRACTICE RELEASED HealthLink, Australia’s largest provider of secure clinical messaging solutions, has publicly released a draft code of practice for “Communications Service Providers/Integrators” in the Australian Healthcare sector.

In its current form, signatories to the document are required to adhere to 10 core requirements which revolve around standards compliance, message management and continuity of service. Specifically, signatories are required to use and promote Health Level 7 (HL7) wherever possible, play an active role in the development of healthcare messaging standards, and work with other signatories to develop interoperable solutions.

The importance of practice software in the messaging loop is recognised, with a requirement that end-to-end accountability be provided by the combination of the messaging software and the clinical software used by both the sending and receiving healthcare provider/organisation.

Where questions of standards compliance are raised, the code recognises Australian Healthcare Messaging Laboratory (AHML) as the final arbiter.

The two page code of practice is prefaced by a document titled “Safety Through Quality: Improving Electronic Communications in the Australian Health Sector”. This document offers HealthLink’s justification for the need for the code of practice, citing a “lack of certainty”, “lack of accountability” and a “lack of manageability” as problems with the current state of the secure messaging market in Australia.

The proposed code of practice is available at the HeathLink website.

HealthLink www.healthlink.net AHML www.ahml.com.au

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BITS & BYTES

TAIWAN LAUNCHES WIRELESS HEALTH NETWORK Chunghwa Telecom, Taiwan’s largest integrated telecommunications operator is readying the launch of a new wireless network designed to assist with the delivery of healthcare. The initiative, dubbed “Taiwan Mobile Healthcare Services� (TMHS), uses a WiMAX solution developed by Nortel.

WiMAX (or IEEE 802.16) is an emerging network technology that can be used to build “metropolitan� sized wireless networks. The technology is being positioned as a direct competitor to existing third generation (3G) mobile network technology, including that used

by Telstra’s Next G network.

WiMAX utilises a combination of transmission and antenna technologies to maximize performance. It is claimed that the TMHS network will deliver enough bandwidth to facilitate highquality mobile video.

The TMHS will assist with the provision of emergency medical assistance and other patient care services that routinely take place outside of medical facilities. Healthcare workers in the ďŹ eld will be able to connect to centralised medical resources, including patient medical records, diagnostic images and reference material in various multimedia formats.

The TMHS will be demonstrated by Chunghwa Telecom and Nortel at the 2007 Taipei Summit – Asia-PaciďŹ c WiMAX Conference and Exhibition being held on May 14 to 15 in Taipei.

it makes the clinicians life easier. The choice of wizards enables accurate high quality assessments to be produced in minutes rather than hours.�

The ANDGP plans to provide further integration between MHAGIC and GP clinical software in the future.

Nortel www.nortel.com

GLOBAL HEALTH WEAVES MHAGIC IN ADELAIDE Global Health has announced a successful deployment of their mental health software in the Adelaide Northern Division of General Practice (ANDGP).

MHAGIC (Mental Health Assessment Generation and Information Collection) is a software application designed to support mental health practitioners in the management, assessment and evaluation of mental health patients.

MHAGIC uses a “tick and click system� to ensure accuracy and consistency of the assessments and outcome measurements.

The Adelaide Northern Division has the largest mental health program in South Australia and has been using MHAGIC since February 2007. Since implementation, MHAGIC has received strong endorsement by key Division stakeholders.

Deb Lee, a Mental Health Clinician now using the software, stated that “MHAGIC compiles all the information required,

“In the next phase, we intend to incorporate secure messaging for our GPs to do one-click referrals, and equip our clinicians with laptops to remotely access MHAGIC from wherever their patient encounter is located....the importance of MHAGIC is that you can share information with other clinicians, communicate directly with GP’s via ReferralNet (Global Health’s secure encrypted e-messaging solution) and also collate data to analyse reports�, said Barbara Magin, Deputy General Manager of the ANDGP. The software was originally developed in conjunction with ACT Health in 2002 to improve clinical care and assist with the collection and aggregation of data across the territory. Since its initial deployment, the software has evolved and is now in its fourth major iteration.

Presently, more than 500 staff in the ACT use the application with concurrent connections typically exceeding 90.

Global Health www.global-health.com ANDGP www.andgp.org.au

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BITS & BYTES

APPLE GOES GREEN Having received sustained criticism over a number of years about his company’s environmental practices, Apple CEO, Steve Jobs has published an open letter on his company’s website.

In the letter, Mr Jobs outlines Apple’s plans to remove various toxic materials from the manufacturing processes of future Apple products. Substances slated for reduction or total removal include lead, mercury, arsenic and PVC. Mr Jobs also scorecards his company’s present and planed environmental efforts against rivals HP and Dell, maintaining that Apple is performing significantly better than Green groups would have the public believe.

To complement the more environmentally friendly manufacturing processes, Apple plans to increase the percentage of computer they recycle from around 10% currently, to nearly 20% by the year 2010.

Apple

NPCC ATTRACTS FUNDING AND NEW CLINICAL DIRECTOR In the recent Federal Budget, the Government announced that it will provide $34.6 million over the next four years to continue and expand the Australian (National) Primary Care Collaboratives Program (NPCC).

The funding includes an additional $12.7 million over the four years to 2010/2011, in addition to the $22 million slated in the existing forward estimates.

This budgeted figure is double the amount received by the NPCC to date, and will allow the Program to take on an additional 800 practices.

Currently there are 500 practices and 43 Divisions participating in the Program.

The additional funding will bring this figure to 1300 or approximately 20% of all general practices. The number of Divisions involved in the initiative is expected to double to 90.

The NPCC’s recently appointed Clinical Director, Dr Lynne Davies said that, “The Australian Government has recognised the amazing achievements of the Collaboratives Program in improving patient outcomes and systems of care within Australian general practice.”

“This is a tremendous credit to the NPCC and Collaborative Program Managers based around Australia and all of the practices involved in the Program so far”.

Dr Davies succeeds Dr Dale Ford, the Programs Clinical Director since February 2005.

“It has been a great privilege to be involved in the Collaboratives. To see the change in participating general practices over the three Waves of the Program, and improvement in the measures, was more than I thought I would see in a lifetime of being in general practice”, said Dr Ford.

“This is a wonderful opportunity for Dr Davies, one of the many Collaboratives ‘champions’, who has been involved from the outset, to lead the Program into the future,” he said.

Dr Davies brings with her over 17 years experience as a GP and her clinical leadership roles include current positions as Chair of the NPCC CHD Expert Reference Panel and Director on the Northern Rivers General Practice Network GP Executive Committee.

Dr Davies works as a practising GP at the Tintenbar Medical Centre, is a Vocational Medical Officer (VMO) in emergency medicine at the local area hospital, and is extremely proactive in her work with the local community on health initiatives such as walking groups and dietary changes in local schools.

Dr Davies has been an active supporter of the Collaboratives Program since its inception in 2005 as presenter, at both National and Virtual Learning Workshops, and a participant when the Tintenbar Medical Centre took part in Wave 1 of the Program.

National Primary Care Collaboratives www.npcc.com.au

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BITS & BYTES

PLAYSTATION 3 JOINS MEDICAL RESEARCH EFFORT Sony has released a software update for their PlayStation 3 gaming console that allows its customers to participate in the Folding@Home initiative (pronounced folding at home).

The project is a research effort seeking to better understand “protein folding”, a term used to describe the chemical process where amino acids assemble themselves into the building blocks of protein.

Improperly formed proteins are linked to a number of diseases, including Parkinson’s, Alzheimer’s, Cystic Fibrosis, Lou Gherig’s disease and mad-cow disease.

Coordinated by a team from Stanford University the project relies on volunteers who “donate” their unused computing resources. There is no physical exchange of hardware, but rather, Folding@Home participants install software on their computer that regularly downloads small segments of data via the Internet.

The software then performs a series of complex calculations, and sends the results back to Stanford to be collated with the results from the hundreds of thousands of active participants enrolled in the scheme.

Above - Sony’s PlayStation 3. Retailing for $999, this gaming console is providing a significant boost to protein related disease research.

As the computations use significant resources, volunteers usually configure their systems to process their data allocation when they are not using their computers for more routine tasks e.g. over night.

The PS3 is especially conducive to this type of project, as it includes a very powerful processor and can easily be connected to the Internet via broadband.

Only a month after the Folding@Home software was released for the PS3, more than 250,000 users have registered for the project. Combined, these users are contributing over 582 teraflops

Below - A visualisation of the simulated development of a protein displayed on a Sony Playstation 3 gaming console. The PlayStation 3 platform is now the most substantial contributor to the Folding@Home project, eclipsing the contributions of all the major computing platforms combined.

of computational power, more than doubling the capacity of the network, which can now achieve a total of 892 teraflops.

The PS3 has also been attributed to an increase in awareness of the project, with the number of people running Folding@Home software on PCs increasing by 20% since the gaming console was brought online.

On the back of this rapid adoption, the Folding@Home distributed computing network has developed into the most powerful of its kind. Sony has begun actively promoting the initiative, and expects that it will only be a matter of months before the network has a petaflop (1000 teraflops) of processing power at its disposal.

According to Folding@Home project lead, Vijay Pande, “The PS3 turnout has been amazing, greatly exceeding our expectations and allowing us to push our work dramatically forward. Thanks to PS3, we have performed simulations in the first few weeks that would normally take us more than a year to calculate. We are now gearing up for new simulations that will continue our current studies of Alzheimer’s and other diseases.”

Stanford University Folding@Home http://folding.stanford.edu/ Sony Playstation http://au.playstation.com.au

14 PULSE + IT

We’re seeking Expressions of Interest (EOI) from:

• medical software providers to develop an electronic version (the template) of the Centrelink Medical Certificate and include it in their respective general practitioner software, and • medical practices to develop an electronic version (the template) of the Centrelink Medical Certificate to be placed on their general practitioners’ desktops.

AH1464.0702

The template is to allow general practitioners to complete and store the certificate on their computer, populate fields with general patient details, print, sign and give it back to patients to lodge at Centrelink.

This initiative was successfully piloted in 2005–06 with a limited number of vendors.

We now want to extend its availability to all medical software providers and medical practices pending Centrelink’s acceptance of their EOIs. To register your preliminary interest and obtain an information package outlining Centrelink’s requirements, call Ian Delzoppo on 02 6208 8027 or Zbiggy Zmurko on 02 6208 8046 or:

e-mail:

zbiggy.z.zmurko@centrelink.gov.au

write to: Ian Delzoppo, Job Capacity and Disability Services Branch, (L 7–1 Bowes Place) Box 7788 Canberra Mail Centre, ACT 2610

Approvals of EOI are subject to meeting Centrelink requirements stipulated in the information package and it will involve a written submission addressing these requirements. It is essential that interested parties obtain the package as indicated above.

E-RESOURCES GPCG

Jane London

If you were to provide care as per guideline recommendations for the 10 most common chronic conditions to your patient base, it would require 10.6 hours per day1. Extending this figure to include preventive services would require another 7.4 hours per day2. And what about all the other information that you need to keep on top of? Trawling through hard copies of new guidelines and journals is clearly impractical.

Electronic resources are a fast and effective way to retrieve pertinent

information when you require it. You may find that your clinical software has the information that you may need (e.g. drug-drug interaction information), however, often you will need to look beyond this to find the answer to specific patient issues. With near universal Internet access in Australia this solution can be either closer, or further away, than you think.

To be useful, the information you use must be reliable, current, evidencebased and relevant. Think about where the source is located in the information hierarchy (Figure 1). This hierarchy allows you to distinguish between Level 1 (e.g. a general Google search, Wikipedia) through to robust Level 4 evidence-based guidelines (e.g. RACGP Red Book). Level 5 patient material is the least common and is generally only available on a

Figure 1 - Information hierarchy (GPCG, 2005. Reproduced with permission).

Level 5

Quality patient material

Level 4

Distilled best practice guidelines, e.g. Australian Immunisation Handbook

Level 3

Meta-analysis, systematic reviews, e.g. Cochrane library, NHRMC guidelines

Level 2

Original scientific reports, e.g. observational studies, controlled clinical trials

Level 1

All information available electronically, including the good, the bad and the crazy

16 PULSE + IT

number of specialised sites. Therefore, once you have defined exactly what you need to know, a good idea is to start with Level 4 information and work down.

When you have successfully retrieved the information, don’t forget to ascertain when it was written, what journal it was published in, whether it has been reviewed or whether any endorsing bodies have approved the site (e.g.

Health on the Net, a Swiss Foundation who champion the use of high quality medical information via the Internet). This will help you determine the information’s currency and validity.

Quality consumer information can be found via the RACGP website in the ‘For Patients’ section. This allows you to use a single search function to gather information from the Better Health Channel and Health Insite.

The DISCERN tool is an instrument that can help you assess the validity of this and other consumer health information.

This 15 question tool has been designed to gauge the reliability of health information by rating it on separate quality criterion.

My General Practice is also another tool that can be used as an information filter.

This desktop tool has been designed by the RACGP and facilitates access to a wide range of online guidelines, patient education materials, journals, Evidence Based Medicine (EBM) resources and learning modules.

Once you are comfortable that you have reliable information, there are a number of other factors to take into account when applying the information to your patient. Participants in research trials are generally homogenous, in order to successfully observe results without influencing factors. Patients that

GPCG you treat will often differ from those treated in a study. Co-morbidities are a common problem, especially when looking at a complicated condition such as diabetes. You need to assess the relevance of a clinical trial’s findings to your patients.

Taking note of the Number Needed to Treat (NNT) is also a useful way to interpret results and apply them in your practice. This epidemiological formula tells you the number of people that you need to treat before a patient benefits from that therapy. This information is useful when discussing treatments and consent. NNT is explored further in the RACGP Green Book (Appendix 3), giving specific examples of preventive care.

The recently released Green Book (2nd Edition) is available to download from the RACGP website.

THE GPCG ELECTRONIC RESOURCES MODULE

Better Health Channel

This education module is designed to guide GPs and practice staff through the effective use of electronic resources in retrieving health information. It has a multitude of useful links and delineates the difference between various types of information. It has clear learning objectives, and contains exercises and tips to guide you.

www.betterhealth.vic.gov.au

CONTACT

www.healthinsite.gov.au

Should you wish to know any more details or get your hands on a copy of the module, you can contact Jane London at the Royal Australian College of General Practitioners. It is also available on the GPCG website.

Jane London works in the Quality Care Unit of the RACGP.

DISCERN www.discern.co.uk Google www.google.com Health Insite

Health On The Net www.hon.ch Wikipedia www.wikipedia.com GPCG www.gpcg.org.au

1 - Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003 Apr;93(4):635-41.

RACGP

2 - Ostbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005 May-Jun;3(3):209-14.

www.racgp.org.au Jane London jane.london@racgp.org.au

Weekend 23 & 24 June 2007 Rosehill Racecourse, Sydney

Education Expo Everything Educational for Parents, Students and Teachers • • • • • • • • •

Schools of every type, pre-schools, colleges, universities Careers, TAFE, vocational training, tutors Courses for 50+ and U3A E Study skills, gap year, exchange programs FRE & Chess, intelligent toys and a robotics workshop ntr y g e Wellbeing for learning kin par Holidays with kids, outdoor education IT and software demonstrations Government agencies, community assistance, and much more . . .

PULSE + IT 17

Ph 02 6643 4643

www.edexpo.info

NEHTA

HEALTH LEVEL 7: THE NATIONAL STANDARDS FOR E-HEALTH MESSAGING IN AUSTRALIA Dr Ian Reinecke Scale The simple point-to-point messaging that occurs today is not capable of efficiently handling the future demands of e-health for large scale and complex information interactions.

NEHTA’s work will provide the foundation for secure electronic communications amongst healthcare providers by defining a set of messaging standards to be used in e-health.

These standards will allow for a flexible and dynamic approach to e-health interoperability, and can help ensure the evolution of an e-health environment that is sustainable and affordable.

Creating messaging standards does not mean that everything achieved to date needs to be turned off. It is vital, however, that the exchange of health information is conducted in an appropriately secure manner.

There are a number of current examples of information being transferred securely in the health sector. However, the current situation cannot meet the diverse and increasing demands of e-health. The reasons for this are outlined below.

Compatibility Currently, the e-health systems in use in different public health institutions are generally incompatible and unable to exchange health information safely.

Setting standards for secure electronic messaging is important to ensure safe information exchange across all systems.

Coherency A plethora of different approaches to messaging currently exists across the health sector, as each e-health vendor is able to choose or develop their own approach. This creates significant costs as a complex range of skills must be employed to maintain them.

18 PULSE + IT

Sustainability E-health technologies, like all technologies, must adapt to the emerging needs of e-health and the inevitable demands for existing services to be put to new uses, with minimal impact on users. Current information transfer approaches are generally designed for a specific purpose and therefore not all are readily adaptable to this complex set of ever-changing requirements.

Therefore, to ensure that all systems across Australia do have the ability to reliably and safely communicate with each other, a standard exchange format is required. That is why NEHTA has recently determined that this standard will be based on the HL7 family of standards.

This decision provides a clear national direction. Those who develop these systems now have certainty about what their Australian customers will require.

Without all systems in the healthcare sector using common standards such as this, the promise of electronic health communication can’t be fulfilled on a national scale.

To assist the health IT sector to migrate to this standard, NEHTA has identified the following approach: • Where HL7 version 2.x standards are already extensively used and yielding benefits, for example pathology and patient administration, these standards should continue to be supported.

Where HL7 standards are not in use, they should be factored into system upgrades where practicable.

• NEHTA will now focus on developing Web services specifications based on

work undertaken by the HL7 Services Specification Project (HSSP), and content specifications based on the HL7 Clinical Document Architecture – Release 2 (CDA R2) for areas such as referral, discharge, prescribing, dispensing and pathology.

• This work will then form the basis by which industry will migrate to HL7 version 3.

This approach ensures that migration occurs in a consistent manner, and in conformance with NEHTA’s requirements.

NEHTA will work closely with HL7 Australia and Standards Australia in this development work. In addition, we will be closely liaising with our international counterparts - such as the UK’s National Health Service and Canada’s Health Infoway - to ensure that the specifications developed in Australia are consistent with international efforts.

This direction is consistent with the endorsement of HL7 standards for use in Australia by the National Health Information Group in 2004. In the international community, the largest adopter of HL7 v3 standards is the Connecting for Health program run by the UK’s National Health Service; the UK, US and Canada have also adopted HL7 CDA specifications.

We will be releasing a report providing further details on this decision shortly.

Further information about HL7 standards can be found at the HL7 Australia website.

Dr Ian Reinecke is the CEO of the National E-Health Transition Authority (NEHTA).

NEHTA www.nehta.gov.au HL7 Australia www.hl7.org.au

AMA

CONNECT NOW Dr Mukesh Haikerwal MB ChB, Dip IMC RCS (Ed), DRCOG, FAMA

The AMA has maintained its strong support for the vital and high level work being undertaken to develop the building blocks for e-health in Australia, and particularly those that will contribute to the reality of a shared electronic health record. Connectivity, however, is the key and, I would argue, the priority. The environment, however, is one of variable uptake of information technology within the health sector for the secure transfer of health information and indeed basic communication.

Although there remain pockets of general practice that do not have the capacity to communicate and transfer information securely, GPs are generally well connected electronically and they consistently express frustration at the fact that there are few outside general practice with whom they can communicate securely. NonGP specialists (with the exception of pathology and radiology in particular) are behind the game in terms of electronic communication and there is significant variability across the hospital sector.

While we wait for the big issues to evolve and complex applications that are under development, it is my view that we can make important changes that will deliver significant improvements in connectivity now. Measures that will allow, encourage and perhaps even help drive basic but secure communication will in turn have an impact on culture change, an issue

20 PULSE + IT

increasingly being recognised as vital to the successful implementation of ehealth initiatives. It is relatively simple to deliver the means to get the profession/ sector talking to each other and doing so securely. The basic but everyday tasks of sending and receiving referrals and discharge summaries can occur securely if, for example, both ends have Public Key Infrastructure (PKI)1. While developing nationally standardised electronic discharge summaries and health records are important tasks, do we have to wait for these before we can start communicating? I don’t think we do.

We already have examples of hospitals that have developed electronic discharge summaries but are unable to send them securely because of the poor uptake of PKI within some areas of general practice. We know that GPs are frustrated at receiving specialist letters and reports by paper or fax and for those practices that are well set up electronically, this is a significant burden.

One practice I spoke to this week has 15 doctors, is very highly computerised but has to scan around 1,000 documents per week from hospitals and specialists. This is madness.

The speedy electronic transfer of discharge summaries has been a key demand from general practice for years.

Certainly we need to keep working on the quality of discharge summaries, but why can’t we get discharge summaries moving along the electronic highway now? Even if the quality of an electronic discharge summary leaves something to be desired the fact that an electronic version will be legible and can be transferred in a timely manner, rather than two weeks after the patient has left the hospital, represents a vast improvement on the current situation.

And the reality is, whether there is compliance with the quality standard for a discharge summary or referral is not a product of the technology itself.

Standards around the type and content of information that should be contained in a discharge summary or referral already exist, and should be complied with regardless of the means used to communicate. The standards and the need to comply with those standards do not change because of the means by which they are communicated.

Variable levels of compliance with the standards do not prevent paper-based communication so why should it prevent electronic communication?

We need to get the profession communicating electronically and securely now, and we must continue to promote the quality standards related to the content of information being transferred. We don’t need to wait for a national standardised shared electronic health record, referral or discharge summary to begin communicating.

In terms of promoting connectivity, at this point in time there needs to be less concern about what doctors, hospitals and pharmacists are communicating, and more focus on enabling them to communicate in a secure environment.

To quote Professor Michael Georgeff “… don’t spend time getting agreement on the data, don’t spend time ensuring all the systems conform – get connected”2.

While there is a focus on connectivity, the profession can continue to promote compliance with quality standards related to the information being supplied and, as they are agreed, implementation of electronic system standards.

If we can create a situation where doctors and hospitals are already communicating well, change management may not be as great a challenge as more complex applications are introduced. Importantly things like electronic prescribing can be taken up with relative ease if the profession already has the means and the experience to communicate securely.

Do we really want, for example, to

AMA spend the time and money developing an e-prescribing system only to realise at the 11th hour that the means for secure communication between doctors and pharmacists does not exist? Even stopgap proposals prior to development of a national e-prescribing system such as point-to-point electronic prescribing from GPs to pharmacists identified by an aged care facility, will require basic secure communication.

will ensure that all types of secure communication can begin now within the health sector.

There is little doubt that incentives need to be discussed, particularly with the non-GP specialist sector, and a concerted effort needs to be applied whereby practices of all types can be assisted where necessary to register for PKI.

The AMA strongly believes that Government must make connectivity among all health professionals and across all modes of practice one of its highest priorities and wants to work with the Minister for Health and Ageing and his department to develop measures aimed at pursuing this objective.

The AMA will continue to lobby Government to make a real push into the uptake of PKI and/or compliance with the PKI standard throughout the sector, but particularly with GPs, non GP specialists, hospitals and pharmacists.

Broad take up of the PKI standard

We can get connectivity happening now rather than waiting for, and depending on, complex applications to drive what is really quite basic communication. Doctors, non-GP specialists and hospitals could share vital patient information now with

Dr Mukesh Haikerwal, President of the Australian Medical Association, is a working GP in his busy practice in Melbourne. Dr Haikerwal was recently appointed by the Minister for Health and Ageing, Mr Tony Abbott, to the E-Health Ministerial Advisory Group.

1 - PKI has been adopted by the Australian Government to provide a robust system of security for online health transactions and is essentially a secure method of transmitting information electronically by providing both authentication and

the implementation of appropriate authentication and encryption systems.

Australian Centre For Health Research www.achr.com.au

encryption. Medicare Australia requires the use of PKI for all electronic data

National E-Health Transition Authority

interchange (EDI) and e-business solutions, while NEHTA recommends compliance

www.nehta.gov.au

with the standard for PKI systems used in the health industry.

2 - Georgeff, Professor Michael, “E-Health and the Transformation of Healthcare”, Australian Centre for Health Research Limited, April 2007 (page 9)

Australian Medical Association www.ama.com.au

Introducing HealthLink’s Partner Systems

A secure and reliable electronic communication system has to be fully integrated with its partner systems. HealthLink focuses on integration with its partner systems and works together with them to implement and test new communications services so they are easy to use and 100% reliable. By taking this approach HealthLink ensures that clinicians can concentrate on providing care for

patients rather than worrying about messaging.

HealthLink believes that compromising service quality is not acceptable in today’s healthcare environment.

Tel 1800 125 036 enquiries@healthlink.net

www.healthlink.net

PULSE + IT 21

INTERVIEW

INTERVIEW:

BEST PRACTICE Pulse+IT checks in with Dr Frank Pyefinch, Best Practice’s founder and lead programmer.

With Best Practice, I have tried to get back to the concept of a program that is focussed on the needs of practicing GPs. I still practice 12 hours per week myself and I think that this keeps me in touch with the issues facing GPs in daily practice.

• Live drug database updates are performed on the server only. No need to log users out of the system during the update.

• Flexible, intuitive prescription module.

• Full occupational history.

• Progress notes that include images. The images then stay in place within the notes when they are inserted into letters etc.

• Multiple reasons for visit can be recorded.

• Flexible Past History entry.

• The Autotext feature includes character formatting and bulletted/numbered lists.

• Percentile charts using Australian data.

• EPC module including 45-49yo Health Check.

• There is a single Inbox for incoming reports for each doctor with flexible notation of results and the ability to allocate incoming reports to either the Investigations section or the Correspondence In section.

• Reminder system including comprehensive management of previously sent reminders.

• Doctor’s To-Do list.

• Internal messaging system.

• Highly customisable user permissions.

• Patient records can be made confidential within the practice.

• A very flexible Search utility allows SQL queries to be run against the database.

This enables very complex searches and searches on criteria other than the supplied preset ones to be performed.

Some of the features of BP that are particularly worthy of mention include:

Pulse+IT: Which competing programs can you import data from?

• No advertising.

• No intrusive prompts.

• Comprehensive family and social history.

Currently we can only convert data from Medical Director 2. Later this year, we will be looking at some of the other packages and also at MD3.

Pulse+IT: What products does Best Practice have available to GPs and Specialists?

We currently have 2 products, Best Practice and Top Pocket. Best Practice is a Windows desktop application. It has two components, Clinical and Management. The basic application is Clinical and includes script writing, progress notes, pathology and radiology, correspondence etc. The Management module is an optional component that includes an appointment book, waiting room, billing and reporting features.

Together, they form a fully integrated practice management and clinical package.

Top Pocket is an application that runs on the Pocket PC type of PDA (Personal Digital Assistant). Patient data, including demographics, current medications, allergies and past history, can be transferred from Best Practice to Top Pocket for home or nursing home visits.

This can then be re-sychronised back into the Best Practice database.

Pulse+IT: What Best Practice features are new users attracted to?

22 PULSE + IT

Pulse+IT: How is the data conversion performed?

We install the conversion program into the Best Practice section of the Windows start menu. When it is run, it prompts for the location of the MD2 data to convert and then starts converting it. The MD2 data can be either in its normal DBF file format or in a zipped backup. No changes are made to the data during the conversion, but we do have to modify some of the indexes, so we do not recommend that the conversion is run on the practice’s live data. The size of the converted data is roughly the same as the size of the uncompressed MD2 data, so you need to ensure that you have enough free disk space before starting. The conversion takes approximately 40 minutes per 5000 active patients on a reasonably powerful computer. The largest sites we have converted have had over 130,000 patients.

Pulse+IT: In addition to your own practice management solution, do you allow other solutions to interface with your clinical product?

Yes. We recognise that many practices are happy with their existing PM system.

Ours is very new and may not yet have all the features that their current system has, so we are able to link BP Clinical with any other PM system that can share data via the “patients.in” file format. This includes most of the systems currently in the Australian market.

Pulse+IT: Which secure messaging products does Best Practice integrate with?

BP creates HL7 REF messages that can be interpreted by programs like Argus,

INTERVIEW HealthLink and Medical Objects. These programs can determine the addressee from the HL7 data and then encrypt it appropriately for transmission to the correct person.

Pulse+IT: How is training and support provided?

All support is via telephone or e-mail. We have an after hours roster of the support staff to ensure that someone is always available, particularly on weekends when most conversions are performed. Because our philosophy is to keep program and drug database updates separate, we do not have to rush out program updates to coincide with the date that the drug database changes take effect. This means that we can test program updates and release them when they have been thoroughly debugged. Consequently, we give the user a stable program and at the same time minimise our support load.

For training, we have a series of training DVDs that we provide free to our customers. BP includes a comprehensive help file and the CD contains an extensive series of FAQ documents explaining how to perform common tasks in BP. Pulse+IT: How many people make up the Best Practice team?

We are a small team, currently 9, but we have a lot of experience in developing and supporting medical software, with 7 of us having previously worked within the industry. There is no strict division of the staff into development/support/ documentation roles. We all contribute where necessary and I am on the after hours support roster myself. We do not have an automated telephone system, so support calls are answered by real people who can generally help immediately. Our ratio of staff to users is higher than that of our major competitors and that enables us to provide a better quality service.

Pulse+IT: Overview your pricing structure. $1100 per practice to purchase the application plus an ongoing annual fee that starts at $550/full time doctor/year.

The management module is an optional extra costing $275 per full time doctor/ year. We use a sliding scale and the annual fee reduces slightly as the number of users increases.

Part time users are generally charged half of the full time user fee (depending on the average hours worked per week).

Anyone interested should contact our sales desk by phone or email for an individual quote.

Pulse+IT: In addition to the Best Practice licences, what other costs may practices have to meet?

The vast majority of BP sites are using either MSDE or the newer SQL Express.

These range from small sites to very large practices (with 30+ doctors). Practices with very large databases may need to move to the full version of MS SQL Server, although at present, we have very few sites that have needed to do this. Most of the sites that are using full SQL Server had already purchased it as part of the MS Small Business Server package. There are no special OS or hardware requirements.

Obviously the hardware required will vary depending on the size of the practice.

Since the server processes all of the data in an SQL based system, it needs to have plenty of RAM and fast hard disk access. The workstations don’t need to be as powerful, and as a rule of thumb, a workstation that runs MD2 adequately will run BP as well, so practices changing from MD2 do not need to replace their workstations. There are more detailed hardware specifications on our website.

Pulse+IT: How frequently does Best Practice release drug updates?

We release drug updates to coincide with the PBS changes and these are currently being produced monthly.

They are available on our website for download. For practices with poor internet connections, we can supply the updates on CD. Our updates only need to be applied on the server and can be done live without needing to log anyone out of the program during the update.

Generally, the whole process can be performed in under 10 minutes and can easily be done by IT competent practice staff.

Pulse+IT: How frequently does Best Practice release program updates?

There is no set interval for our program updates. We supply them independently of our drug database updates. This means

that we can test them extensively before releasing them.

We aim to provide at least 2 program updates per year, but sometimes we may have to release a minor upgrade to incorporate a change required by Medicare e.g. the Streamlined Authority Sytem, or a change to the immunisation schedules.

The program updates are available both on the web and as a CD. Pulse+IT: Is professional IT assistance required to perform these updates?

Not if the practice staff are reasonably computer literate. Program updates need to be done on each computer. The installation program auto-loads from the CD and it is then a matter of following the prompts. Of course a backup should always be performed beforehand.

Pulse+IT: How many practices are currently running Best Practice?

Approximately 2000 users at 300 sites.

Pulse+IT: What new features are you working on that Best Practice users should look forward to?

Our current focus is on finishing the Online Claiming module. After that we intend to do some work on the clinical module, particularly the skin and Musculo-Skeletal sections. We also intend to enhance the management module further as we get feedback from the initial users.

We will also be incorporating the Streamlined Authority prescribing initiative that Medicare Australia are introducing from 1st July. This allows us to automatically populate the Authority approval number on the prescription, saving the doctor from having to ring for approval. This will apply to around 200 of the more commonly prescribed drugs that require authority prescriptions and I think it will be a major time saver for GPs. Pulse IT invites organisations and individuals interested in participating in a future interview to contact the editor.

Best Practice Software www.bpsoftware.com.au

PULSE + IT 23

COVER STORY

EASE INTO EASYCLAIM Simon James BIT, BComm

INTRODUCTION Announced by Prime Minister John Howard on the 13th of August 2006, Medicare Easyclaim (formerly known as Electronic Medicare Claiming) is a new patient payment system developed by Medicare Australia for Specialist and General Practice.

Set to be introduced in “the second half of 2007”, the system will utilise the EFTPOS network for the transmission of data from practices to Medicare Australia and participating financial institutions.

HOW DOES IT WORK? Medicare Easyclaim has been designed as a stand-alone system and doesn’t require practice software or a computer to operate. Instead, receptionists will use the practice’s EFTPOS terminal to process claims.

In its proposed form, there are three billing scenarios where Medicare Easyclaim can be used: Bulk Bill Claims Following the consultation: 1. The patients Medicare card is swiped through the EFTPOS terminal by the receptionist.

2. The item number/s, provider number and cost of the consultation are entered into the EFTPOS terminal by the receptionist.

3. The EFTPOS terminal sends a claim to Medicare Australia.

4. Medicare Australia sends back an approval message to the EFTPOS terminal.

5. The patient is then asked to press “OK” on the EFTPOS terminal to allocate the Medicare Australia payment to the doctor.

6. The EFTPOS terminal will print a receipt for patient.

24 PULSE + IT

This completes the transaction and no further information or paperwork needs to be provided to Medicare Australia.

Payment from Medicare Australia should arrive in the practice’s nominated bank account by the next business day.

Privately Billed Patients Where the account is paid following the consultation: 1. The practice presents the patient with an invoice.

2. The patient pays for the consultation with cash, cheque, debit card or credit card.

3. The receptionist then swipes the patient’s Medicare card through the EFTPOS terminal.

4. The item number/s, provider number and cost of the consultation are entered into the EFTPOS terminal by the receptionist.

5. The EFTPOS terminal sends a claim to Medicare Australia.

6. Medicare Australia sends back an approval message to the EFTPOS terminal.

7. The patient’s debit card is swiped through the EFTPOS terminal.

8. The patient enters their pin number and specifies whether they would prefer the money to be paid into their savings or cheque account.

9. The EFTPOS terminal prints a receipt and the money is transferred into the patient’s bank account.

Unpaid Accounts For unpaid accounts, the following procedures will apply: 1. The patients Medicare card is swiped.

2. The item number/s, provider number and cost of the consultation are entered into the EFTPOS terminal by the receptionist.

3. The EFTPOS terminal sends a claim to

Medicare Australia.

4. A cheque is sent from Medicare Australia to the patient who then brings it back to the practice.

BENEFITS The benefits of the Easyclaim system as purported by Medicare Australia are: • Other than the patient’s receipt, there is no paperwork generated with bulk bill claims.

• Payment for bulk bill services will usually arrive on the next working day.

• Concession entitlements for bulk bill claims are verified in real time.

• Via the EFTPOS terminal, practices can request ‘pay doctor via claimant’ cheques for unpaid accounts, providing greater certainty the claim has been made.

• Participating practices will be providing a service that 84% of patients who “usually pay” for medical services say they want.

EASYCLAIM Q&A As with any new system, there is the potential for confusion amongst practices as they adopt Medicare Easyclaim. To assist practices to better understand the new Medicare initiative, the rest of this article is devoted to answering a number of questions that have been raised since Medicare Easyclaim was first proposed.

Why is Easyclaim being introduced?

Medicare Australia has stated that Easyclaim is designed to provide greater convenience to patients and doctors than existing systems currently provide.

According to Medicare Australia, up to 80,000 people per day visit a Medicare office to claim their rebate. Medicare Easyclaim promises to make their lives simpler, especially if they are currently

COVER STORY attending a practice that doesn’t use the private patient claiming features of Medicare Online Claiming.

Bank and Tyro (formerly Money Switch) have signed contracts with Medicare Australia .

Which peak bodies did Medicare Australia consult with during the development of Easyclaim?

The AMA originally proposed an EFTPOSbased system around three years ago and has been working with the relevant Ministers and the Department of Human Services throughout the development of Easyclaim. In addition, the AMA has had onging consultation with various financial institutions during the development of their product offerings.

The Commonwealth Bank have badged their Easyclaim solution as “MediClear” and have included information about their services on their website.

How much will Easyclaim cost?

There is no direct cost levied on practices for transactions processed using the new system.

How Easyclaim will affect overall practice efficiency remains to be seen.

It is likely that indirect additional costs or cost reductions will vary widely and be largely dependent on the current billing arrangements of practices.

Financial institutions are paid 23 cents per transaction by Medicare Australia, one aspect of the system that has caused some consternation amongst practice software developers and proponents of gap billing.

Which banks are signed up to provide Easyclaim services?

At the time of writing, the Commonwealth Bank, National Australia

Who and what is Tyro?

Tyro is a relatively new financial institiution, specialising in payment solutions for merchants (including practices). Tyro operates under a recently created financial licence, specialising in electronic payment related services (i.e. credit, debit and EFTPOS transaction factilities).

What options are available to my practice if our EFTPOS supplier doesn’t offer Easyclaim functionality?

In the first instance, Practices are advised to contact their financial institution and ask whether they have plans to become a Medicare Easyclaim certified partner.

Practices should also speak to their practice software developer to discern whether they have plans to integrate with any financial institutions, and if so, which one/s.

If it becomes apparent that your EFTPOS provider has no plans to facilitate Easyclaim transactions, your practice will have to decide whether to change financial institutions, or persist with your existing arrangements.

Is the Easyclaim system secure?

All information transmitted via the EFTPOS terminal is encrypted, and financial institutions are not permitted to store any sensitive information.

Information that is stored includes a transaction identification number, the date and time of the transaction and the rebated amount paid into the patient’s account.

Prior to being certified to offer Easyclaim services, participating financial institutions need to complete an accreditation process with Medicare Australia.

This accreditation process includes a comprehensive security audit conducted by Defence Signals Directorate approved assessors to ensure that messages are carried and handled securely and in accordance with Government policy.

Will patients require a new Medicare card?

No, Medicare Easyclaim operates using existing Medicare cards. When the Access Card is released, financial institutions need to provide EFTPOS terminals capable of handling the advanced security features of the proposed card.

What if the patient forgets their Medicare card, or the EFTPOS terminal or magnetic strip on the card is faulty?

In the event that a Medicare card cannot be swiped, reception staff

PULSE + IT 25

COVER STORY are able to manually enter Medicare numbers into the EFTPOS terminal.

practice’s EFTPOS terminal is capable of performing Easyclaim transactions.

What happens if incorrect information is entered into the EFTPOS terminal?

If an error occurs when a privately billed patient’s claim is being processed, the claim can be cancelled before the patient’s debit card is swiped and the transaction re-done.

In addition, Medicare Australia plans to work with the relevant professional bodies to keep practices informed, and has already conducted Easyclaim forums with several state branches of the AMA.

For more information about integrated Easyclaim solutions, refer to “Easyclaim Integration” on pp28 of this edition of Pulse+IT.

Kathryn Conroy, the Media Officer for the Australian General Practice Network (AGPN), indicated that the 119 divisions of general practice have the capability to work closely with Medicare Australia to assist general practices to become familiar with the new system.

To speed things up for bulk billed transactions, am I allowed to press “OK” to complete the procedure on the patient’s behalf?

As outlined at the start of this article, having reviewed the claim information on the EFTPOS terminal screen, the patient is required to press “OK” to assign their benefit to the doctor.

If the error occurs after a bulk bill claim is submitted, the practice would need to contact Medicare Australia to fix the error using the dedicated practitioner help desk line.

Will this replace Online Claiming (formerly HIC Online)?

No. All Online Claiming services are going to be maintained, and practices are free to use Easyclaim concurrently with Online Claiming if they wish.

What about Department of Veterans Affairs (DVA) claims?

DVA claims cannot be transmitted using Medicare Easyclaim. According to Medicare Australia, the additional information required by DVA could not be efficiently entered into an EFTPOS terminal. Practices will continue to process DVA claims using existing lodgment methods.

Are there any mobile billing solutions available to practitioners?

All financial institutions presently signed up to deliver Easyclaim services have mobile EFTPOS terminals, however none have publicaly stated whether these devices will be compatible with Easyclaim.

Practices should contact their bank and enquire about the possibility of obtaining a mobile EFTPOS terminal suitable for Easyclaim transactions.

How will training be provided?

Given the repetitive nature of patient billing and the limited number of Easyclaim “compatible” scenarios, it shouldn’t take staff long to get up to speed on the new system. Like any new system however, there will be a learning curve for practice staff.

Medicare Australia has indicated that participating financial institutions will provide training materials and ensure the

26 PULSE + IT

Ms Conroy went on to say that, “Should there be any gaps in training, general practice Medicare representatives may be able to attend Division Network GP education evenings. Representatives would be able to demonstrate how the system works. Such evenings have the potential to include live demonstrations and Q&A sessions.”

How will patients be informed about Easyclaim?

A patient centric education campaign is scheduled to commence in mid August this year. Practices will also be provided with resources to pass on to patients who request information about the Easyclaim system.

Medicare Australia are promoting the fact that Easyclaim is a standalone system as a benefit, but won’t this result in double entry?

While EFTPOS keypad shortcuts will streamline the process somewhat, until practice software vendors release versions of their programs that integrate with EFTPOS terminals, double entry will be a reality for practices who adopt Medicare Easyclaim.

Fortunately, some financial institutions and practice software vendors have been collaborating to develop integrated solutions, which should streamline the process of using the Easyclaim system significantly.

At the time of writing, it is unclear which financial institutions and practice software vendors will collaborate on integrated Easyclaim solutions. Because of this uncertainty, practices are strongly

advised to avoid entering into long term EFTPOS contracts which may limit their options in the future.

Patients will be informed of this legislative requirement. If a practice is found to not follow the prescribed procedure, Medicare Australia will take steps to investigate.

How will practices reconcile Easyclaim transactions given that the EFTPOS terminal only produces receipts for the patient?

Medicare Australia is currently developing a daily report that will allow practices to reconcile the payments they receive against the claims made.

This report will be made available to practices via a secure website.

Presumably once integrated solutions are released, similar fuctionality will be replicated within the practice software.

Simon James is the editor of Pulse+IT.

Australian General Practice Network www.agpn.com.au Australian Medical Association www.ama.com.au Commonwealth Bank - MediClear www.commbank.com.au/mediclear Medicare Australia - Easyclaim http://tinyurl.com/3exmmf National Australia Bank www.nab.com.au Tyro (formerly MoneySwitch) www.tyro.com

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FEATURES

EASYCLAIM INTEGRATION Simon James BIT, BComm

INTRODUCTION Starting from the day it was announced, Medicare Easyclaim’s supposed lack of integration with practice software has been cited as one of the system’s major deficiencies. And whilst it is true that Medicare Australia have developed Easyclaim as a system that can be used independently of practice software, the expectation has always been that software developers would interface with the solution at some point in the future.

Since Medicare Easyclaim’s inception, the AMA claims to have consistently advised financial institutions that the solutions that will be most attractive to practices will be those that deliver tight integration with practice software. At the most recent AMA Council of General Practice (AMACGP), meeting members unanimously passed the following resolution: “That AMACGP note that the new improved Medicare electronic claiming and payment system can be adopted as a stand-alone or practice software integrated system and urges general practices to consider moving to an integrated system as soon as it becomes available.”

10 years. Founded as “MoneySwitch” in 2003, the company operates under a special financial license that allows it to provide credit, debit and EFTPOS merchant services.

Following the partnership announcement, representatives from HCN and Tyro demonstrated an Easyclaim-Blue Chip prototype to senior Medicare Australia staff, including CEO Catherine Argall and Deputy CEO Rona Mellor.

HCN’s CEO, John Frost, stressed the importance of integrated solutions, stating that his company is also developing a version of PracSoft that can interface with Medicare Easyclaim, through Tyro.

“The development of integrated EFTPOS and Easyclaiming is progressing very well. We are encouraged by Medicare’s willingness to work with us to streamline the integrated claiming process as we believe good integration with PracSoft and Blue Chip is critical to the success of Easyclaiming. The prototype is an important step to demonstrate the solution to receive user feedback,” said Mr Frost.

SO WHO’S INTEGRATING?

HOW WILL INTEGRATED SOLUTIONS WORK?

On the 26th April, Tyro announced that it has been working with the Health Communication Network (HCN) to develop an integrated Medicare Easyclaim solution.

With Medicare Easyclaim yet to be launched in any form, it is not surprising that there is almost no publicly available information detailing what an integrated solution will look like.

HCN is Australia’s market leading practice software developer, with over 3,700 GP and Specialist practices using either PracSoft or Blue Chip.

John Frost indicated that “The driving force behind integrated EFTPOS and Easyclaiming is to streamline the payment and claiming workflow. This means, firstly, operating it from PracSoft and Blue Chip as a natural part of the payments workflow rather than from

Tyro is the first new entrant to the Australian EFTPOS services market in

28 PULSE + IT

the EFTPOS terminal; secondly, no time wasting and error prone duplicate data entry; and finally, a minimum of manual steps like card swipes. Users of the integrated solution will see big benefits in faster Medicare payments with no paperwork, streamlined patient payments when they pay with a card, and an ability to easily provide the customer service benefit of ‘paid patient’ rebates from Medicare.”

Estimated release dates for Easyclaim enabled versions of PracSoft and Blue Chip have not yet been announced.

Jost Stollmann, Tyro’s CEO, indicated that while his company is currently focusing on integration with HCN’s practice management solutions, Tyro will pursue other collaborations once HCN’s Easyclaim-enabled products are released to the market.

“I think that medical practitioners and their staff want to look after their patients. They are neither technology wizards nor government clerks. A truly easy claim means zero configuration hassles, therefore a low support requirement and zero data re-entry. We will deliver this, because our terminal works like a PC talking to the PMS [Practice Management Software] PC. It is all seamless and integrated. You do not need much to Google, so you do not need much to claim. We use new world technology,” Mr Stollmann said.

Developed by BankSys, Tyro’s EFTPOS terminals appear outwardly similar to traditional devices. There are two technical factors however, that make the devices especially conducive to practice software integration: 1. Tyro’s EFTPOS terminals are essentially self-contained computers driven

FEATURES by the open source Linux operating system.

2. Unlike traditional EFTPOS terminals, Tyro’s devices communicate via the Internet and don’t require a telephone connection.

Wireless connection options are available, however typically a practice would connect a Tyro EFTPOS terminal to their practice network via an Ethernet connection. Once physically connected to the network, the device is able to automatically detect the practices Internet connection (via DHCP), and transactions can be performed immediately.

Speaking about the virtues of Medicare Easyclaim and his companies offering more generally, Garry Duursma, Tyro’s Vice President of Sales and Marketing stated, “Medicare Easyclaim is a good opportunity to migrate into the new world. The Tyro solution is fast, economical and secure. It integrates the billing, payment, claiming, and reconciliation into one seamless process, without re-keying of data.”

“I’m confident that we will deliver what medical professionals really need and want. I only hope that practices do not

get locked into a stand alone solution before witnessing the ease of use that we deliver,” concluded Mr Duursma.

WHAT ABOUT THE BANKS? Other than Tyro, the only financial institutions signed up to deliver Medicare Easyclaim services are the Commonwealth Bank (CBA) and the National Australia Bank (NAB). It is expected that other financial institutions will purse Easyclaim, and Medicare Australia is not aware of any banks that have ruled out providing the service in the future.

Neither CBA or NAB have publicly announced plans to allow practice software vendors to integrate, however it isn’t unrealistic to expect that both banks will facilitate Medicare Easyclaim integration in the future.

INTEGRATION CHALLENGES Software vendors will face several obstacles when (and if) they attempt to integrate their solutions with Medicare Easyclaim: 1. Unlike the banks, practice software developers are unlikely to be paid per transaction fees or any other financial incentive by Medicare Australia.

Below - An EasyClaim window from a pre-release version of HCN’s Blue Chip package. In the bottom half of the window, the blue text indicates the current instruction, while grey text indicates tasks that have already been completed.

2. While integration programming is likely to be relatively straight forward, practice software vendors may need to develop multiple interfaces (as many as one for each bank). As such, practice software vendors will need to expend significant resources if they wish to integrate with multiple banks.

3. In the early stages, many software developers (and perhaps even some financial institutions) may find themselves temporarily locked out of discussions as “first mover” parnerships emerge.

CONCLUSION Pulse+IT has witnessed concrete evidence that integration is both possible and well underway.

Despite the criticism leveled against the “double entry” aspect of Easyclaim, the development of the system by Medicare Australia as a stand-alone solution is welcome.

While a stand-alone solution may not be well received by practice staff, this is an important “feature” of the Medicare Easyclaim system, which will ensure uptake occurs at a significantly faster rate than Online Claiming (formerly HIC Online).

While stand-alone Easyclaim adoption may be relatively painless, practices may find that they need to switch EFTPOS providers, or practice software vendors to achieve an integrated solution.

Simon James is the editor of Pulse+IT. BankSys www.banksys.com Commonwealth Bank - MediClear www.commbank.com.au/mediclear Health Communication Network www.hcn.com.au Medicare Australia - EasyClaim http://tinyurl.com/3exmmf National Australia Bank www.nab.com.au Tyro (formerly MoneySwitch) www.tyro.com

PULSE + IT 29

FEATURES

SECURE ELECTRONIC MESSAGING WITH HEALTHLINK Simon James BIT, BComm

INTRODUCTION

IT TAKES THREE TO TANGO

As highlighted in the last edition of Pulse+IT (February 2007, pp29), secure electronic communication has enormous potential in the health sector. There are many reasons that this potential has not yet been realised, however the purpose of this article is not to examine these issues.

In the context of Specialist and General Practice, there are typically three software applications used to perform secure electronic messaging:

Instead, this article is designed to demonstrate a working secure messaging scenario involving software technology that is available now!

Clinical Software For the purpose of this article, we selected Genie and Mercury as the two clinical packages to send messages between.

Fortunately, the example presented in this report isn’t an isolated one, however it is not feasible to deal with all or even several of these examples within the space constraints of one article.

Given this fact, this article will be the first in a perpetual series designed to highlight practical examples of how secure messaging can be used effectively by both Specialist and General Practices.

This article consists of three sections: 1. A brief outline of the software referenced in the article.

2. An overview of the installation and configuration procedures required to prepare the software for the demonstration.

3. A demonstration of one possible use of the combined software solution.

Given this broad scope, some of the technical explanations in this article are dealt with less comprehensively than others. Where further explanation is required, the vendors mentioned in this article will be happy to assist practices to apply the information presented to their own situation.

30 PULSE + IT

1. The sender’s clinical software.

2. The messaging software.

3. The recipient’s clinical software.

Other clinical packages will be the subject of future demonstrations, however these two products deserve early recognition because of their proactive approach to secure electronic communication.

Messaging Solution HealthLink was the secure messaging solution selected to transport the messages between the two aforementioned clinical packages. As it is compatible with both the Macintosh and Windows platform, the use of HealthLink software has not only allowed the demonstration to span different clinical software packages, but also different operating systems.

As is the case in the clinical software market, there are several vendors competing for attention in the health sector; these solutions will be recognised in future articles in this series.

THE SOFTWARE Genie Developed by Genie Solutions, Genie is a fully integrated clinical, appointments and billing system. It was originally written for the Macintosh platform,

however has long been capable of running on Windows also. Genie Solutions now boasts 900 sites, and continues to grow at an impressive rate.

While Genie performs well in both GP and Specialist practice deployments, for the purposes of the demonstration it will be installed at the general practice.

Mercury Developed by MedTech Global, Mercury is a relatively new clinical package designed primarily for the Specialist market. On the surface, Mercury resembles an email program.

Unlike traditional email clients however, Mercury natively sends HL7 messages.

The program can also send XML messages, optionally with attachments.

Having recently acquired Australian Healthcare Technology Limited, Medtech Global now claims to be the “second largest provider to the Australian healthcare professionals”.

Mercury will act as the Specialist clinical system for the purpose of this demonstration.

HealthLink Hailing from New Zealand, HealthLink has been providing secure messaging solutions to Australian healthcare organisations for many years. The company has a large number of GP and Specialist sites using the software, most for the purposes of downloading pathology and radiology results.

In addition to these relatively simple tasks, Healthlink’s software can be used to send and receive other types of health correspondence, including referrals, specialist reports and discharge summaries.

FEATURES SETUP Following are the steps that need to be performed before Genie and Mercury can be used to send and receive correspondence via HealthLink.

1. Register with HealthLink.

2. Update the clinical software.

3. Install the HealthLink software.

4. Configure the clinical software to interface with HealthLink.

5. Configure HealthLink to interface with the clinical software.

6. Update your clinical software address book.

7. Inform your colleagues that you are able to send/receive correspondence via HealthLink.

These steps are outlined in more detail below. While these instructions are specific to Genie and Mercury, practices using other clinical software should be able to apply significant parts of the information presented to their own circumstances.

1. Register With HealthLink To order a HealthLink software installation pack, practices need to visit the HealthLink website and complete a short application form. This application form can be found here: http://www.healthlink.net/apply/au.htm The practice should receive this installation pack within a week. Along with a CD containing the HealthLink

software, printed installation guides are included that detail all aspects of the HealthLink setup.

A disk containing the digital certificates used to encrypt your messages is also included in the package.

2. Update Your Clinical Software While Genie has long integrated with HealthLink and other secure messaging solutions, recent updates have significantly improved the way the program handles electronic correspondence. As such, it is recommended that all Genie users interested in secure messaging update to the latest version of Genie via its builtin software update mechanism.

Mercury users should also ensure they are running the latest version.

3. Install HealthLink Practices running Genie in a client-server environment are advised to install the HealthLink software on a reception or administration client computer, i.e. NOT the computer running Genie Server.

All Genie computers on the network communicate with HealthLink “through” Genie via the network (i.e. folder paths do not need to be mapped).

To minimise complexity, the computer hosting the practices pathology and downloading programs could be used.

Practices running Genie on a single computer (i.e. Genie Solo) obviously

need to install the HealthLink software on the computer running Genie.

Mercury users can install the HealthLink software on any computer connected to the practice network.

The HealthLink software installation procedure is straightforward and well documented by the manuals included in the installation pack.

4A. Configure Genie To Use HealthLink To let Genie “know about” the HealthLink installation, you need to: 1. Create a “Healthlink” folder inside the “Genie“ folder on the computer that now contains the HealthLink software.

2. Create “Incoming” and “Outgoing” folders within this “Healthlink” folder (see Figure 1).

3. Start Genie if it isn’t already running, then select “Practice Preferences”, which is found under the “File” menu.

4. Select your practice from the list (usually there will only be one), then click on the “Carrier Identifiers” tab at the top right of the window.

5. Enter your “HealthLink EDI” into the appropriate field on this screen. This unique identifier will be included with your installation pack.

6. Click “Save”, close any open windows then quit Genie.

4B. Configure Mercury to Use HealthLink Mercury comes pre-configured with the necessary HealthLink folder paths

Left - The directory structure used by Genie to send and receive secure electronic correspondence via HealthLink. The “Errors” directory is created by Genie automatically. The complete file paths are Mac: /Applications/Genie/HealthLink, Windows: C:\Genie\HealthLink Below - The Mercury settings panel, showing the default (and correct) HealthLink file path entries.

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FEATURES

3

(assuming HeathLink is installed on the same computer as Mercury). These settings can be reviewed or modified by selecting “Settings” from the “File” menu (see Figure 2).

Once the folder paths are confirmed as accurate, clinicians will need to enter their unique EDI into their own Mercury address book record.

5A. Configure HealthLink To Use Genie HealthLink needs to know where to place incoming correspondence and where to look for outgoing messages.

As you may have guessed, these folders are the ones we created inside the Genie folder in step 4A. To “point” HealthLink at these folders:

Above - The “Advanced HealthLink Options” program showing the RSDAU message type selected.

RSDAU is HealthLink’s term for HL7 messages used for Referals, Summaries & Discharges in Australia.

Below - The “Message Directories” screen in the “Advanced HealthLink Options” program, showing the correct settings required to integrate HealthLink with Genie on a Macintosh.

Bottom - The “Message Directories” screen in the “Advanced HealthLink Options” program showing the correct settings required to integrate HealthLink with Genie on a computer running Microsoft Windows.

4

1. Ensure that there are no HealthLink programs or services running.

2. Start the “HMS Advanced Options” program. This can be found in the following locations: Microsoft Windows: C:\Program Files\HealthLink SIX Client Software\HMS Advance Options.exe Apple Macintosh: /Applications/HealthLink/HealthLink SIX Client Software/HMS Advance Options.app 3. From the “Configuration” menu, select “User Settings”.

4. Click the “Message Types” tab.

5. Select “RSDAU” from the list on the right hand side of the window. You may need to scroll to the bottom of the list to find this entry.

6. Click the “Directories” tab. Your screen should now look like Figure 3.

5

Below - Dr Edwina Hutton’s Genie address book entry for Dr Tim Bettington, a specialist who uses Mercury for his records keeping and HealthLink for his secure electronic correspondence. Note that Dr Bettington’s fictional HealthLink EDI is “randwic1”.

6 32 PULSE + IT

FEATURES 7. Click the “Edit/More” button located at the bottom right hand side of the window.

8. The “Message Directories” window will appear. Update the file paths to reflect the settings shown in Figure 4 (Mac) or Figure 5 (Windows).

7. Click the “Close” button located at the bottom right hand side of the window.

8. From the “File” menu, select “Save All”.

9. From the “File menu”, select “Exit”.

7

8

5B. Configure HealthLink To Use Mercury As Mercury uses HealthLink’s default message repository (i.e. the “HLINK” folder), no further configuration is required.

6. Update Your Address Book Having taken the time to install and configure HealthLink, you will now need to find out which practices you can communicate with, and collect their EDI’s.

Both Genie and Mercury have integrated EDI search features that allow practices using these packages to search for other HealthLink users and automatically import their EDIs into their contact address book.

Mercury’s built-in EDI search function is located at the bottom right of the address book demographics window.

Genie’s EDI search function can be accessed by clicking the “Web Search” button at the top of the address book screen.

7. Contact Your Colleagues Regardless of whether the colleagues that you wish to correspond with are already using HealthLink, it is a good idea to let them know about your plans to commence secure electronic communication with them.

DEMONSTRATION Having outlined the process involved with installing and configuring HealthLink for use with both Genie and Mercury, this section of the article will demonstrate how this combination of products can be used to communicate in a typical, real-world scenario.

Meet The Doctors Dr Edwina Hutton is a GP from Clovelly.

Top - The top right hand corner of Genie’s letter writer. The “Prefers” field is automatically populated with the recipients prefered method of communication, retrieved from the address book. After the letter has been completed and the “Send via 3rd party” checkbox ticked, the “Save” button is used to send the electronic correspondence to the appropriate folder for HealthLinks to collect and send.

Above - The top left hand corner of Genie’s letter writer. The options selected are those required to send the letter via Healthlink.

Dr Hutton’s practice runs Genie on Macintosh computers. Dr Tim Bettington is a Neurologist from Randwick. Dr Bettington runs Mercury on a laptop running Windows XP. Both practices have HealthLink installed and configured correctly, and correspond using the solution regularly.

The Scenario For the purposes of this demonstration, the following “patient flow” scenario has been constructed: Louise Joseph bumps her head on the steps at the Clovelly beach. With the assistance of her mother, she presents at her usual general practice, and is attended to by Dr Hutton. Louise is subsequently referred on to Dr Bettington. Dr Bettington gives Louise the “all clear”, and sends a report back to Dr Hutton.

The electronic communication interactions relating to Dr Hutton’s referral message to Dr Bettington are outlined in detail below:

addresses it to Dr Bettington and writes her referral. As shown in Figure 7, HealthLink is displayed as the preferred correspondence method. This information is populated automatically, using information retrieved from Dr Bettington’s address book entry.

Dr Hutton then ticks the “Send via 3rd party” checkbox located near the top left of Genie’s letter writer. As Genie knows HealthLink is Dr Bettington’s prefered communication method, the list of 3rd party communication options defaults to HealthLink (see Figure 8).

A dialogue box appears, asking Dr Hutton to specify the message priority (i.e. Routine/Critical/ASAP) and classify the letter (see Figure 9).

Below - A section of the HL7 message classification window, showing the available priority options.

9

1. Sending The Referral Letter Dr Hutton opens Genie’s letter writer,

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FEATURES

10

Dr Hutton then clicks “Save” (Figure 7) to close Genie’s letter writer. This action stores the referral letter within Genie’s database, and within 60 seconds, a HL7 file will be dropped into Genie’s outgoing HealthLink folder (see Figure 10): /Applications/Genie/HealthLink/Outgoing On a predefined schedule (or when triggered manually), the HealthLink software picks up this message, encrypts it, and sends it to HealthLink’s servers.

Time passes...

Receiving The Referral Letter The next time Dr Bettington’s HealthLink installation is run (typically on a schedule every hour), the letter sent by Dr Hutton will be downloaded from the HealthLink servers. Once the letter is received and decrypted, it is deposited into the following folder (see Figure 11): C:\HLINK\HL7_in\RSDAU

11

Importing The Referral Letter Into Mercury Dr Bettington uses Mercury to check for new incoming messages periodically, by selecting “Check for new messages” from the “File” menu.

After importing the letter, a dialogue will appear, indicating that the letter for Dr Hutton has arrived. The letter can then be read in much the same way as an incoming message in a typical email client (see Figure 15).

Sending the ACK Once the letter is imported, Mercury creates an acknowledgement message (ACK) and deposits this into the following directory (see Figure 12): C:\HLINK\HL7_out\RSDAU The next time the HealthLink software runs at Dr Bettington’s, this ACK is encrypted and sent to the HealthLink servers.

12

Receiving The ACK The next time the HealthLink software runs at Dr Hutton’s practice, the ACK is downloaded from the HealthLink servers and deposited into the following directory (see Figure 13): /Applications/Genie/Healthlink/Incoming

13

Above - (10) Dr Hutton’s outgoing referral letter in HL7 format. The message is awaiting encryption and transport via HealthLink. (11) Dr Hutton’s referral letter, ready to be imported by Mercury on Dr Bettington’s computer. (12) The HL7 ACK on Dr Bettington’s computer, ready to be encrypted and transported to Dr Hutton. (13) The decrypted HL7 ACK, waiting to be imported by Genie on Dr Hutton’s computer.

34 PULSE + IT

Within 60 seconds, Genie imports this ACK and reconciles it against the original referral letter. As shown in Figure 14, the original letter in Genie has been marked as “Delivery Acknowledged”, indicating to Dr Hutton that her referral has been imported into Mercury by Dr Bettington.

Genie also maintains a log of all electronic correspondence, both incoming and outgoing. This feature allows practitioners to easily audit the status of their sent messages, without having to open each letter individually.

FEATURES

14

15

Top - The original referral letter displayed in Genie after the ACK knowledgment has been received. At the top of this window, Genie indicates that the letter has been sent (“Sent” checkbox), and importantly, that it has arrived at its intended destination (“Delivery Acknowledged” checkbox).

Above - Dr Edwina Hutton’s referral letter displayed in Mercury, Neurologist Dr Tim Bettington’s clinical software.

PULSE + IT 35

FEATURES

DR HUTTON’S GENERAL PRACTICE Genie Database

“HealthLink” Folder

HealthLink Software

HEALTHLINK

DR BETTINGTON’S NEUROLOGY PRACTICE

HealthLink Servers

HealthLink Software

“HLINK” Folder

Mercury Database

Genie Letter

60 seconds

HL7 Referral

HL Schedule

HL7 Referral

< 5 seconds

Secure HL7 Referral

HL Schedule

Secure HL7 Referral

< 5 seconds

HL7 Referral

< 5 seconds

“F9”

Mercury Letter

HL7 ACK

HL7 ACK

HL7 ACK

Secure HL7 ACK

Secure HL7 ACK

Genie Letter HL7 ACK

HL7 ACK

< 5 seconds

HL Schedule

< 5 seconds

HL Schedule

< 5 seconds

60 seconds

Above - This diagram outlines the journey of Dr Edwina Hutton’s referral letter to Dr Tim Bettington. The HL7 acknowledgment’s (ACK) return journey is also shown. Note that after the letter is saved in Genie, the only human interaction required in the entire process is a single keyboard stroke (F9) to import the letter into Mercury. All other steps displayed in the diagram are triggered automatically by the relevant program’s scheduling mechanisms.

36 PULSE + IT

FEATURES WHAT ABOUT THE SPECIALIST REPORT? Because of space constraints, the journey of Dr Tim Bettington’s report back to Dr Edwina Hutton cannot be demonstrated in the same level of detail as the original referral message. This scenario however, has been detailed in an extended version of this article available via the Pulse+IT website. It has also been summarised below: 1. Dr Bettington constructs a report to Dr Hutton, which when sent via Mercury, is deposited into the outgoing “HLINK” folder.

2. The next time the HealthLink software is run at Dr Bettington’s practice, the report is encrypted and transported to the HealthLink servers.

3. The next time the HealthLink software is run at Dr Hutton’s practice, the report is downloaded from the HealthLink server, unencrypted and deposited into Genie’s “Incoming HealthLink” folder.

4. Within 60 seconds, Genie will import the message, and generate a “Genie Task” for Dr Hutton to flag the arrival of the message.

5. An ACK will be deposited into Genie’s “Outgoing HealthLink” folder, and sent to HealthLink’s servers the next time the HealthLink software is run at Dr Hutton’s practice.

6. The next time the HealthLink software is run at Dr Bettington’s practice, the ACK will be downloaded into the incoming “HLINK” folder and imported into Mercury when Dr Bettington next checks for incoming messages.

COST

clinical software packages capable of sending and receiving HL7 messages.

Unfortunately, because Medical Director (MD) cannot presently generate HL7 referral messages, the vast majority of general practices will not be able to send electronic referrals via HealthLink.

Fortunately however, like the other clinical packages listed, MD users can receive and import HL7 messages.

Under HealthLink’s pricing model, the sending party bears the cost of the message transmission (i.e. there is no cost involved with receiving messages).

There are many pricing options available to larger health organisations (e.g. pathology labs, radiology and hospitals), however GPs and Specialists are charged a flat rate per month as follows: GPs: $20 + GST per month Specialists: $30 + GST per month

Importantly, all of the packages listed in the Table 1 have the capacity to send acknowledgement messages (ACKs) on receipt of a properly constructed incoming message.

There is no cost levied for the HealthLink software or help desk assistance.

As you would expect, nether Genie Solutions or MedTech charge their users to transport secure messages via HealthLink or other secure messaging providers.

As outlined in the demonstration and detailed in the diagram on the facing page, these ACKs are an essential part of a properly implemented secure messaging solution, and provide the necessary assurance that the original message has not only been sent, but also received by the intended recipient.

CONCLUSION This article has outlined the steps involved with configuring Genie and Mercury to use HealthLink to send and receive secure electronic correspondence.

Simon James is the editor of Pulse+IT.

Genie Solutions www.geniesolutions.com.au

While the detailed demonstration contained in this article dealt exclusively with a GP to specialist referral, other types of correspondence can be sent and received using HealthLink, including pathology and radiology results, specialist reports and discharge summaries.

HealthLink www.healthlink.net MedTech Global www.medtechglobal.com Pulse+IT (Extended article available) www.pulsemagazine.com.au

Other Clinical Software?

As Table 1 indicates, there are several

Table 1 - A selection of the clinical software that can interface with HealthLink. (Reproduced with permission from HealthLink).

Product

Company

Website

Send

Receive

Receive an ACK

Send an ACK

Best Practice

Best Practice

www.bpsoftware.com.au

Y

Y

Y

Y

Incisive

Incisive

www.incisive.com.au

Y

Y

Y

Y

Genie

Genie Solutions

www.geniesolutions.com.au

Y

Y

Y

Y

Medical Director 2

HCN

www.hcn.com.au

N

Y

N

Y

Medical Director 3.6

HCN

www.hcn.com.au

N

Y

N

Y

MedTech32

MedTech Global

www.medtechglobal.com

Y

Y

Y

Y

Mercury

MedTech Global

www.medtechglobal.com

Y

Y

Y

Y

Practix

IBA

www.ibahealth.com

Y

Y

Y

Y

Profile

IntraHealth

www.intrahealth.com

Y

Y

Y

Y

VIP

Houston Medical

www.houstonm.com

Y

Y

Y

Y

PULSE + IT 37

FEATURES

NEXT G WIRELESS BROADBAND Simon James BIT, BComm

INTRODUCTION Having used an EV-DO mobile wireless broadband modem from BigPond for some time, (Pulse+IT, November 2006, pp33) the author watched the launch of Telstra’s Next G network with interest.

In late January, Pulse+IT was provided with various BigPond Next G modems for the purpose of evaluation. Among these were the USB Desktop and USB Mobile modems. On its release in April, Pulse+IT was also sent a Next G ExpressCard modem.

As Mac compatible drivers were not available at the time, most of our initial testing was performed on a Windows XP computer. Thankfully, Mac (and Vista) drivers are now available.

NEXT G Built in just 10 months and launched with much fanfare in October 2006, Telstra are promoting their new mobile network as one of the most advanced and widely cast in the world. The network, dubbed “Next G”, cost in excess of $1 billion and promises to deliver significantly improved services to both mobile phone and wireless Internet users.

Mobile phone users connected to the network are able to make video calls, view FOXTEL and other selected TV programming, whilst mobile Internet users can enjoy significantly better performance than was possible with previous BigPond wireless broadband offerings.

The network operates in the 850MHz spectrum, which Telstra claims provides better range and “in-building” performance than rival third generation

38 PULSE + IT

networks that use the 2100MHz frequency.

The introduction of Next G signals the beginning of the end for the CDMA network. Popular amongst users in regional and remote areas because of its large footprint, the CDMA network is scheduled for closure in 2008. By this time, Telstra claim that Next G will provide the same or better coverage and quality of service than the CDMA network.

COVERAGE On launch, Telstra declared that the Next G network was capable of providing coverage to 98% of the population. This figure increased slightly to 98.8% in February this year, primarily due to the selective deployment of cutting edge hardware with an impressive range of up to 200kms (up from the previous limit of 50km).

Despite the impressive footprint, the sporadic nature of wireless networks means that some customers may not receive adequate reception or performance. Acknowledging this as a potential issue (even in capital cities), BigPond offer a 10-day money back guarantee to allow customers to trial the service before committing financially.

HARDWARE BigPond customers can select from a range of Next G mobile broadband modems: PCMCIA Card Manufactured by Option and released alongside the Next G network, this modem is suitable for laptops with a PCMCIA slot.

The only visibly interesting feature this devices possesess is a retractable “butterfly” antenna, which is less intrusive than the antenna on the authors EV-DO PCMCIA card.

USB Mobile Card Manufactured by Maxon and appearing outwardly like an oversized flash drive, this modem is the most versatile in the range and can be paired with any computer with an available USB port.

The male USB plug on the modem is designed to rotate and allows the device to be positioned on various angles to optimise the connection’s reception.

ExpressCard Modem ExpressCard is a relatively new expansion slot for laptops, touting a higher performance interface than the ubiquitou-s PCMCIA slot found on most laptops. The ExpressCard standard defines two slot widths, namely 54mm and 34mm.

BigPond have settled on a 34mm ExpressCard modem developed by Option. Because all ExpressCard devices sport the same sized connector, clever engineering means this card is also suitable for use in laptops with 54mm ExpressCard slots.

USB Desktop Modem Like the USB Mobile Card, BigPond have sourced this device from Maxon.

Requiring an external power supply, this device is primarily aimed at customers who don’t require a mobile solution and are unable to access cabled broadband solutions like ADSL.

FEATURES Antennas As the benchmarks on the following page show, reception quality has a dramatic effect on the speed of the connection. Maxon retail a range of optional antennas suitable for their BigPond branded modems. Using a compatible cable adaptor, these antennas are also suitable for use with the other BigPond modems.

Ethernet Docking Station Maxon have plans to release an Ethernet docking station, which will allow a USB modem to be shared by an entire network of computers.

This device is scheduled to begin shipping in July and will be available individually, or in a package containing a USB mobile modem.

Below (clockwise from the top) - ExpressCard Modem, USB Mobile Card, PCMCIA Card, USB Desktop Modem

WHY COLOUR COUNTS All the devices and services discussed in the main body of this article are branded and promoted

by BigPond, Telstra’s consumeroriented Internet division.

Before choosing a BigPond plan, customers should note that Telstra’s business unit also retails wireless broadband solutions. Beyond the colour scheme (Telstra use an unfortunate orange coloured plastic), there are several important functional differences between the Telstra and Bigpond offerings: Live IP Address On connection to the Internet, BigPond wireless broadband customers receive a “real” IP address, whereas Telstra customers are allocated an “internal” Telstra IP. Given that the Telstra branded solutions are targeted at business users, intuatively, this arrangement seems to be back-to-front!

Bundled Hardware At the time of writing, it wasn’t possible to bundle a BigPond wireless modem with a data or time based plan. Telstra business customers however, have access to a variety of plans that allow the cost of the modem to be factored into a contract.

Uncapped Speed?

Perhaps because BigPond quote speeds below their modems current maximum (i.e. 3.6Mb/s), there is an incorrect perception in the market that Telstra customers will enjoy faster performance than those using the fastest BigPond plan (i.e. 550Kb/s - 1.5Mb/s). According to BigPond, this is incorrect; neither Telstra nor BigPond impose an artificially speed cap on their service.

PULSE + IT 39

FEATURES SOFTWARE

to be connected to the Internet and local network services such as network printers. Fortunately, simple workarounds are available that allow multiple network connections to be used simultaneously.

BigPond supplies all the software required to configure the Next G modems on a CD. The installation process is very intuitive and should be able to be completed without assistance from the included hard-copy manual.

SPEED Telstra launched the Next G network with a peak download speed of 3.6Mbit/s in October 2006. This capacity was upgraded to an impressive14.4Mbit/s in February this year, a figure that is slated to climb to 40Mbit/s as early as 2009 if company estimates are on track.

Supported operating systems include: • • • •

Windows 2000 Windows XP Windows Vista MacOS X 10.3.9 or later

Currently shipping Next G modems cannot take full advantage of the networks capacity however, most topping out at 3.6Mbit/s for downloads.

All BigPond branded Next G modems will be able to be upgraded to higher speeds (potentially as high as 7.2Mbit/s) via firmware updates later in 2007. More significantly, this upgrade will improve the networks upload capacity to 1.9Mbit/s, up from the current speed of 384Kbit/s.

Linux is not supported by BigPond, however 3rd party tutorials exist on the Web, which suggests Linux users need not miss out.

The software, “BigPond Wireless Broadband”, stores the user account information, displays reception quality and tracks connection statistics. It also includes a software update mechanism that makes it easy to download updated versions of the utility as they become available.

To test the real world performance of the technology, I transferred a 5MB file to and from the Pulse+IT web server via FTP, using a variety of Internet connections, antenna configurations and locations.

The results are displayed below in Table1.

To avoid potential network conflicts, the utility tries to prevent the computer having two active connections (e.g. an Ethernet or local Wi-Fi connection). This may cause issues for users who need

Connection Type

Gundagai (Rural NSW) Download

ADSL 1500/256 Bigpond EV-DO Modem*

Upload

mm:ss

KB/s

mm:ss

148.43

0:34

24.87

3:25

-

-

-

45.81

1:50

34.90

While our testing only demonstrates the network’s performance with moderately large file transfers, our observations of other Internet activities were in line with these results. We found web browsing and Terminal Services remote access to be only slightly more “jerky” than the ADSL connection, and significantly better than when using an EV-DO card.

CLINICAL APPLICATIONS Portable Next G solutions can be used by clinicians to great effect in settings where a suitable Internet connection is not available. These localities may include aged care facilities, patient’s residencies and hospitals, and indeed, non-work related environments.

Coupled with a secure remote access solution, clinicians can now have access to their base practice’s clinical software database, anytime, anywhere, without the potential problems associated with taking practice data offsite.

Coogee (Eastern Sydney) Reception

KB/s

The performance of the Next G modems was very impressive, exceeding my expectations by a wide margin. The upload performance of the solution was particularly impressive, soundly trumping the upload speed of ADSL in all but one configuration. Also of significance was the amount by which the larger antenna improved performance, particularly in the rural setting of Gundagai.

Download

Upload

Reception

KB/s

mm:ss

KB/s

mm:ss

N/A

147.22

0:35

25.11

3:23

N/A

-

0/5

21.66

3:56

15.64

5:26

1/5

2:26

3/5

197.93

0:24

41.67

2:02

3/5

USB Mobile Modem - No external antenna - Small antenna

60.90

1:22

41.21

2:04

3/5

204.33

0:24

41.16

2:04

3/5

- Large antenna

280.73

0:18

41.82

2:02

4/5

206.36

0:24

42.15

2:00

4/5

USB Desktop Modem - 1 small antenna

49.38

1:42

42.02

2:00

4/5

186.24

0:26

41.09

2:04

3/5

- 2 small antennas

35.49

2:24

42.15

2:00

4/5

192.69

0:25

41.53

2:02

3/5

- 1 large antenna

46.76

1:48

41.60

2:02

4/5

202.41

0:24

42:01

2:01

4/5

Table 1 - Next G Performance Comparison: In each test, a 5MB file was transfered to and from the Pulse+IT web server using the File Transfer Protocol (FTP). Data transfer rates are shown in KiloBytes per second. The reception score refers to the number of reception bars shown in BigPond connection software. All tests were run using a PowerBook G4 running MacOS X 10.4.9. Small antenna = Maxon Unity Gain Spike Antenna (8cm); Large antenna = Maxon Unity Gain Base Station Antenna (40cm); *Superseded and no longer shipping, included for comparison only.

40 PULSE + IT

FEATURES Clinicians should note however, that like all devices that draw their power from the computer, Next G devices adversely effect laptop battery performance. As such, if a mobile solution needs to be used for extended periods, additional laptop batteries or frequent recharging may be required.

SECURITY Unlike typical modem/router combinations used for ADSL and Cable connections, BigPond wireless modems do not contain a built in firewall. As such, the user needs to ensure that a software firewall is activated and strong passwords are used for both the operating system account and any clinical software installed on the computer. File sharing services should be disabled, and Windows users should ensure that they have also have suitable anti virus and spyware protection installed and configured correctly.

COST

CONCLUSION

All of BigPond’s mobile modems have a recommended retail price of $299, however the desktop modem is slightly cheaper, retailing at $249.

Next G represents a quantum leap in wireless network technology, and provides Australian’s with a fast, high quality broadband service.

BigPond’s usage plan options are outlined below in Table 2. As is to be expected, the solution is significantly more expensive than ADSL or Cable Internet services, especially for users with large download requirements.

As such, wireless broadband is not recommended for use as a primary Internet service if a suitable alternative is available.

With their near universal coverage, BigPond has set themselves up as a formidable force in the emerging mobile broadband sector. Despite the company’s early dominance, traditional rivals are lining up for a piece of the action. Three, Optus, Vodafone and Unwired all offer wireless broadband solutions, however none yet compete with the Telstra Next G network’s superior coverage footprint and performance.

In what should be of interest to jet setters, BigPond has partnered with several international carriers to allow their customers to access Internet services while abroad. International roaming at broadband speeds is available in over 30 countries, albeit at the exorbitant rate of $15+GST per MB.

Simon James is the editor of Pulse IT. BigPond www.bigpond.com Maxon www.maxon.com Option

Table 2 - BigPond’s current pricing model. I’ll leave it as an excercise for the reader to figure out why BigPond charge more for their Mobile modem plans than for their Desktop modem plans.

Speed Download 256Kbps

550Kbps to 1.5Mbps (Average)

Upload 128Kbps

384Kbps

Desktop Plan

www.option.com Optus

Monthly Allowance

Mobile Plan

10 hours

$34.95

N/A

200MB

$54.95

$39.95

1GB

$84.95

$49.95

20 hours

$54.95

N/A

400MB

$84.95

$49.95

1GB

$114.95

$79.95

Vodafone

3GB

$184.95

$149.95

www.vodafone.com.au

www.optus.com.au Telstra www.telstra.com.au Three www.three.com.au

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. PULSE + IT

41

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

DIGITAL CLINICAL PHOTOGRAPHY

DIGITAL PHOTOGRAPHY FOR BUSY CLINICIANS Part 4 - Getting Organised - What To Do With Your Photos

Dr Daniel Silver MBBS, Bmed Sc, DRCOG, FRACGP This fourth and last article in the series about digital photography for busy doctors describes how one can use and look after your digital photographs.

Previous articles dealt first with the reasons why digital photography was worthwhile in the clinical setting, then provided some simple guidelines for choosing a good camera for closeup photography, and most recently, some tips for taking good close-up photographs in the clinic.

FIRST CHECK YOUR PHOTOS Let’s assume that you now have a great digital camera in your clinic specifically to use for clinical photography, and, having initially practised your technique of closeup photography on your partner, your children and the dog, you have now taken a few photographs of a patient’s skin lesion during a consultation. You really want to get those photos out of your camera and onto the computer so you can make sure that they are as good as they need to be and you’d love to show the patient these fantastic pictures of their wart or Basal Cell Carcinoma! But this is going to take even more time and you’re already running 45 minutes behind time now!!! What do you do?

This is the stage where things just might come unstuck and it might be tempting to say to the patient – “I’ll just treat your skin lesion now and I’ll have a look at your photos later on when I get a chance…” and then quickly freeze off their wart or rush down to the treatment room to remove their skin cancer.

The reality is that checking one’s photos CAN be done very efficiently with a very simple setup, however it’s probably worth first practising how to transfer the photos you’ve taken when you’re not under the pressure of work.

42 PULSE + IT

There are several different ways to transfer your photos onto your computer and what you choose to do may depend partly upon what you intend to do with your photos, partly on what computerised medical record system you use and partly upon how technically proficient you are with computers.

Taking clinical photos is only useful if you definitely intend to look at them in the future. To do that in the context of a busy clinical setting you need to be able to retrieve the photos as efficiently as possible.

The easiest way to check whether your photos are in sharp focus is to look at them on the LCD screen on the back of your camera. This is usually very quick; most cameras allow you to zoom in or magnify the image to allow you to check out the fine detail. You are able to delete substandard photos directly from the camera’s memory card, which then saves you from having to load these images onto the computer and then to delete them. However this method, while relatively quick, is still not as good as viewing the images on your computer’s monitor, and you can’t label the photo with the patient’s name while it’s still on your camera’s memory card. Assuming you wish to archive your photos, you will eventually have to upload the images onto the computer, label them and file them away somewhere! In this case sooner is better than later….read on!

A much better option is to immediately download your photos onto your own computer’s hard drive by using an appropriate USB cable to connect your camera directly to your computer. Once the cable is connected at both ends, simply switch the camera on and its icon should appear on your Desktop, just as if it was an external hard drive. Double click on this icon and search through the enclosed folders until you find the

images you’ve taken. It then ought to be simple to select and drag the new photos to copy them into a folder on your Desktop or somewhere else in your computer’s hard drive.

An alternative way to transfer your images from the camera involves removing the camera’s memory card and plugging it into a “card reader”, a small device with one or more differently shaped slots, each capable of accepting at least one of the many differently shaped memory cards. Card readers typically connect to the computer using a USB or FireWire cable. Using a card reader will free up the camera for someone else to use (with another memory card) while you transfer images from the memory card you’ve just removed from the camera.

The memory card will appear on your computer’s desktop in just the same way as if it was still in your camera. You can then access the photos and drag them into a folder to copy them onto your computer’s hard drive.

You can then view the photos by double-clicking on them to have them opened up by a photo-editing program such as Photoshop, Photoshop Elements, Microsoft Paint, Apple Preview or Apple iPhoto. It’s crucial to check the photos you’ve just taken to ensure that they’re in sharp focus and that the skin lesion/wound/visual sign is adequately documented, especially if you’re about to remove or “modify” a lesion with diathermy or cryotherapy. Similarly, if you want to review the lesion in a month or three you must ensure that you have an adequate image of the lesion in question before the patient leaves your surgery!

It follows then that if the photos you’ve just taken are not sharp or are not adequately exposed, you really ought

DIGITAL CLINICAL PHOTOGRAPHY to take some more photos immediately, even it takes you more time than you’d allowed. So apologise to the patient, make fun of your inexperience with the camera or the technology and take the time to get photos that serve your needs.

LABEL YOUR PHOTOS Your camera’s internal computer will label every photo you take with a title (usually a number with something like “.jpg” as a suffix). In addition, the camera adds some invisible data (called EXIF data) to every photo, including the date and time the photo was taken, the shutter speed, aperture, focal length, ISO number, and often a lot of other details. This information is accessible using photo editing software but most people don’t ever get around to using this information!

Below - EXIF data displayed in Apple’s iPhoto.

A BRIEF DISCUSSION ABOUT MEMORY CARDS Nowadays, very few digital cameras have any built-in or fixed internal memory for the storage of digital images; instead most digital cameras have internal spaces or slots to accommodate tiny rewriteable memory cards. These come in various physical forms (e.g. Compact Flash, SD, MMC, Sony Memory Stick, XD, etc), speeds and capacities (now 8Gb capacity cards are available!).

Storage Capacity The number of images any particular memory card can store depends on its capacity and how large the individual digital images are. The image size depends upon various factors including how many megapixels your camera’s internal light sensor has, what resolution and file type you set in the camera’s preferences (e.g. small JPG file, normal JPG file, fine JPG file or High JPG file or RAW format), whether you take the photos in greyscale or full colour, and finally, how much detail there is within the image (large areas of blue sky don’t require as much information as more complex parts of an image such as grass or trees, etc).

While the memory cards used in digital cameras are very practical and compact, there are two important reasons why they are not appropriate for long-term storage or archiving. Images saved on a memory card may well remain stored safely for several years without degradation or loss but these cards should not be considered as highly secure forms of storage. Also when compared to the low cost of a blank writable CD or DVD disc or the cost per megabyte of todays huge capacity hard drives, memory cards are much more expensive forms of storage.

Memory cards can have different “speeds” which means some can have data written to them by a digital camera and read from them by a computer at a much higher speed than others. Having “fast” (and more expensive) memory cards is of most value when you own a digital single lens reflex (SLR) camera, which usually have larger image sensors with high megapixel counts. These cameras therefore create larger images files which need to be written to the memory card as quickly as possible so that there is minimal delay until the camera is ready to take the next picture. And even if your camera’s internal data transfer speed isn’t a match for the speed of your memory card, you will still benefit from a faster upload speed from the card to your computer!

As a general rule, it’s useful to have several memory cards so that if one card fills up it’s a simple matter to quickly remove it from the camera’s memory card slot and pop in another one to allow you to continue taking pictures. You can transfer the photos from the card at a later date and Below - The author’s FireWire memory card reader shown with two different types of memory card. then “reformat” or erase the full card to free it up for further use. Each card is good for perhaps as many as 100,000 reuses before it deteriorates and needs to be discarded. Of course there will always be some cards which “die” prematurely for unknown reasons! The good news is that the price of memory cards has dropped dramatically in the past few years and they will continue to get cheaper while their storage capacity rises almost as quickly!

PULSE + IT 43

DIGITAL CLINICAL PHOTOGRAPHY USE YOUR MEDICAL RECORDS SOFTWARE

To make it easy to search and retrieve your photos, it’s crucial to rename the image file with the patient’s name and the date the photo was taken as soon as you are satisfied with its quality. In fact, it’s best to do this while the patient is still with you so that they appreciate the effort you are expending on their behalf! It’s helpful to use a consistent format for labelling your photos such as surname_firstname_year_month_day.jpg e.g. Blogs_Joe_2007_04_02.jpg. If you delay the labelling of the photos until the end of the day, you might struggle to remember which patient belonged to which photo or you may simply never get around to it!

renaming the photos, still a tedious but essential task.

If you don’t label your clinical photos in a timely fashion it won’t be long before you have a large number of photos labelled by your camera’s idiosyncratic internal naming system and it will be extremely tedious going through them one by one to find the particular photo you wanted. That would be totally impractical in the clinical setting and would deter you from ever looking at the photos, making this series of articles a pointless exercise!

Top - A clinical photograph opened within Medical Director.

Bottom - Medical Director’s list of document types that can be used to label imported documents.

If you use this system for labelling your photos, you can be even more systematic by using sub-folders labelled A, B, C,...,Z to store your photos (so that Mr Jone’s photos are placed into a “J” folder, etc) which will make future searches for a particular photo more efficient instead of just dumping all your photos into one single folder.

USE YOUR IMAGE MANIPULATION SOFTWARE Up until now the focus has been on doing everything “manually”.

However it is possible to do things more methodically. Programs such as Photoshop Elements or Apple’s iPhoto have image browser modules which can be set to automatically import your photos into their libraries as soon as you attach either a digital camera or a card reader containing a memory card to your computer’s USB port. This obviously makes the job of importing the images slightly easier and the viewing options make it very quick to check your photos, to enhance somewhat under-exposed images, and to delete inadequate or redundant photos. However there’s still the issue of

44 PULSE + IT

This method of downloading, manipulating/deleting, labelling and storing your clinical photos is without a doubt easier than doing it all manually in a series of folders within your computer’s hard drive. However it requires you to launch another program to handle or retrieve your photos whenever you need to access them, either when you first take the photos or when you review the patient and their lesion(s).

This is where the sophistication and intelligence of your medical records software can really shine or completely let you down!

Your medical records software will accept your typed data and downloaded pathology/radiology reports and even emailed letters.

However not all medical records software makes it just as easy to import, label, manipulate or delete photos directly from your camera or a card reader. And yet, it is as logical for your software to do this and to attach photos

DIGITAL CLINICAL PHOTOGRAPHY directly or indirectly to your patient’s medical records as it is to attach downloaded pathology reports.

Medical Director (MD), the most widely used medical records software program in Australia, is capable of importing photographs directly into patient records. However it has a very limited ability to edit or manipulate images once they have been imported. It should be remembered however, that the need to edit photos depends largely on how well they’re taken in the first place! MD allows users to view, zoom into and scroll around enlarged photos so that they can be examined in detail.

Photos can of course be edited using other software before being imported into MD, but this is fiddly and will take more time.

Genie, an integrated practice software solution for both Macs and PCs has much greater flexibility in the way it handles imported photographs. Like MD, Genie allows one to zoom into a photograph and scroll around the image to see more detail about a lesion. In addition, photos can be lightened, sharpened, and cropped.

Importantly, Genie allows the user to name multiple photos for one patient as a batch and then attaches a suffix such as _1.jpg, _2.jpg to each photo as it imports them. This dramatically simplifies the job of importing several photos.

If one has misspelled or otherwise inappropriately labelled the photos, it is a simple process to rename the images.

Another strength of Genie’s photo handling functions is that the photos aren’t actually embedded in the medical records database. Instead images are stored in a folder unique to the patient (every patient has their own folder within an “Images” folder on the practice server) and a link to the photo is inserted into the patient’s medical record which, when clicked, opens up the photo within Genie. This feature helps to prevent the database growing rapidly as one adds more photos to the system!

Scanned correspondence or other documents are handled by Genie in just the same way with rapid retrieval of images, be they of imported photos or scanned images of correspondence, by a single click on the link to that image.

The author is unfamiliar with the features of the other commonly used medical records software programs and cannot provide readers with information on how those programs import, store, provide access to or retrieve, and manipulate clinical photographs. Regardless, he considers Genie an excellent example of what medical records software should do to make clinical photography an integrated part of everyday medical documentation (there are no prizes for guessing which program the author uses!!!).

So, now that you’ve examined your photos and are happy with them and have copied them onto your computer and possibly directly into the patient’s medical record with new labels, what else can you do with your photos?

It will eventually be necessary to erase all the images on your memory card to free up space for more photos. The simplest way to do this is within the camera itself using the “Reformat” menu item accessible via the camera’s LCD screen. This deletes the directory information so that the camera assumes that there’s nothing left on the card

Below - Genie’s Image Browser window, showing a list of attachments (including digital photos) on the left side of the screen.

PULSE + IT 45

DIGITAL CLINICAL PHOTOGRAPHY (although in fact the images remain on the card until they are “overwritten” by new photos). However it’s best not to reformat your memory card until you’re certain that you have made all the copies you need and have a backup secured somewhere away from the clinic. So this brings us to the topic of “Backups”.

photos folder so that only newly added photos are backed up. Using optical media (CD or DVD) for backups is probably more secure in the longterm however. Don’t forget that it’s considered more secure to keep one’s backup copies off site and it’s far easier to take home a DVD than to cart around an external hard drive!

PRESERVE YOUR CLINICAL PHOTOGRAPHS WITH BACKUP COPIES

Remember that there are only two types of computer users….those who have already lost data and those who will!

Just as it is vital to regularly create a backup copy of your practice software database, it is just as important to regularly backup your clinical photos. It may not be necessary to perform these backups of clinical photos quite as often as the medical record database (once or twice daily backups seems to be the norm for the latter whereas twice weekly photo backups is also fairly common). The author uses DVD to backup the medical records database AND all imported photos and scanned documents once daily. Backup onto an external hard drive can be done easily with software that automatically synchronizes the contents of one’s

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USING YOUR CLINICAL PHOTOGRAPHS FOR TEACHING PURPOSES About 15% of all consultations with General Practitioners involve skin conditions, be they exanthems, rashes either acute or chronic, trauma, skin lesions or ulcers. As a consequence, they observe large numbers of interesting sights for which they have had, by and large, absolutely no training! The author has collected a vast number of clinical photographs since entering General Practice as a solo GP in 1980 starting with ordinary film-based photos but finally moving to digital photography

in 1998. A carefully selected and deidentified portion of the collection of digital photographs has been perused regularly by both the medical students and the GP Registrars who spend time under his supervision in General Practice. Because this field of clinical medicine has all but been removed from the curriculum of most medical schools, both medical students and GP Registrars continue to find this resource to be incredibly useful. These digital photographs are in many ways superior to photos within Dermatology textbooks as the author is able to “attach” a clinical story, diagnosis, management plan and outcome (sometimes including “after” photos as well) to the photos during teaching sessions. And where a diagnosis was initially lacking, subsequent diagnosis by a dermatologist or a pathologist when a biopsy was performed can subsequently be related to the original photographs.

If you use clinical photographs for teaching purposes, it is very useful to keep extra copies of the most interesting photos in a separate folder specifically for teaching purposes. These photos

DIGITAL CLINICAL PHOTOGRAPHY can be relabelled to maintain patient confidentiality if this is necessary and they can also be sorted into separate folders according to the conditions they demonstrate e.g. Basal Cell Carcinomas, Melanomas, Viral Exanthems both specific and non-specific, trauma, before and after photos (to illustrate the outcomes of surgical techniques when excising lesions). Keeping copies of photos separate for teaching purposes can be particularly useful if you normally use a medical records software program such as Medical Director or Genie to import clinical photos directly into patients’ medical records. In this situation searching for interesting photos can be difficult especially if you have forgotten which patient had the interesting Lichen Planus rash for example.

With a little bit of practice it is possible to combine particularly good clinical photos with some clinical information to create useful PowerPoint presentations for teaching purposes. Alternatively, simple slide shows of interesting clinical photographs can be very useful for teaching both medical students and GP Registrars.

If you want to conduct a clinical audit of the results of surgical excisions keeping copies of before during and after photos can be very useful and may help you to refine your excision techniques.

USING CLINICAL PHOTOGRAPHS IN REFERRALS TO MEDICAL COLLEAGUES Patients often consult their GPs relatively early on in the evolution of their rashes or skin lesions, and having photos of rashes or lesions as they change can be very useful for diagnosing obscure or atypical conditions. These photos can be printed and sent with the referral letters or sent directly to the specialist as attachments to emails, assuming that the specialist has caught up with the digital revolution!

If sending photos by email is acceptable to the specialist it may be necessary to first make smaller or lower resolution copies of the photos you wish to send by email in order to reduce the time it takes to upload them. Even with broadband, uploading files usually takes substantially longer than downloading them!

PHOTOGRAPHS CAN BE PRINTED! For most clinical purposes photographs are usually retrieved only once or twice ever and then are nearly always just examined on a computer monitor. In fact, the author admits to having had very few occasions in recent years where photos actually needed to be printed out. Nevertheless it can be very useful to have a high quality inkjet printer somewhere in the clinic for those occasional situations where clinical photographs need to be printed out.

Printing high resolution colour photos is usually dramatically slower than printing

Below - A photo quality bubble jet printer with an LCD display to allow photos to be printed directly from a camera, memory card or mobile phone!

ordinary text documents. As such, it is logical to print colour clinical photos outside of one’s consulting room so as not to tie down your computer!

While the consumables (ink and photoquality paper) are quite expensive in relation to the cost of the printer itself, if there is a need to print a photo then it follows that the prints ought to be of a high quality! There are a large number of very high quality inkjet printers available at relatively low prices. If used infrequently, the cost of printing clinical photographs is usually not prohibitive.

By the way, buying no-brand or generic printer ink cartridges and cheap photographic paper instead of the cartridges and paper recommended by the printer’s manufacturer often proves to be false economy as the quality of the photos may well turn out to be very much less than desired. Further, it is quite common to hear stories of cheap printer inks eventually clogging up the tiny inkjet nozzles, rendering the printer quite useless and, in this age of throwaway things, virtually unfixable! So it may be better to pay more initially in order to spend less in the longer term!

SIGN OFF This concludes the series of articles designed to stimulate doctors to use digital photography to document their clinical work. The author is happy to be contacted by email if readers have questions about clinical photography and related topics.

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.

Genie Solutions www.geniesolutions.com.au Health Communication Network (HCN) www.hcn.com.au Dr Daniel Silver dansil@vic.chariot.net.au

PULSE + IT 47

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48 PULSE + IT

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PULSE + IT 49

SHUTDOWN

SAVE TIME, WASTE TIME Trevor Hendry

The concept of simple, single purpose computer programs has been around for decades. Over the last few years however, there has been an explosion in the number of said utilities available to computer users. Now commonly referred to as “widgets”, these programs are as varied as they are numerous. In fact there are literally thousands of widgets available, with new ones popping up daily.

The vast majority are both free and easy to install, factors that have no doubt contributed to their popularity. Some widgets are immensely useful, some are fun, and as alluded to in the title of the article, some can actually make you more efficient at wasting time!

WHAT’S AVAILABLE? While there are exceptions, most widgets are designed to simply display information in an easily accessible format. There are widgets dedicated to the weather, the stock market, parcel tracking, snow reports, calendars, calculators, dictionaries and language translators. Widgets that display information from news and other frequently updated websites also feature prominently in widget directories.

Other than these “useful” applications, there are plenty of widgets designed purely for entertainment purposes.

Hundreds of simple games exist, including Crosswords, Tetris, Solitaire, Pacman, Space Invaders, Chess, and the highly addictive Sudoku.

START YOUR ENGINES While all modern widget systems are built on popular web technologies, several widget platforms have emerged.

Apple first introduced its widget offering, Dashboard, as part of MacOS X Tiger in 2005, while Microsoft released its remarkably similar “Gadget” technology in Vista more recently.

There are also several third-party developers with widget platforms, Yahoo’s cross platform solution being the most widely adopted.

Regardless of their flavor, widgets can either be permanently fixed to the screen, or set to stay out of view and await a predefined keyboard or mouse command. Once summoned, the user’s widgets spring to life, ready to perform their duty. To expel widgets from view, the user need only perform another keystroke or click on the mouse.

Because of the fact that it is easy to both summon and dismiss multiple widgets at once, they are an efficient way to access a wide variety of information in one place.

Below - A selection of the IceTV program guide widget. This is available for the widget environments from both Apple and Yahoo.

I’m not aware of any Australian medical centric widgets, but can think of at least a few that would be useful.

I’d like to see widgets for identifying drug side effects, dosages and antibiotic guidelines. Being able to type in a symptom and get a list of differential diagnoses would also be useful. There is also strong potential for their use with evidence based medicine and searching online databases.

AUTHORS FAVOURITE: ICE TV While I have experimented with hundreds of widgets, the ones that I’ve retained and use regularly all perform fairly simple tasks. Though I’m loath to admit it, the widget that I refer to most is an Australian developed widget called IceTV. As you may have guessed from the name, this widget is devoted to the humble television. Specifically, IceTV is a electronic program guide that allows you to view up-and-coming television shows for all the free to air and most of the digital channels available in Australia, all at the press of a button.

Save time, waste time indeed!

Trevor Hendry admits to being a “House” fan.

Apple Dashboard http://tinyurl.com/ypj78wIceTV IceTV www.icetv.com.au Microsoft Sidebar www.microsft.com.au/sidebar Yahoo Widgets widgets.yahoo.com

50 PULSE + IT

Practice going Paperless?

Why not consider the Wacom DTI-520, interactive pen display...

FOR MORE INFORMATION VISIT WACOM AT GPCE SYDNEY (Stand 0908, May 18-20)

RRP

$1650

Available from all good computer hardware suppliers.

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More Information: www.wacom.com.au