Pulse+IT - November 2006

PULSE IT Ã

Australia’s First & Only Health IT Magazine

Issue 2: November 2006

Features PIP IM/IT Changes Demystified

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ARTICLES FOR

Mobile Broadband VOIP Web 2.0 Digital Clinical Photography

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Filmless Imaging Interactive Pen Displays

Regulars Interview: Medical Objects Question Time: Software Vendor Epidemiology Mr Fixit

Columns General Practice Computing Group Health Informatics Society Australia Medical Software Industry Association

PIP IM/IT CHANGES DEMYSTIFIED

National E-Health Transition Authority National Primary Care Collaboratives

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PULSE+IT Publisher Pulse Magazine 3/61A Bream Street Coogee NSW 2034 ABN 19 923 710 562 www.pulsemagazine.com.au Editor Simon James 0402 149 859 simon.james@pulsemagazine.com.au Art Director Mark Duncan Advertising Enquiries ads@pulsemagazine.com.au Subscription Enquiries subscribe@pulsemagazine.com.au About Pulse IT Pulse IT is produced by Pulse Magazine, the most innovative publisher in health. Over 10,000 copies of Pulse IT are distributed quarterly to medical centres and IT professionals across Australia.

Contributors Dr David Brookman, Ms Linda Hein, Dr Tony Lembke, Ms Jane London, Dr Brendan Lovelock, Dr Paul Mara, Dr Vincent McCauley, Dr Ian Reinecke and Dr Daniel Silver.

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

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

Copyright 2006 Pulse Magazine No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form by any means without the prior written permission of the Publisher.

Subscription Rates (inc GST) 1 year: $99 Back issues: $22 Bulk rates: POA

DESERT ISLAND APPLICATION: WEB 2.0 PAGE 26

COVER STORY PAGE 20 DEMYSTIFYING CHANGES TO THE PIP The 2006 IM/IT changes to the PIP represent a significant shift in gears for the program, however compliance should be possible for most practices.

GUEST COLUMN PAGE 07 HEALTH PROVIDERS BENEFIT FROM BROADBAND The e-Health and Technology Branch of the Department of Health and Ageing discusses the benefits of broadband for health providers.

IT/IM Survey PAGE 06 IT/IM INNOVATIONS FOR GENERAL PRACTICE SURVEY Learn more about the survey that accompanies this magazine.

BITS & BYTES PAGE 08

MEDICAL OBJECTS PAGE 16

POTS AND PANS PAGE 24

FEATURES

REGULARS PAGE 06 STARTUP Simon James outlines Pulse IT’s new email service and podcast.

PAGE 07 GUEST COLUMN The e-Health and Technology Branch of the Department of Health and Ageing discusses the benefits of broadband for health providers.

SHUTDOWN PAGE 42

PAGE 14 NEHTA Dr Ian Reinecke outlines NEHTA’s specifications to standardise how medications are identified, named and described.

PAGE 15 GPCG Jane London encourages clinicians to maximise their use of their existing computer systems.

PAGE 20 DEMYSTIFYING CHANGES TO THE PIP Simon James unravels the IM/IT changes to the PIP. PAGE 24 POTS AND PANS Dr Tony Lembke discusses the evolution of the telephone.

PAGE 08 BITS & BYTES News from IT companies operating in health.

PAGE 16 INTERVIEW Pulse IT talks with Dr Andrew McIntyre of Medical-Objects.

PAGE 26 DESERT ISLAND APPLICATION: WEB 2.0 Dr Tony Lembke describes the latest generation of web applications.

PAGE 10 MSIA Dr Vincent McCauley introduces the Medical Software Industry Association.

PAGE 18 QUESTION TIME Pulse IT has a bunch of questions to ask your potential software vendors.

PAGE 28 DIGITAL CLINICAL PHOTOGRAPHY Dr Daniel Silver helps us choose a digital camera for clinical work.

PAGE 11 NPCC Linda Hein provides an update on the National Primary Care Collaboratives.

PAGE 38 EPIDEMIOLOGY Dr David Brookman helps you prepare your data for accurate recalls and self-directed audit.

PAGE 33 TELSTRA MOBILE WIRELESS BROADBAND Pulse IT takes a look at Telstra’s “go anywhere” Internet solution.

PAGE 42 SHUTDOWN Mr Fixit gets hot under the collar.

PAGE 34 INTERACTIVE PEN DISPLAYS Pulse IT rediscovers the pen with Wacom’s interactive displays.

PAGE 12 HISA Dr Brendan Lovelock discusses the importance of education in the spread of health information technology.

PAGE 36 FILMLESS IMAGING TECHNOLOGY Pulse IT takes a look at MD3’s filmless imaging solution.

www.pulsemagazine.com.au

PULSE IT 2.0 STARTUP

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

This edition’s cover story deals with the recent PIP IM/IT changes, new requirements that have caused a concern in many general practices. We hope that this article will be of benefit to practices struggling with the new rules, as well as to those who have already declared compliance.

Complementing a range of articles from the GPCG, HISA, NEHTA and the NPCC, this edition also includes an article from Dr Vincent McCauley, President of the Medical Software Industry Association.

We take a look at Wacom’s interactive pen displays, Telstra’s mobile broadband solution and the filmless imaging technology built into MD3.

Follow-up articles from Dr Daniel Silver and Dr David Brookman on clinical photography and epidemiology respectively are included, and Dr Tony Lembke discusses VOIP and the new breed of web applications.

Responding to numerous requests from our readership, we have decided to compliment our quarterly print publication with a bi-weekly email broadcast. The service will commence in

mid-November, with the first edition containing timely health IT news along with follow-ups to several of our popular first edition articles.

Fans of the podcasting medium may be interested to note that we will be launching our own podcasting service in late November. In addition to providing our readership with an alternative way to access our articles and news pieces, we hope to deliver interviews and audio grabs from the numerous health and IT events we attend.

Thanks to all our editorial contributors and advertising sponsors who have helped to make this edition a reality. I’d also like to thank the dozens of people who have contributed feedback and encouragement since our launch in August. As always, we welcome any input that will help us to improve and evolve our offering.

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

IT/IM Innovations for General Practice Survey There are many things that people suggest that Information Technology (IT) and Information Management (IM) can do to improve general practice. These improvements can be concerned with practice efficiencies, safer patient care, better patient outcomes, more sustainable business, more profitable business and cost effective delivery of treatments.

However, until now no one has ever asked GPs and medical practices what they believe are the most important IT/IM innovations/enhancements that would contribute the most to improving General Practice. The survey is aimed to provide clear direction on what IT/IM end users want industry, government and academia to concentrate their efforts on to improve general practice for GPs, staff and patients.

The survey is being conducted by Pulse IT and Geoffrey Sayer. It can be completed using the attached fax back form or online at the Pulse IT website. The survey is anonymous and all information is unable to be linked back to a single respondent.

The survey was designed by Geoffrey Sayer, with valuable input from members of the General Practice Computing

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Group (GPCG) email list, academia contacts, the Medical Software Industry Association (MSIA) email list, the AusGP online forum and other GP software product forums.

The results will be made available through the February edition of Pulse IT and its website. The results will also be made freely available through the MSIA membership, the GPCG forum, the National E-Health Transition Authority (NEHTA), the RACGP, the AMA, the ADGP and other organisations upon request.

Geoffrey Sayer (PhD) is currently employed by HealthLink as Market Development Manager. He has worked in the Health IT industry for the past 6 years in research and development; and as an epidemiologist and statistician in academia, the private sector and the public health system for the past 15 years. He pursues his own interests in research and development in general practice through consulting services and independent research.

For more information: Email: geoff.sayer@healthlink.net Mobile: 0403 034 925

GUEST COLUMNIST

HEALTH PROVIDERS BENEFIT FROM BROADBAND Thousands of healthcare providers throughout Australia are now reaping the benefits of business grade broadband, thanks to the Australian Government’s Broadband for Health program.

Business grade broadband is a highspeed, always-on, communications link that provides faster access to vital healthcare information such as pathology results, hospital discharge summaries, specialist reports and X-ray images.

High-speed access to clinical information is helping to improve healthcare processes; reduce the need for travel; improve communication; assist in education; reduce phone costs and lessen isolation for those especially in rural and remote areas.

The Australian Government’s Broadband for Health program will spend $69 million over three years to 30 June 2007 to support the uptake of broadband services in general practices, Aboriginal Community Controlled Health Services ����������������������������������� and community pharmacies nationwide.

The Australian Government’s Eastern Goldfields Regional Reference Site (EGRRS) is an excellent example of how broadband can improve healthcare services in regional communities by increasing safety, quality and efficiency though communications infrastructure.

In recognition of its excellence, on 7 March 2006 the EGRRS project won the Australian Telecommunications Users Group award for Best Communications Solution (Regional).

Dr Andrew Siegmund, an EGRRS participant and a general practice project manager, said that with the implementation of the network, his practice had gone from very basic systems to a cutting-edge technology network without problems.

“We can see benefits. The network is running smoothly and we are saving on costs. We’ve seen improvements in the way we run our practice using the applications the network carries,” Dr Siegmund said.

EGRRS participants moved on 1 July 2006 to the locally owned GoldHealth

Network and continue to see the benefits of being part of a health services network.

The Broadband for Health program draws together several Government initiatives including the Access to Broadband Technology initiative to support health sector broadband connectivity. It has strong links to the National Broadband Strategy that is managed by the Department of Communications, Information Technology and the Arts.

The program receives stakeholder input through the Broadband for Health Working Group, made up of key health, consumer, government and industry representatives.

For more information about the Australian Government’s Broadband for Health program and the new Managed Health Network Grants initiative, please see www.health.gov.au/ehealth This article was supplied by the e-Health and Technology Branch of the Department of Health and Ageing.

PULSE + IT 7

BITS & BYTES

TV FOR GPS

JANINE CHARMS JUDGES

Seeking to provide a more timely and engaging way for doctors to get their medical news, GPTV is predicting the Internet will become GPs preferred way to receive their news.

Janine Garrett, CEO of Charm Health has recently won the business category of the Smart Women - Smart State awards.

Launched in late July, Mike Kossenberg from GPTV claims that the program has been viewed over 6500 times.

News is currently updated twice weekly and delivered primarily by GP presenters.

Starting with a recently launched feature on Stroke, more comprehensive special stories will also be made available from the site.

In addition to its filmed episodes, GPTV offers aggregated news stories from various sources including Australian Associated Press (AAP). A weekly audio podcast is also available which allows the programs to be listened to using portable media players including iPods.

All episodes are available free, however some content is restricted to registered users who receive email broadcasts notifying them of new podcasts and special features.

These awards recognise Queensland women who excel in their field and seeks to encourage young women to consider a career in these fields.

Charm Health, creators of Charm, have been developing and trialing their flagship product for 3 years. Charm is an oncology information management solution designed to improve the management of patients with cancer.

The Charm system automatically generates a complete treatment calendar with all doctor appointments, pathology/radiology orders, pharmacy and day unit requirements mapped out for the patient’s entire treatment schedule. Charm also collects and archives all data required by cancer registries and interfaces with hospital systems using HL7.

Charm is currently deployed in 10 hospitals, a number that Janine expects to double in the coming year.

GPTV uses Flash to encode its video which provides impressive quality at efficient data rates. The same technology is used by Internet video sensation “YouTube”, Google’s latest acquisition.

Prior to establishing Charm, Janine was the Director of Pharmacy at Gold Coast Hospital. During this time, she completed a Masters degree in Information Technology which prepared her for her role as Charm Health’s lead developer.

GPTV www.gptv.com.au

Charm Health www.charmhealth.com.au

HEALTH IN MOTION Motion Computing CEO Scott Eckert and Louis Burns of Intel’s Digital Health Group discussed a planned “mobile clinical assistant”, at the recent Intel Developer Forum.

While health is already a key vertical market for the “slate” tablet PC maker, this is Motion’s first attempt at building a device specifically tailored for the health sector.

The computer is scheduled for release in the first half of 2007 however its specifications are yet to be announced.

Unlike most tablet PCs that are based on a convertible laptop design, Motion Computing’s products jettison the keyboard and optical drive to minimise size and weight.

With a substantial following overseas, Motion Computing, has started to make inroads into the Australian market with several recent deployments including one at the Sydney Adventist Hospital (SAH). This hospital recently attracted the interest of mainstream IT media because of a decision to to deploy a wireless network based on the relatively obscure 802.11a protocol. To interface via this network, the SAH chose Motion Computing’s LS800 tablets, favouring this model over the larger LE1600 because of its ultra-portable form-factor.

Motion Computing www.motioncomputing.com.au

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BITS & BYTES

RETURN OF THE PEN

VISTA PRICED, IE7 OUT

Absolute e-Comm, a company specialising in digital pen technology has expanded its range to include the Laser Digipad. Roughly the size of a clipboard, this device allows hand written notes to be digitised in any location. When connected to a computer it can also function as a writing tablet with direct on-screen input.

Microsoft has announced Australian retail pricing for its forthcoming operating system titled Vista.

This device complements the Pegasus PC Notetaker and the Pegasus Mobile Notetaker, two existing digital ink devices already retailed by the company.

Unlike other digital ink solutions that require special pre-printed paper, these devices use electromagnetic signals to track the pen’s position on the page.

After the pen strokes have been captured, the images can be uploaded to a computer using supplied software.

Diagrams and editable text can then be extracted for use in other applications.

The products can also interface with FormFiller, software that allows structured forms to be generated. After a form has been completed, the uploaded image can be checked for accuracy and corrections made. The information retrieved from documents processed by FormFiller can be exported in common data formats for use in other systems.

Absolute e-Comm www.absecomm.com.au

With an expected launch date in January, Vista will be released in four flavors with the following recommended retail prices: Home Basic: $385 Home Premium: $455 Business: $565 Ultimate: $751 A fifth version for the Enterprise will also be released but is unlikely to be relevant or available to medical practices.

As with XP, purchasing Vista bundled with a new PC will minimise the cost of the new software. Discounted prices will be available for people upgrading from previous versions of Windows, however steep hardware requirements will limit this as a viable option for many.

Among Vista’s most touted features are integrated digital pen functionality, voice recognition and speech synthesis, desktop applications dubbed “Gadgets”, an improved local search engine, better security and a refreshed appearance.

Practices are advised to discuss any potential upgrade to Vista with their software vendor and IT support organisation to avoid compatibility issues.

Vista will ship with Internet Explorer 7 (IE7), Microsoft’s upgrade to its ageing web browser. Having made little improvement to its web offering since IE6 was released in 2001, IE7 has done a good job of of catching-up with rivals including Firefox, Safari and Opera.

Launched on 19th October, IE7 is available now to users of Windows XP. Microsoft Vista www.microsoft.com/windowsvista/

FIREFOX 2 LAUNCHED Mozilla has released version 2 of Firefox, the web’s second most popular browser.

Since its release in November 2004, Firefox has captured a significant percentage of the browser market with users drawn to its tabbed interface, extendibility, adherence to standards and open source foundations.

Much of the update is concerned with backend improvements and added functionality for developers, however there are several features that users will appreciate.

Built-in spell checking allows forms to be proofed, a feature that will become increasingly useful with the increase of web based applications.

The graphical appearance of the browser has been refreshed and RSS feeds can now be directed to an external reader or viewed in a summary page.

Phishing protection warns users if Firefox suspects the site may be a forgery (for the purpose of stealing personal details such as net banking information).

Existing FIrefox users may need to update their third-party extensions as compatibility isn’t guaranteed with the new version of Firefox.

Firefox is free and available for Mac, Windows and Linux systems. With over 230 million downloads, it is one of the most popular open source projects of all time.

Firefox www.getfirefox.com

Microsoft Internet Explorer 7 www.microsoft.com/windows/ie/

PULSE + IT 9

INTRODUCING COLUMNS: MSIA

THE MEDICAL SOFTWARE INDUSTRY ASSOCIATION Dr Vincent McCauley MBBS (Hons), Ph.D

•

The Medical Software Industry Association (MSIA) was established in 1995 to provide a forum for Australian medical software vendors and related organizations to address common issues and provide a single contact point for government and consumers.

The MSIA membership comprises more than 50 companies (listed on the MSIA website) which represents the majority of companies actively supplying software to the Australian e-health marketplace.

The membership includes the large international health software companies such as Sun Microsystems and Cerner Corporation, local corporate market leaders such as HCN, and smaller companies with niche markets and expertise. The MSIA membership supplies the vast majority of medical desktop software for Specialists and General Practice in Australia as well as a large proportion of medical software deployed in public hospitals.

The objectives of the MSIA include representing the interests of the Australian commercial software industry which develops, supplies and services information management products and services for healthcare practitioners, healthcare service providers and healthcare organizations.

Other functions of the association include: • Providing a collective and representative voice in discussions and negotiations with government, other associations and representative

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•

•

•

bodies, individuals and commercial companies.

Providing a mechanism for other organizations and individuals to communicate effectively with MSIA members.

Providing a means by which intelligence and information can be distributed to members.

Providing a forum for effective cooperation by members in areas which will be mutually beneficial Providing an agreed public Code of Practice for members.

MSIA has been/is represented and/or contributes expertise in many forums including: • Medicare Australia – Stakeholders advisory committee (SAC), Eclipse Reference, Group (ERG), Doctors’ Communication Group (DCG), HIC Online Software Vendors Working group.

• Pharmaceutical Benefits System (PBS) Software vendors workgroup.

• RACGP – Practice standards Committee.

• AMA – Expert Advisory Committee on Information Technology.

• Standards Australia – MSIA is represented on the peak e-Health Standards committee, IT-14. Many members also contribute to numerous IT-14 sub-committees.

• National e-Health Transition Authority (NeHTA) joint workshops.

• HealthConnect.

• Broadband for Health Working Group.

• National Pathology Accreditation Advisory Council (NPAAC) IT Data Standards sub-committee.

• The National ICT Industry Alliance.

MSIA has effectively fostered the development and adoption of Standards to promote safety, quality and

interoperability in the Australian eHealth marketplace and has recently formed a formal Interoperability committee to take this work forward.

The Australian medical software market is in a healthy state with an excellent record on innovation and quality. MSIA members such as Ocean Informatics and Pen Computing are leading International Standards efforts in Electronic Health Records (EHR) and Clinical Decision support and MSIA will provide a forum to promote adoption of standards and technologies as they mature. The MSIA membership is in a strong position to deal with the near future challenges of standard medications and clinical terminologies, pervasive shared electronic health records, interoperability and accreditation/compliance. The rapid changes that adoption of these technologies will require and promote, will be a major challenge to software vendors, government and users alike.

I look forward to MSIA providing a common meeting point to encourage and facilitate standards and technology adoption, education and change management.

Dr Vincent McCauley is the President of the Medical Software Industry Association.

QUICKCLICKS MSIA www.msia.com.au Medicare Australia www.medicare.gov.au NEHTA www.nehta.org.au

COLUMNS: NPCC

COLLABORATIVES: ENHANCING PATIENT CARE THROUGH CLINICAL AND BUSINESS SYSTEM IMPROVEMENT Linda Hein of General Practice to aggregate data and produce the NPCC measures.

NPCC has also been working closely with leading software suppliers and now eight software suppliers have included NPCC reporting functionality within their software.

The health technology and software currently available to GPs provides them with enormous computing power.

However using it effectively to establish and sustain patient management systems, and improvements in patient care and business efficiency, is another thing!

The $17 million Commonwealth funded Collaboratives program is helping over 500 general practices and primary health care providers Australia wide to do just that. The NPCC (National Primary Care Collaboratives), based at Flinders University in Adelaide, is working directly with general practices across the country to improve systems using an internationally acclaimed improvement model developed in the US and adapted in the UK. The program focuses on three topic areas, Diabetes, Coronary Heart Disease (CHD) and Better Access for patients to primary care.

Measurement is a vital element of this innovative improvement model and is used to provide feedback to practices on their progress. A total of 13 measures are collected by participating practices and submitted to the NPCC monthly via a secure online reporting site, in what is one of the first data collections of this type in primary care on a national level.

The CHD and Diabetes measures are collected using clinical software which initially posed a challenge for the program. To overcome this challenge, NPCC developed an extraction tool with the assistance of the Canning Division

Each month, NPCC analyse the data and provide feedback for practices, allowing them to monitor improvement.

The NPCC also monitors divisional and national results and progress towards the overall aims of the program. The measures are sensitive enough to track change as practices focus on different areas of their clinical or business systems, and provide assurance that changes implemented have resulted in an improvement.

Most GPs know, for example, that a patient is taking aspirin for a CHD condition, having prescribed it themselves, or aware of the prescription from the hospital or cardiologist.

However, when reports are run for the first time, often they cannot recognise or find data to produce accurate reports.

This is a direct result of coding and data entry protocols adopted by GPs and the broader practice team.

One practice in the Collaboratives program reported that each GP in the practice used a different term for Diabetes, finding Type 1, IDDM, NIDDM, and Diabetes Mellitus among the codes. Another practice recalled a male patient for a gestational Diabetes review, while many others reported embarrassing and upsetting recall letters sent to spouses of deceased patients.

“Practices need to adopt a standardised approach to data capture as this allows more effective reporting, which if used appropriately, can lead to significant improvement,” said Megan Grigg, NPCC Manager of Data and Information.

Participants in the Collaboratives program have invested significant time cleaning up patient records to establish accurate registers and commence accurate measurement. By coding correctly and consistently, such as recording a patient’s BP or HbA1c results in the right area, the clinical software can produce meaningful reports. Often, after the production of accurate reports, GPs find opportunities for improvement in many areas.

A large practice in Victoria reported that in the first week of their participation in the program they archived over 20,000 patients through diligently cleaning up their systems. They not only examined their CHD and Diabetes registers but the whole practice system, archiving deceased patients and all patients who hadn’t attended the practice in 2 years.

They have also noticed an increase in the speed of their software as a result.

With clean registers and effective systems GPs can know more about their patient population. They can accurately identify patients for recall and review, initiate exercise programs and diabetes education sessions, coordinate team care arrangements with allied health professionals, assess the need for a chronic disease clinic, and identify patients within high risk groups, or with increasing risk factors, for intervention and management.

General practice databases contain enormous amounts of valuable data that GPs can us to deliver proactive, systematic care, and many software packages have sophisticated tools to assist. But unless the patients are coded correctly and consistently, the software can’t retrieve the information GPs need to make informed decisions about patient care.

Linda Hein is the communications officer for the National Primary Care Collaboratives (www.npcc.com.au).

PULSE + IT 11

EDUCATION AND THE SPREAD OF HEALTH

COLUMNS: HISA

INFORMATION TECHNOLOGY Dr Brendan Lovelock, PhD, AFAIM, MRACI, C Chem

that education has become one of the critical factors limiting the deployment and effective use of health information technology in Australia. Let me explain the rationale for this.

Yes I admit it - I do have a passion for continuing education, particularly when it comes to health informatics. Education is a central part of the culture within HISA and is reflected in the delivery of our conference and seminar programs and our work with other associations. The last 6 months have seen a further growth in these activities, as we build our new online education programs aimed at enhancing the health informatics skills of both the general healthcare community and health informatics specialists. There are number of reasons why we are extending our educational services, but a core driver is the growing realisation

In Australia there are some compelling forces driving the increased use of health information technology. The growing complexity of health care, an ageing and more demanding population, along with limited financial resources have all led to a common belief in the need for change in our healthcare system, and the importance of information technology in enabling that change. Alongside this we have significant investments from information technology providers developing innovative solutions to these specific healthcare challenges. However, even with all this interest and activity, we

are finding it enormously difficult to implement the required system and process changes.

This difficulty seems to be independent of the model for delivery of these improvements. From the centralised change model of the British NHS, to the highly decentralized approach in the US, there is a universal concern that the changes we are driving are taking much longer and are much harder to deliver than was ever anticipated. To better understand this challenge we need to look in more detail at the forces that drive technology diffusion within a healthcare organisation.

Healthcare does have its own distinctive ecosystem of clinicians, managers and supporting staff, with often highly personalised motivations for the work

q Figure 1: Factors impacting Health Technology Diffusion

EXTERNAL INFLUENCES • Regulatory • Patient/User • Technological • Financial

Health Information Technology Diffusion

• Internal Perceptions • Change Characteristics • Management / Leadership

CAPABILITY • Skills • Physical resources

12 PULSE + IT

INTERNAL INFLUENCES

COLUMNS: HISA they do. However, within this unique environment, the factors that accelerate or restrict change appear to have strong similarities to industries outside of healthcare.

This was one of the conclusions of the Rand Corporation in their extensive review of the subject published in late 20051. Here they looked at the way health information technology, and in particular the electronic health record (EHR) had penetrated healthcare in the US. They found health technology diffusion could be interpreted with the same generals parameters used to understand technology diffusion in a broad range of other industries.

So what are some of these parameters?

The drivers of change within any organisation can be described by a combined set of external and internal influences as summarised in Figure 1. The internal organisational influences have been traditionally grouped into three categories (Rogers2) and they include the organisation’s perceptions of the innovation, their “culture” of change (innovators to laggards) and their leadership/management.

A primary conclusion from the Rand review for the healthcare community was the importance of perceptions.

That is, how people within the affected community perceive the benefit of the change, its compatibility with their own experiences, the complexity and risks associated with the changes.

There is a third set of influences that are often not well articulated when the subject of technology diffusion in healthcare is discussed. These are the factors related to the capability of an organisation to respond to change, the availability of staff with the skills and physical resources to envision, lead and manage change. It is this capability which strongly influences the clinician’s

perception and acceptance of change.

This issue of capability is at the heart of Berwick’s3 7 rules for technology diffusion in healthcare.

While, for Information technology projects, the physical resources of hardware and systems can usually be externally purchased, the challenge lies in developing the skill levels of personnel within the organisation. How do you create an environment where clinicians and health care managers understand and believe in the benefits of the information technology changes and the ability of the organisation to deliver them? This is the key question when trying to convince busy and committed healthcare professionals to divert their personal time and resources into systems changes where the benefits are often not immediately observable.

Developing this level of competency within an organisation requires not just the importation of a few health informatics experts or leaders (although this can be an important catalyst); it is about progressively building the information systems skill levels throughout the operation. This is a commitment that should be made at the earliest possible stage, and certainly before the critical systems design phase of any major implementation. This commitment needs to be maintained to ensure that investment in change finds strong roots within the organisation and is used to build future improvements.

To engage a highly educated and committed workforce, with little if any spare time, requires the delivery of compelling educational content, relevant to their skill level and needs, delivered on a flexible, as required basis.

It also needs to be highly customizable, to account for the broad spectrum of information systems skills and learning interests. Finally it needs to reflect the stage of development of the healthcare

organisation as a whole and be able to deliver on specific and immediate needs within the operation.

Now, while I don’t want to drag the conversation back into the 90’s with overused management clichés promoting the need to create a “learning culture”, the recognition and reward of skills improvement is going to be critical to success.

One of the challenges we have in health information technology is that education is often delivered during or after a change or system implementation has occurred. However education is a necessary precursor to effective change. To be able to engage the appropriate clinical and health managers and to ensure the support of the general healthcare community we need to significantly strengthen their health information systems awareness and skills. Their commitment and direct involvement is essential to the effective design and acceptance of complex health technology systems.

While HISA, through its national and international network of Health Informatics educators, has its own approach to targeted, flexible education, there are many approaches to delivering these skill development programs. I strongly urge health management and clinical leaders as well as individuals to seek out these options and further build the health information technology skills within their organisations.

If you are interested, I would be happy to further discuss these skills development issues. You can call or email me at HISA anytime.

Brendan Lovelock is the General Manager of the Health Informatics Society of Australia (HISA)

REFERENCES

QUICK CLICKS

1 - Bower AG, The Diffusion and Value of Healthcare Information Technology, Rand Corp 2005.

HISA www.hisa.org.au

2 - Rogers EM, Diffusion of Innovations, 4th ed. New York, NY. Free Press; 1995

Brendan Lovelock brendan.lovelock@hisa.org.au

3 - Berwick, DM, JAMA 2003, 289: 1969-1975.

PULSE + IT 13

COLUMNS: NEHTA

NEHTA DELIVERS SPECIFICATIONS TO STANDARDISE MEDICATION INFORMATION Dr Ian Reinecke In addition to this Medication Data Specification, which is contextindependent, NEHTA is developing further specifications to record and report medication information for specific needs – for example

Currently in Australia there are no standards relating to how medications are identified, named and described by computer systems used in the healthcare sector. This limits the extent to which medication information can be electronically exchanged between healthcare professionals and limits the efficiency with which healthcare can be delivered.

NEHTA has recently released specifications aimed at standardising the identification, naming, and describing of medicine information.

These specifications are: • Medication Data Specification, and • Australian Medicines Terminology Technical Specification.

UML Class diagrams complement both specifications and explain relevant information structures, concept names and data types in a concise, industrystandard format.

MEDICATION DATA SPECIFICATION NEHTA’s Medication Data Specification defines standard requirements for the electronic collection and exchange of data used in prescribing, dispensing, administering and reviewing medications to individuals.

The Medication Data Specification standardises the language used to name and describe clinical concepts related to medications, for use by computer system designers where medication information is to be captured, stored, exchanged or displayed.

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consistent with international standards, as NEHTA is working in collaboration with the UK’s NHS Dictionary of Medicines and Devices and the SNOMED CT Pharmacy Working Group.

... NEHTA is working in collaboration with the UK’s NHS Dictionary of Medicines and Devices and the SNOMED CT Pharmacy Working Group. e-prescribing, admission and discharge medications and medication lists for shared electronic health records. These context-specific specifications will all use the definitions and structures from this Medication Data Specification.

The Technical Specifications are part of a set of documents being developed by NEHTA to describe the scope, purpose, use, technical structures, governance and editorial policy of the Australian Medicines Terminology.

The Medication Data Specification forms part of a suite of data specifications that NEHTA is developing. The suite comprises specifications for a range of health topics or “data groups”, such as medications and adverse reactions and alerts, which are generally agreed to be of high priority to standardise.

ONGOING DEVELOPMENT

This Medication Data Specification is to be used in conjunction with other relevant NEHTA specifications, in particular the Australian Medicines Terminology.

Further information on NEHTA’s overall work program can be found at the NEHTA website.

AUSTRALIAN MEDICINES TERMINOLOGY The Australian Medicines Terminology delivers standard identification of branded and generically equivalent medicines and their components, and standard naming conventions and terminology, to accurately describe medications. The terminology is for use by computer systems, in both primary and secondary healthcare.

The ongoing development of the Australian Medicines Terminology will be

As the development of a terminology and data specifications is an iterative process, these specifications will evolve to accommodate changes in healthcare practices and feedback from users that share medication information between systems.

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

QUICK CLICKS NEHTA www.nehta.gov.au SNOMED International www.snomed.org UK National Health Service www.nhs.uk

COLUMNS: GPCE

COMPUTERS & CLINICAL CARE Jane London

In today’s Australia it is highly unusual to find a workplace that does not avail itself of information technology. General practice is no different, with less than 1 in 15 general practitioners working in a non-computerised practice1. However, information as to exactly how GPs and general practice staff use computers is relatively unmapped.

A recent Medical Journal of Australia article2 explored clinical uptake of computers and found it was reasonably high. Computers were used by 98% of the sample for prescribing and 85% to order laboratory tests. However, gaps remain where the use of computers is still only at low to moderate levels: recording reasons for prescribing (65%), recording progress notes (64%) and accessing patient material (63%) among them. BEACH data confirms these figures, noting that computers are predominantly used for prescribing purposes, with administrative functions such as billing also quite common3.

So how do we plug the gaps? What can you do with a computer to provide clinical care? Actually the question

should be: what can’t you do? Health summaries, past medical histories, prescribing, progress notes, recording investigations, immunisation information, chronic disease management, letters, audits, recalls and a number of other functions are contained within clinical software packages. It is simply a matter of learning to appreciate the advantages of electronic health records over your paper based system. If you are concerned your computer abilities aren’t up to scratch it is important to start small – once you have gained familiarity with one task, you can then opt to tackle another.

Therefore whilst the trusty computer is playing a part in the doctor-patient relationship there still exists the opportunity for further development of this tool. Behavioural adaptations are required by both GPs and practice staff. Relevant training and knowledge of software packages is also required.

Given that general practice has only increased its IT focus over the last 10 years, this ‘computer know-how’ could be a knowledge gap that needs to be bridged before behavioural adaptation can be properly tackled. Your local Division of General Practice may be able to provide you with IT training.

So what can busy GPs do to take charge of their clinical IT systems? : Do not try to take on too many new functions at once. If you currently use

REFERENCES 1 - Britt H, Miller GC, Knox S, Charles J, Pan Y, Henderson J, Bayram C, Valenti L, Ng A, O’Halloran J. 2005. General practice activity in Australia 2004–05. AIHW Cat. No. GEP 18. Canberra: Australian Institute of Health and Welfare (AIHW) (General Practice Series No. 18). Available at: www.aihw.gov.au/publications/index.cfm/ title/10189 [Accessed 15 May 2006].

2 - McInnes DK, Saltman DC, Kidd MR. General practitioners’ use of computers for prescribing and electronic health records: results from a national survey. MJA 2006; 185 (2): 88-91.

3 - Britt H, Miller GC, Knox S, op. cit.

your system for a number of tasks, add one more until you have successfully incorporated it into your consultation.

Be comfortable with your level of skill, rather than embarrassed – your patients know that you are a doctor, not an IT expert!

Also, find a routine that works for you.

Every doctor will have a different level of knowledge that they need to obtain, and therefore a different rate of uptake.

Talk to your practice colleagues and collectively agree on which functions you will adopt.

THE GPCG COMPUTERS AND CLINICAL CARE MODULE This education module is designed to guide GPs and practice staff through some of the tasks a clinical software package can perform. It is non-specific, so regardless of what kind of software package you have this module is relevant. It has clear learning objectives at the outset, begins with more basic concepts and contains a number of practical exercises to guide you. It is all about using the computer on your desk to improve the care of patients.

CONTACT 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 coordinating ongoing GPCG activities.

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

PULSE + IT 15

INTERVIEW

INTERVIEW: MEDICAL-OBJECTS Pulse IT checks in with Dr Andrew McIntyre, Director of Medical-Objects.

PULSE IT: What is a practice required to do to get up and running with MedicalObjects?

All that we require is a signed application form with Provider Number and address details to be faxed to us.

Installation takes about 10 minutes to complete if there are no firewall issues to resolve.

A HESA Location Certificate is not required, although should be loaded if available as it increases the flexibility of the clients.

With Specialist installs we need to understand the needs of the practice and plan the install a little more but each client install takes about 5-10 minutes.

PULSE IT: Can Medical-Objects be installed by a practice member, or is professional IT help required?

A practice member with basic skills and a login that allows administrator privileges is all that is required usually. If there are firewall issues to be resolved then IT support can be useful.

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

Anyone can install a client to receive messages for no cost. A client to send PKI signed referrals and GP to GP record transfers is also free. A basic specialist install with a Word Plugin is $450 a year including installation and telephone support. Additional workstation installs are $50 each. A more advanced Client with the ability to send images and create quick notes to GPs etc is $750 a year. Small pathology and radiology practices pay $1500 per copy annually.

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PULSE IT: How does Medical-Objects integrate with the practice’s clinical package, and which packages are supported?

Given the lack of standard integration points we generally integrate via the work plugin and can access demographic data for many standard packages. A number of lower level integrations are currently underway (using COM+ objects/SOAP and custom import routines).

PULSE IT: How is support for MedicalObjects supplied?

Telephone support is available 6am-5pm Monday-Friday EST. PULSE IT: In which geographical areas has Medical-Objects flourished?

We have 95% of Sunshine coast GPs online as this is where we started and continue to trial new software here. We have a large proportion of Geelong and Northern Rivers areas of NSW online and have all practices in the eastern Goldfields area online. Most of the Bayside and Redcliffe areas of Brisbane are online and we are slowly installing throughout Brisbane and the Gold Coast. There are scattered installs elsewhere, including PNG. PULSE IT: What technical aspects of the Medical-Objects offering differentiates it from other solutions on the market?

Medical-Objects has been designed from the ground up to be a Electronic Health Record Solution rather than a “messaging solution”. Delivering results to end users is a trivial role for the HL7 Framework behind Medical-Objects and whenever we strike problems in

integrating with a particular package we have the ability to massage the data in real time to overcome the issue.

Whenever possible we use real-time messaging for delivery and there is no central server or single point of failure in the system. We work hard to comply with standards and are the only organisation in Australia with AHML compliance for our messages. Our applications are native, and generally single exe solutions and with the exception of our J-Client do not require Java installed.

While HTTP is our preferred transport we can and do support Argus compatible Email, PGP and GNUPG Email and have a proved SOAP interface. Recently we added AS2 (RFC 4130) to our list of supported transports. Our latest generation of GP clients use a proxy interface which allows real-time point to point delivery to GP systems sitting behind firewalls. All protocols are open and specifications are publicly available.

In fact the network is open now to PKI encrypted/Signed result transfer.

As part of the Medical-Object solution we provide a HL7 based Provider Directory which relieves specialists from manually configuring every new GP and allows the discovery of remote Providers when you see patients who are on holidays away from home.

We are the only organisation with PKI signatures which allow paperless referrals. All other systems without this require that referrals be hand signed and the paper forwarded. In addition we support the dynamic conversion of reports to PIT, Text or Images, HTML or even a TWAIN emulator to allow scanning of HL7 data. We can modify the data at the endpoint to suit the needs of a particular PMS. This allows us

INTERVIEW to send images in HL7 and extract them as image files at the destination.

With Medical-Objects you have a messaging system designed for the world of real-time Electronic Health Records, rather than a system adapted to do the job now, but with no long term future. We use open standards and uniquely have proven compliance with standards. We are the only messaging provider that provides complete interoperability with another systems (Argus at this time) Currently a specialist with Medical-Objects can communicate with both Medical-Objects and Argus connected GPs. PULSE IT: What solutions does MedicalObjects offer Mac and Linux users?

We have our J-Client that runs on OSX, Linux, Solaris and Windows. It is a client that can receive results. Specialist with OSX can use Virtual PC to send out results. We are investigating a Native sending client for OSX and Linux.

We have also run our real-time Download Client and Medical-Objects Explorer successfully working on Intel based Macs and Linux using the CodeWeavers CrossOver tools.

PULSE IT: What role did MedicalObjects play in the Health Informatics Conference Interoperability Demonstrations in August?

Medical-Objects had software installed with every vendor in the demo and did all of the transport and interface engine work for the demo. We also played the role of several Hospital Specialists, a cancer registry, and provided provider lookup services for the demo. We also did all of the HL7 display for IBM using a HL7 to HTML SOAP service we have.

The demo was very ambitious and with only one setup day prior to the event the first day of the demo was very busy for us and many of the interactions were not working fully, mostly because of minor incompatibilities in the HL7 between the vendors. As we have seen in the real world simply connecting people is not enough, you need to be able to massage the HL7 a little to make things work smoothly. On the first day we had to identify the issues and configure our

clients to make the necessary changes to the messages as they flowed through to recipients. Once this had been done the demo worked pretty well.

Our delivery is really a small part of what we do and mirrors what happens in the rest of the applications except we save the results as files rather than display it.

Not all vendors had AHML compliant 2.3.1 HL7 messages, and some were running older versions of HL7. To get 10 vendors talking to each other in 2 days is actually an example of how solid HL7 V2 actually is, as the level of complexity of the data was quite high.

On the Sunshine Coast about half the specialists use Medical-Objects and many allied health providers are now using it as well. We are also handling all the clinical data for the Outpatients at our local hospital as we can bring together all the data sources and present it as a homogenous HL7 based interface. We have successfully integrated with the discharge summary system at the local public hospital without installing a single piece of software on their system.

We used our new real-time SOAP/HTTP clients for the demo and it was a big workout for them. We also implemented AS2 (RFC 4130 MIME-Based Secure Peer-to-Peer) to talk to the SUN identity service and that worked flawlessly.

Communication between the players was all encrypted and all real time, using a combination of HTTP, AS2, SOAP and HL7 Lower Level protocol. You really need a have a Swiss army knife client to make things happen in the real world, and the demo was really quite similar to the real world.

For the GP nodes in the demo we provided our Referral client that uses PKI individual tokens to digitally sign the messages with a HESA Signature, making them acceptable to Medicare Australia as paperless referrals.

On the specialist side we demonstrated archetype based orders, with automatic transfer of cancer diagnoses to the cancer registry. We also used the Word Plug-in to generate reports which were then sent to other parties in AHML compliant HL7.

Overall it was positive evidence that interoperability is possible now.

PULSE IT: Aside from secure messaging products, what other solutions does Medical-Objects offer?

We started out looking to build HL7 reporting tools, and realised that a component based software framework was the only sensible way to go to enable reuse of code to occur. This was a much bigger job that initially thought, its probably taken 5 years to mature, but now allows us to rapidly build any application that requires HL7 processing, communication or display.

We also understand SNOMED-CT well and have a SMOMED-CT server available now. We have DICOM and picture archiving abilities and this is used by radiologists and as we grew out of a Day surgery this is in use by ourselves and many other specialists.

We were the first, and are still the only HL7 system that has been certified as being compliant with the Australian standards by the Australian Healthcare Messaging Laboratory (AHML).

More recently we have been extending the framework to incorporate advanced clinical decision support tools and have implemented Archetype support, and a Gello compiler (The first Gello compiler in the world) and with this have been doing a project to provide high level decision support for lymphoma treatment in conjunction with Haematology Society of Australia and New Zealand , the Leukaemia Foundation, Sullivan Nicolaides Pathology, and Queensland Medical Laboratories.

Pulse IT invites organisations and individuals interested in participating in a future interview to contact the editor.

QUICK CLICKS Medical-Objects www.medical-objects.com.au Health Informatics Conference www.hic.org.au

PULSE + IT 17

QUESTION TIME

QUESTION TIME: SOFTWARE VENDOR

Pulse IT has some questions for your potential practice software vendors.

Computers continue to play an ever-increasing role in the delivery of health care. From an IT perspective, nothing has more of an impact on the way a practice functions than the practice software and the company behind it. To that end it is crucial that you are well informed about both the product and the organisation.

How is support provided?

While the features of a software package are easy to evaluate, the quality of the support an organisation provides is much more difficult to assess.

In addition to references and testimony from other practices, the following information should be of assistance: • Can the data conversion, software installation and training be performed in-house or is a company representative required?

• What times is telephone support available?

• Does your company have any staff or agents in our area for problems requiring onsite assistance?

• Can your company remotely access our practice to provide assistance and training?

Does my Division have expertise in your product?

While Pulse IT strongly suggests choosing a software vendor that provides direct technical support for their products, Divisions have long provided effective IT support to practices. Most Divisions are proficient with Medical Director, but more progressive groups are also able to assist with competing packages such as Best Practice, Genie, MedTech and Practix.

Which IT support organisation do you recommend?

As most software vendors try to avoid involvement in network and hardware related issues, all practices need to have a relationship with an IT support organisation if an appropriately skilled practice member isn’t available.

Compared to common Microsoft programs and other mainstream software solutions, practice software is relatively rare. To that end, many IT support organisations will not have heard of practice your software, let alone know how to effectively support it.

Your software vendor should be able to suggest IT support

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organisations that have expertise in their software and practices that should be able to provide references for these groups.

What competing packages can you convert data from and to?

While data conversions are obviously important when you change practice software, it is also important to be confident that your software vendor can import data from other clinical packages in the event of a practice merger.

It is equally important for practice software to have the ability to export data into a format that other vendors can access easily.

How often are software updates provided?

While some see software updates as a blessing and others a curse, they are an essential component of practice software. As practice software has matured, updates have become easier to install, however pre-planning is still necessary to ensure a smooth upgrade.

Unless there is a regulatory requirement or critical flaw that will be addressed by an update, Pulse IT encourages practices to defer upgrades for at least a week after their release. Usually this is enough time for other users of the package to identify any bugs and for the developer to provide a solution.

How are software updates delivered?

As broadband Internet becomes more prevalent, most vendors have opted to make at minor updates available online.

QUESTION TIME If, for some reason, you are resisting broadband, ensure that your software vendor will continue to supply you with regular updates on disk.

Is the program’s manual updated with each software revision?

When requesting an evaluation version of a practice software package, take note of how well its features and functionality match the supplied documentation.

Even the most comprehensive manual will be of limited benefit if it lags behind the version of the software your practice is running.

What other training resources are available?

Despite many vendors producing high quality documentation, a significant number of doctors, practice staff and IT professionals seem averse to the notion of actually reading it.

Perhaps in an effort to cater to this group, some vendors and third party companies have put considerable resources into developing training videos that provide a concise overview of their products capabilities.

Training videos don’t negate the need for comprehensive written documentation, but they can be an effective training tool, particularly for new staff.

Do you have a web forum or email discussion list?

Most doctors, practice staff and IT professionals who subscribe to these services find them to be a very useful resource. In many cases they also provide an avenue for the users of the software to liaise with its developers.

Monitoring a vendor’s forum is perhaps the best way to gauge satisfaction levels of the existing user group.

Which secure messaging products do you integrate with?

There are many products that enable efficient, secure and audited transmission of patient information over the Internet. In addition to discussing your requirements with potential messaging providers and the colleagues with whom you will be corresponding, it is a good idea to discuss these products with your practice software vendor.

While basic compatibility with most secure messaging solutions is probable, some products will have tighter levels of integration resulting in a more efficient workflow.

What major developments are you currently working on?

While all vendors have ever-expanding “feature request” lists, it is useful to know what enhancements to expect around the corner.

How many practices do you currently have using your solution and what is your growth rate?

The number of practices using a software product is not necessarily a good indication of the strength of the solution, but it does provide an indication of the ongoing viability of the organisation.

The growth rate (i.e. the number of new sites a vendor is installing per week) is perhaps the best indication of how a product is being received in the market.

What is the cost of an additional license and what is it based on?

As staff numbers increase and practices become more computerised, additional licenses will generally be required. For budgetary reasons it is useful to know what additional upfront and recurring costs will be associated with an additional license. It is also worth asking what a license is measured against i.e. per computer, FTE, concurrent user etc.

Do you make provisions if we want to reduce the number of licenses?

As many vendors themselves have to pay license fees for the software they sell, it is unlikely that a license fee will be refunded in the event of a staff member leaving your practice. Annual fees however, should reduce slightly in such an event.

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COVER STORY

PIP IM/IT CHANGES DEMYSTIFIED Simon James BComm, BIT

INTRODUCTION In November 2005, the Honorable Mr Tony Abbott, Minister for Health and Ageing announced changes to the Information Management/Information Technology (IM/IT) component of the Practice Incentive Program (PIP).

point to the short time between the information packs reaching practices and the compliance deadline as being unreasonable, especially given the significant additional effort practices will need to expend to comply with the new requirements.

When general practices received the details of the changes from Medicare Australia in August, the reason for the warning became apparent. While the overarching tier structure had been simplified, the specific requirements of each new tier were significantly more substantial than their predecessors.

Practice Software And Enforcement Most popular software products can’t easily or accurately extract information that compliance relies upon. Though this may change with future software updates, most practices will not be able to easily extract the number of “active patients” i.e. the number of patients that have attended a the practice three or more times in the past two years.

Further, at least one popular clinical package stores allergy information in a manner that makes it difficult to check compliance of the Tier 1 allergy requirement.

PROBLEMS

BENEFITS

Practices have identified several issues with the new requirements and the way in which they have been imposed on general practice:

Despite these issues, the new requirements are based on technically sound principals and shouldn’t be dismissed as needless bureaucratic interference. Actively engaging these requirements can yield many tangible benefits including:

Despite the number of incentive tiers dropping from three to two, the ministerial press release warned that the changes would require “lead time for GPs to organise their practices to meet the new Tier requirements.”

Ambiguous Requirements Many GPs have cited ambiguous and contradictory passages in the supplied documentation as a cause of confusion and frustration. As many people have publicly reported, conflicting answers from Medicare Australia to relatively straightforward enquiries have compounded these problems.

Inadequate Timeframes Despite being announced in November 2005, there is still the perception that the PIP changes have been imposed with unrealistic timeframes. Many

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Money Being a financially driven incentive program, the prospect of maintaining or increasing their existing IM/IT payments will be the primary motivating factor for all practices.

As demonstrated in this article, compliance doesn’t have to be costly or time consuming. With a potential combined payment of $7 per SWPE per annum, the financial incentives

available are reasonable for most practices and should outweigh any compliance costs.

It could be acknowledged, however, that smaller practices with minimal levels of computerisation may not find the incentive enough to justify the substantial time investment required to comply.

Improved Risk Management Most malpractice stories report problems relating to poor clinical records management. By complying with the new PIP and accreditation requirements and making better use of their existing computer systems, practices should be in a much better position to minimise medico-legal risk as well as improve patient care.

Future Proofing The core of the previous IM/IT requirements date back to 1999, however the next IM/IT revision won’t take 7 years to materialise. Compliance with the new requirements will improve a practice’s preparedness for future computer related challenges.

DISCLAIMER While every effort has made to ensure the content of this article accurately reflects the intent of the 2006 IM/IT PIP requirements, practices will need to take into account their individual circumstances and the information provided my Medicare Australia when preparing for compliance. If you have any queries, please contact the PIP enquiry line on 1800 222 032.

COVER STORY TIER 1 - BASIC To be eligible for Tier 1, practices must: 1. Use electronic patient records to record allergies/sensitivities.

2. Implement various IM/IT security measures as outlined in the Security Self Assessment tool (SSA).

Allergies The recording of allergies, including a positive statement that there are no known allergies if appropriate, is now a requirement for both new accreditation standards and the IM/IT PIP changes.

The recording of allergies provides a means (with most software packages) to automatically identify potential risks to patients when prescribing.

IM/IT Security Measures Compliance with this component of Tier 1 is far more interesting.

The SSA lists 27 sub-requirements which Medicare Australia claims may be used to assess compliance at audit.

These requirements are heavily based on the comprehensive GPCG Security Guidelines (GPCGSG) created prior to the groups defunding.

Among other things, adhering to the SSA essentially requires a Computer Security Policies and Procedures Manual (CSPPM) to be created. Fortunately the GPCG have a skeleton template that should facilitate this documentation process.

Both the GPCGSG and CSPPM template are available from the GPCG website or directly from the following links: • GPCGSG - tinyurl.com/yc3hbk (PDF) • CSPPM - tinyurl.com/yfp7vh (Word) It is recommended that both of these documents be available while considering the SSA. Please note that the section numbering in the CSPPM doesn’t directly match that of the SSA provided

by Medicare Australia. Further, the CSPPM contains additional sections that practices are not required to complete to comply with the new requirements.

The following section of this article provides specific guidance to assist practices to comply with the requirements outlined in the SSA.

1. PRACTICE COMPUTER SECURITY COORDINATOR 1.1 Practice IT security coordinator nominated.

For most practices, this requirement will simply formalise the position of a person already acting in this role.

In addition to an IT coordinator within the practice, increasingly practices will have to engage qualified IT personnel or consultants on a part time, or even full time basis for larger sites. Having a practitioner with an interest in IT may simply not be enough and issues such as continuity of service need to be considered.

1.2 Practice IT security coordinator’s role description written.

A few generalised dot points should be all that is required to encapsulate the role of the IT security coordinator.

1.3 IT security training for coordinator provided.

While the concepts of IT security are easily understood, it is unrealistic to expect a staff member without formal IT education or professional work experience to make informed IT security decisions. To that end, “training” is likely to be ineffective and qualified IT assistance should be engaged for matters relating to networks and the secure transmission of clinical data.

1.4 Security coordinator’s role regularly reviewed.

This task could be performed every three months and after any major staff changes.

2. PRACTICE IT SECURITY POLICIES AND PROCEDURES 2.1 Person appointed to document security policies and procedures.

The practice or nominated IT security coordinator will need to appoint someone for this task.

2.2 IT security policies and procedures documented.

As indicated earlier, the CSPPM template available from the GPCG website is a good starting point for this document.

Once completed, this document should form part of the wider practice systems manual.

2.3 IT security polices and procedures documentation regularly reviewed.

This task could be performed every three months and after any significant IT system change.

2.4 Staff trained in IT security policies and procedures.

As with requirement 1.3, training should be aimed at the conceptual level with the specifics left to IT professionals.

3. ACCESS CONTROL 3.1 Staff policy developed on levels of electronic access to data and systems.

All modern practice software allows different permission levels to be assigned to different users. Before attempting this in your software, simply document the access level assigned to each user.

3.2 Staff have created personal passwords to access appropriate level.

After assigning and documenting these access levels, configure these in your practice software. Consult your software vendor if you need clarification on this procedure.

3.3 Passwords are kept secure.

In other words, passwords should be nontrivial, only known by their owner and committed to memory. Ideally staff will be required to change their passwords at regular intervals. An overarching administrator password for the practice principle should also be established.

4. DISASTER RECOVERY PLAN 4.1 Disaster recovery plan developed.

Practice staff are used to dealing with imperfect IT systems and many already have contigencies plans in place to deal with downtime. Common scenarios to consideration include: • • • • •

Front desk computers down Clinicians computer down Server down Internet unavailable Data corruption

The most important piece of information in any disaster recover plan is the contact details of qualified help if the disaster deviates from or exceeds the recovery plan.

4.2 Disaster recovery plan tested.

Testing the above scenarios in a controlled environment is essential if the

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COVER STORY recover plan is to be relied on. In most cases it should be easy to simulate the disaster for testing purposes.

4.3 Recovery plan regularly updated.

Recovery plans need to be reviewed with the installation of new hardware, software, backup systems or Internet connections.

5. CONSULTING ROOM AND “FRONT DESK” SECURITY. 5.1 Practice aware of need to maintain appropriate confidentiality of information on computer screens.

Staff should simply be reminded that their computer terminals are the gateways to large amounts of sensitive information. Screen savers are now an accreditation requirement and their presence shouldn’t be unfamiliar to practice staff.

5.2 Screensavers or other automated privacy protection device enabled.

In addition to having screensavers configured to engage after short periods of inactivity, a key combination or “hot corner” to manually activate the screen saver should also be configured.

Wearable hardware devices that activate and disable screensavers based on the user’s proximity can also be deployed and can make compliance less invasive to a practice staff member’s workflow.

6. BACKUPS 6.1 Back-ups of data performed at a frequency consistent with the disaster recovery plan.

The concept of backing up data should be well understood and procedures should already in be in place in all computerised practices.

the size of the backed-up data file should be performed daily.

6.4 Back-up procedure has been included in a documented disaster recovery plan.

The back-up procedure needs to be documented thoroughly enough to ensure that any practice staff member can safely complete the procedure.

7. VIRUSES 7.1 Anti-viral software installed on all computers.

Practices are advised to consult with their IT support organisation and practice software vendor to assist in selecting and installing an anti-virus software.

Despite a lack of credible virus threats, Mac and Linux users are not exempt from this requirement. Fortunately free solutions exist for both platforms.

7.2 Automatic updating of virus definitions enabled.

Due to the vast number and frequency of malicious programs released, virus software needs to be frequently updated to ensure it can detect and remove new viruses.

While this process can be performed manually, all modern virus scanning software has an automatic update feature to download new definitions.

There is little downside to enabling this feature and a non-technical user should be able to configure this.

7.3 Staff trained in anti-virus measures as documented in policies and procedures manual.

Staff need to know how to respond to virus warnings and be able to check logs to see if testing is ongoing and working.

6.2 Back-ups of data stored offsite.

A current copy of the important practice data should be taken offsite at the end of each day. The security of this data needs to be ensured. Ideally this will be achieved using both physical and technical methods (i.e. encryption).

Practices should note that virus software has the ability to delete data from a system, so caution needs to be exercised when handling any detected viruses.

6.3 Back-up procedure regularly tested.

Simulating data corruption or loss is the best way to test a backup procedure.

Test restorations and verification should be performed at least each month.

Other simple checks such as inspecting

8.1 Hardware and/or software firewalls installed.

Most modern broadband modems and routers have a basic firewall builtin. These devices are often factory configured with security settings

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8. FIREWALLS

appropriate for immediate use in a typical practice. Despite this, the importance of having your hardware firewall correctly configured cannot be understated and professional IT assistance should be obtained if there are any doubts.

All modern operating systems have built-in software firewalls that can be established to compliment the overarching hardware firewall. Practices should note however that incorrectly configuring a software firewall can have negative effects on your practice software.

8.2 Hardware and/or software firewalls tested.

As with their safe establishment, comprehensive firewall testing is not a trivial exercise. As such, it is unrealistic to expect a typical practice member to be able to meet this requirement and qualified IT assistance should be engaged.

9. SYSTEM/NETWORK MAINTENACE 9.1 Computer hardware and software maintained in optimal condition.

All popular operating systems allow security patches and other software updates to be downloaded easily.

Unless your IT support organisation advises differently, configure your software to regularly check for and download updates.

The physical security of your computer hardware (especially your server) should be considered. In the very least, a specialised computer security cable should be attached to your server to minimise the chance of theft.

10. SECURE ELECTRONIC COMMUNICATION 10.1 Encryption used for the electronic transfer of patient information and/or clinical data.

This requirement is designed to highlight the dangers of using unencrypted (typical) email for the transport of patient information. While we expect fax and the postal system will come under scrutiny in future PIP IM/IT reviews, this requirement doesn’t seek to prevent your practice from using these traditional communication methods.

COVER STORY DEFINITION: ACTIVE PATIENT An active patient has an active health record. The RACGP Standards for General Practices, 3rd Edition defines an “active health record” as a record of a pateint who has attended the practice three or more times in the past two years.

TIER 2 - ENHANCED To be eligible for Tier 2, practices must comply with the requirements of Tier 1 and ensure that two key types of clinical information are recorded electronically for the majority of active patients: 1. Major diagnoses 2. Current medications Medicare Australia leaves the clinician to decide on the definition of both of these terms.

Compliance with Tier 2 is worth an additional $3 per SWPE per annum.

For practices that currently use their clinical software for prescribing only, compliance with Tier 2 is likely to take a concerted effort over many months.

According to staff on the Medicare Australia PIP enquiry line, these practices will need to identify their active patients, and then retrospectively enter major diagnoses (and current medications if this isn’t already stored) into their clinical software.

Dr Paul Mara, managing director of GPA said that practices should develop a formal plan to ensure records are updated as patients present.

“Particular attention to the patient health summary including documentation of allergies, major risk factors, past history and current problems. As the Medicare Australia documentation indicates, it is important to record ‘no known allergies’ and not to have this as an assumption in the absence of recorded data.”

“Increasingly we are noticing that medication lists are out of date. These should be reviewed as part of the normal consultation process.”

SWPE will not go close to meeting the compliance and establishment costs.

The revised IM/IT requirements are appropriate to ensure patient confidentiality and the security electronic health records. They should allow practices to take full advantage of clinical datasets and improve patient care.

The changes are likely to stimulate the secure messaging market, a positive consequence that should result in safer and more efficient communication of clincal information and ultimately facilitate the interoperability of disparate systems.

Practices that have been more proactive with their electronic records keeping are likely to be compliant already and need do little more than tick the “yes” box on the provided application form.

On the back of the confusion and criticism surrounding the changes, it’s difficult to imagine the IM/IT PIP goal posts being shifted in the near future.

Despite this, gradual and more frequent revisions to this incentive would be in the best interest of general practice.

CONCLUSION

PIP IM/IT 2008 anyone?

Compared to the antiquated and modest requirements they replace, the revised IT/IM PIP are likely to have a tangible and immediate impact on the use of computers in general practice.

For large, well computerised practices, the incentives may be adequate and in some cases quite generous. For smaller practices with modest levels of computerisation, the $7 total per

Simon James is the editor of Pulse IT.

QUICK CLICKS Medicare Australia (PIP) www.medicare.gov.au/PIP/ General Practice Computing Group www.gpcg.org.au

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FEATURES

POTS AND PANS Dr Tony Lembke MBBS, FRACGP, FRACRRM, DRACOG

Ring, Ring, Why don’t you give me a call?

My 4th Class textbook was confident that the telephone was invented by Alexander Graham Bell in 1876. His rather uninspiring first words were said to be “Mr Watson, Come here, I want you”.

What Mr Bell wanted Watson for was not documented in ‘Social Studies for 4th Class’, 1972 edition.

Travel broadens the mind. I have recently journeyed to Italy, (well, New Italy, Woodburn, if we are going to be accurate), where I visited a museum devoted to that great Italian inventor, Antonio Meucci, and to the telephone he demonstrated in 1849!

Indeed, Wikipedia informs me that the British government has recently decreed that schools are to acknowledge Meucci as the first inventor of the telephone. (In Australia our post modern curriculum doesn’t bother itself with that sort of stuff). It appears that the major beneficiaries of the new technology for the first 50 years were patent lawyers.

POTS So that’s the POTS (Plain Old Telephone Service). You speak into a diaphragm at one end, the vibration of which causes a diaphragm at the other end of a wire to vibrate the same amount, producing sound. Not much change in the last one hundred years (if you disregard the development of the electret microphone, the manual switchboard, the rotary dial, the automatic telephone exchange, the computerised telephone switch, touch tone dialing, roads, law and sewerage).

PANS Now for the PANS (Pretty Amazing New Stuff). Telephony is going digital - in the same way that digital CDs have replaced analog LPs, and digital DVDs have replaced video tape. The

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advantage of this is that you can make calls via the Internet - bypassing the telephone network, and therefore Telstra and its phone bills. As the Internet network is used, this technology is often known as VOIP (Voice Over Internet Protocol), or Internet telephony.

VOIP The main advantage of VOIP is that it is cheaper than normal telephone calls - in fact, it can be free. There are other advantages with regard to mobility - instead of being tied to a particular physical telephone, your VOIP number can follow you wherever you happen to be. To use VOIP, you do require broadband Internet access, and it is better with unlimited or high data transfer limits.

The clarity of a VOIP call can be quite variable, depending on the Internet access speeds of each participant, the congestion on the network, and the quality of the microphone and speaker used. Sometimes the conversation can be crystal clear, sometimes there will be considerable delay, and ‘jitters’.

So, how do you use VOIP? There are two main ways - one using your computer, with or without accessories, and one using your normal phone.

VOIP USING YOUR COMPUTER Using Internet telephony via your computer requires special software.

There are a number of options, but the most widely used is Skype (which has recently been purchased by eBay).

The Skype software is available free of charge for MacOS X, Windows and Linux. It is easy to set up - you download and install the software, and then register a username and password with Skype. To phone someone who also uses Skype, you search for their username from the Skype database, and press dial. Hey presto - if they are also online, their computer will ring, they answer and

you can speak to them through your computer microphone and speaker.

There is no charge at all for a Skype to Skype call, from anywhere in the world, to anywhere in the world.

Video conferencing, multi-user audio conferences, text messaging and file transfers are also possible with Skype.

Skype Out What if the person you are calling is not set up for Skype, but just has a plain old telephone? No problem. You can get an account with Skype that allows you to call from your computer to nearly any phone number in the world, for about 2c a minute. This is a boon when travelling with your laptop. If you can get an Internet connection, you can, like ET, phone home.

Skype In You can also obtain a phone number through Skype, through which anyone with a phone can contact you. So if you live outside of Sydney, you can still obtain a Sydney SkypeIn number that will enable your family and friends to ring you for a local call. If you do a lot of work in New York, lease a New York SkypeIn number.

VOIP WITHOUT A COMPUTER A number of companies now make it possible to use VOIP services without a computer, although you do need to have a broadband account. For example, the company Engin sells a Voice Box, which you connect to both your broadband line and your existing phone line. After a $10 monthly charge, untimed local calls can be made to anywhere in Australia for 10c, and overseas for 3.5c / minute. Engin to Engin calls are free.

VOIP AT WORK VOIP technology is now often used by companies for their internal telephone systems. North Coast Radiology uses

FEATURES the Asterisk open-source VOIP system to manage calls between their scatterred radiology suites, creating a private exchange that extends over 800km from Sydney to Mullumbimby. Dr Nick Repin is responsible for implementing the system, which has some cool functions that would be impossible to implement without digital telephony. As he says ‘The Linux PBX allows integration with the other IT systems in the organisation to a level we’d never have dreamed of a few years ago.’

For example, to call Nick internally, just dial his initials - ‘nr’. Cleverly, the software looks up the staff rosters to determine where the call should be forwarded - it knows whether he is working that day in Byron Bay or Casino. The prefix 7 enables role based dialling - ‘7012’ will get you the on call radiologist, wherever he or she is.

Nick says ‘Asterisk based conferencing has also been a major benefit, as calls from all internal phones and indials can be joined together simply into (free!) conferences. We are finding this exceptionally useful.’ All the VOIP

phones can dial out into the ‘normal’ phone system - so to ring me as the doctor who referred a particular patient for an X-ray, Nick simply has to click the ‘Referrer’ button in the patient’s window of his reporting software, and I’ll be rung.

The division has applied for a government grant to manage a broadband ‘Health Network’ that, among other things, would facilitate the widespread adoption of VOIP by health providers in this region. All calls between health providers and institutions would therefore be free, and we would have the capacity to utilise some of the technology used by North Coast Radiology. Need the on call surgeon - dial ‘8surgeon’!

station of which plugs into both the computer and the normal telephone socket. It communicates directly with the Skype software, so that you can access your Skype address book from the phone, and make and receive VOIP calls without needing to be seated at the computer. You can, of course, also make and receive normal phone calls from the same phone. And ‘hot off the press’ is the introduction of mobile VOIP phones, which connect to Skype and make free calls without a computer from any wireless hotspot. Sweet, as the gadget kids would say.

Tony Lembke is a GP in Alstonville, NSW, and is a regular columnist on medical computing issues.

GADGETS

QUICK CLICKS

Luckily, you can spend all the money you save on calls by buying VOIP-related gadgets! You can decrease feedback and improve the clarity of your calls by plugging a headset into your computer.

There are also a number of USB phones available, that look like normal phones but attach to a USB port. At home we have a cordless ‘dualphone’, the base

Skype www.skype.com Engin www.engin.com.au Asterisk www.asterisk.org

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FEATURES

DESERT ISLAND APPLICATION:

WEB 2.0

Dr Tony Lembke MBBS, FRACGP, FRACRRM, DRACOG When you are next shipwrecked on a desert island, and find a laptop among the flotsam, you’ll be glad to know that you’ll be able to open all your own documents - of any type - with just one application, which you can download free. (Make sure that you are marooned on an island that has Internet access).

the application market with its Office suite. New tools either developed (or purchased) by Google Labs can replace Word, Excel and Outlook - and are available free. Many of these services are still in beta (testing) mode, and require an invitation to use them.

Recent developments in web programming techniques have enabled the ‘humble’ web browser to perform all the functions normally associated with word processors, calendars, email clients, organisers, photo albums and even spreadsheets.

Internet Explorer is still used by 70% of web users, and can be used to access these new services. However, I recommend you download ‘Firefox’, the latest incarnation of the open source Mozilla / Netscape browser, which has a number of attractive features and is highly customisable. A handy new feature (from Google!) allows your bookmarks, history and passwords to be synchronised between all the computers on which you use Firefox.

The documents you produce using these services are stored on a central server, available from any computer that you happen to be using. I frequently use one of two computers at home, one of many at work or at the division, and sometimes need to use other peoples’ computers.

Using these online services, it doesn’t matter what applications are installed on these computers, or even whether they use MacOS, Windows or Linux - all my documents can be accessed at any time I have Internet access. The software that is used is always the latest version and the documents are automatically backed up.

Apart from this ‘access anywhere’ capability, the great advantage of online services is that they facilitate sharing and collaboration - you can allow selected people to access your documents for viewing or editing, from wherever they may be. Changes made by anyone are logged, and you can compare one version of a document with a previous version. Shared photos and bookmarks add to a sense of community.

FIREFOX

http://www.mozilla.com/firefox http://www.google.com/tools/firefox/ browsersync/index.html

WORD PROCESSING Writely.com, one of Google’s many aquisitions, provides a Word-compatible word processor. It has all the features that you would normally use in Word, including spell checking, toolbars and a WYSIWYG (what you see is what you get) display. Your document is automatically saved every 30 seconds as you type.

You can invite others to collaborate on your document, and you can ‘roll back’ to any previously saved versions you choose. You decide who (if anyone) has access to view or edit your work.

Documents can be exported as Word or web ready HTML files, or be made ‘public’ as they are. In fact, I’m writing this article using Writely!

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Google Mail is a web based email service, like Hotmail. Web 2.0 technology allows for more sophisticated functionality, and Google provides a whopping 2 Gigabytes of storage space. Your messages can be searched using the efficient Google search engine we are accustomed to, or you can download your messages to an offline client (eg. Eudora or Outlook) if you prefer. http://mail.google.com

CALENDAR Google Calendar allows you to organise your schedule and share events with friends and colleagues. Google calendar can integrate with Outlook and iCal, and has the advantage of being accessible online at any time. So make an entry at work, and your home diary will automatically be up to date.

The basic format of Google Calendar will be familiar to those who use Outlook or iCal. You can create as many different ‘Calendars’ as you wish - say Work, Home, Sport - and elect to keep them private, share with particular friends, or make them available for the whole world. So you can now search from within Google for the Lismore Rugby Club Under 12’s draw. As Google Calendar adheres to open standards, many shared calendars are already available, including School Holidays.

The full text of this article is available at:

For a web based application, Google Calendar is surprisingly easy to use - View

by Day, Week, Month, or show your coming Agenda. Add an event just by clicking on the appropriate time slot, or use the ‘Quick Add’ feature to schedule an event with an instruction like ‘Lunch with Mum on Sunday at 2.00pm’. You can be notified of upcoming events by email or even by SMS (US only, currently).

http://www.writely.com/View.aspx?doci d=bcjm23vpqpv2t

You can send invitations to an event, and invitees can RSVP through the

http://www.writely.com These services are sometimes known as Web 2.0, and much of the momentum is being generated by our friends at Google. A showdown is developing with Microsoft, who currently dominates

MAIL

FEATURES calendar. If you have a special event planned, you can create a Button to add to your web site that will automatically add the event to visitor’s calendars.

use Flickr to display their skills, as many excellent shots can be viewed in the public gallery.

We are using Google Calendar at work to provide access to our on-call roster and reminder about particular meetings.

We are also using it at the division so that members can integrate our CPD calendar into their own schedule.

PROJECT MANAGEMENT

http://calendar.google.com

PHOTOS Flickr is an online photograph management and sharing site. You can upload your photos, arrange them into albums, and allow other people to view them (if you wish). You can establish a ‘group’ album, to which others can also add photos - say, a place for all the guests at a wedding to upload their favourite snaps. Tools for Windows and Mac allow you to add a whole bunch of photos at once, and you can even email them directly from your camera phone to your Flickr account. Clearly a number of excellent photographers

http://www.flickr.com

37signals.com has a number of products that facilitate project communication and collaboration. ‘Basecamp’ is their top of the range model. It allows you to assign to-dos and tasks, post messages and gather feedback, schedule, share files and track time. ‘Campfire’ provides a simple chat for your organisation.

‘Backpack’ includes a free lite version that handles the notes and list sharing functions of Basecamp, while Ta-Da list is a very simple (free) to-do list application. http://37signals.com

BOOKMARKS del.icio.us is an unusual concept, but addictive after you get used to it.

Basically, del.icio.us allows an easy method to bookmark sites you are visiting, storing them on a central database. You can access your own bookmarks from any computer, and

‘tag’ them in a certain category. This is useful in itself, but the power of the site comes from the aggregation of the thousands of sites that are bookmarked each hour by the hundreds of thousands of users. The most popular site this hour - ‘You Look Like I Need a Drink - T-Shirts you didn’t know you needed’. http://del.icio.us

NEXT? Alstonville has not yet made it to Google Maps - so I suspect that you’ll still need a chart to find your way off that desert island. Web services haven’t yet replaced local desktop applications in functionality - but their convenience, accessibilty and capacity for collaboration have me convinced. I’ll back Google and Web 2.0 Tony Lembke is a GP in Alstonville, NSW, and is a regular columnist on medical computing issues.

QUICK CLICKS Email Digest www.emaildigest.com

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FEATURES

DIGITAL PHOTOGRAPHY FOR BUSY CLINICIANS

Part 2 - Choosing a digital camera for clinical work Dr Daniel Silver MBBS, Bmed Sc, DRCOG, FRACGP The first article in this series presented a persuasive argument for doctors to consider using digital photography in their routine clinical work. This article will focus on how to choose from the large and ever-increasing number of different models of digital cameras currently available, a task which may seem daunting to those setting out to buy their first digital camera. Almost every day new camera models are announced with more features and greater resolution while at the same time the cost for all these features and increased resolution keeps falling. The complexity of the terminology used to describe new cameras’ features can be baffling for novices and it is not surprising that unscrupulous salespeople persuade novices to purchase cameras inappropriate to their needs and sometimes beyond their budgets.

PURCHASE GUIDELINES Here are some very simple and logical guidelines which will help to reduce the risk of buying something that isn’t appropriate to your needs: 1. Intended Use Decide first up what you want the camera to do for you or, to put it another way, decide what you want to do with the camera. If you want the camera only for clinical work in the surgery then you should choose a camera wich is especially good for closeup or “macro” photography.

Closeup simply means getting as close as possible to the subject so that it appears magnified! Cameras which are able to focus when the front of the lens is as close as 1-3 cm from the subject may provide excellent closeup photos.

However the expensive macro lenses available for digital single lens reflex (SLR) cameras can provide fantastic macro images without having to get so close to the subject. Unfortunately these cameras are quite expensive, bulky and

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heavy and require much more expertise to use correctly than less expensive amateur cameras which may well provide wonderful closeup photographs.

Also, before you buy a digital camera for clinical photography consider whether you want the camera to work with a dermatoscope. Unfortunately only a limited number of digital cameras can be coupled with a dermatoscope.

(Manufacturers of dermatoscopes now list exactly which cameras can be used with their products either directly or with an adaptor device.)

If you want a camera which can be used for a wider range of uses beyond just clinical work, eg. holiday and family snaps, there are a number of other factors which need to be considered including how compact and/or robust the camera needs to be, how much resolution (or megapixels) you want the

images to have, what zoom range you want the camera’s optics to have, how many pictures the camera’s battery will take before it needs to be recharged, whether the camera has a built-in video function and if so, how much and what quality of video it records, and finally how much manual control of the the camera’s functions you want. There are other features of a digital camera which one might consider but those just mentioned are probably the most important features. However please don’t neglect the fact that the camera still has to be able to take good closeup photos if it’s to be of any use in the clinic!

A robust camera is always going to tolerate knocks and mishandling better than a flimsy camera but robustness comes at a price and robust cameras usually weight more than flimsy cameras.

Compact cameras are easy to hold

q The author’s Nikon Coolpix 4500 with a Heine dermatascope attached...

FEATURES with one hand but will shake more easily than heavier cameras and closeup photography requires a very steady hand or lots of light or built-in image stabilisation.

Perhaps one of the most over-rated features of digital cameras is the number of megapixels the camera’s imaging sensor has. There is a virtual “megapixel war” being waged with manufacturers trying to outbid one another to woo purchasers. Admittedly more megapixels does mean more resolution or detail in the photos so that it is possible to crop or trim photos to remove unwanted areas and still print out finely detailed photos. Also pictures with more megapixels enable one to zoom further and further into the picture on one’s computer before the individual pixels start to enlarge and appear as blocky blobs of colour. This feature can be particularly useful in closeup photography. HOWEVER, small compact cameras generally have very small image sensors and as manufacturers cram more and more pixels or lightsensitive dots into these small sensors, each individual pixel must be smaller.

This means that can therefore receive smaller numbers of light photons. Smaller pixels don’t present as much surface area to receive light than larger pixels

and generate more electronic “noise” or static than larger pixels especially when there’s not much light around. This noise appears in photos as grain in darker, less illuminated areas of photos. Larger cameras such as digital SLR cameras have much bigger image sensors with bigger individual pixels and therefore the images made with these cameras have much less grain or noise in low light settings. So there is a tradeoff between resolution and graininess in digital photos and therefore a camera with 10 megapixels isn’t necessarily going to take better pictures than a camera with 6 or 8 megapixels, especially in a clinical setting.

Bear in mind that more megapixels means each photograph taken at full resolution contains more information and therefore each picture takes up more space on one’s computer.

Admittedly digital cameras generally allow pictures to be taken at a number of different resolutions and also it’s possible to reduce the resolution of large digital photos after they’ve been taken by using software, but this requires time which most clinicians won’t have.

No matter how many megapixels a camera’s image sensor has, if the optics are cheap the images may have lots of

q ...and again with the dermatascope’s battery connected via a cable.

distortion or artifacts of light and colour at the edges of objects which may be most prominent at the extreme ends of the range which may include closeup work. Good optics costs money.

Automation of a digital camera’s functions (focus, exposure, whitebalance) is now relatively inexpensive and can allow complete novices using very cheap digital cameras to take quite good photographs. However some particular situations such as closeup photography can be particularly demanding on a digital camera’s inbuilt computer with the result that photos may be poorly exposed or focussed.

Therefore it is useful to choose a camera which provides manual controls for focus, light exposure (via aperture and shutter speed), light sensitivity (ISO rating) and white balance. Of course using these manual controls requires a greater understanding of photography in general and in particular how these features work and when to use them. It also comes at more expense because manual controls requires more knobs and buttons on the camera as well as much more complex internal electronics. In some situations it can also be useful to have manual controls of the camera’s shutter speed and aperture which together influence how much light enters the camera and how much of the image can be in sharp focus i.e. just the object or the object and the background, and so forth.

Also consider whether you will be the only person using the camera for closeup work in your clinic or whether other colleagues or staff members will want to use it. If you intend the camera to be used by others, the choice of camera may depend a little on how competent they are with technology and photography in general. Choosing a simpler but more robust cameras with fewer controls may actually make more sense as long as it can still take good closeup photos.

2. Budget Decide how much you are prepared to spend for the camera and essential accessories. It helps to have already looked around a bit to get a “reality check” or a realistic expectation of what it will cost to buy what you want.

Just remember that good tools are

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FEATURES usually expensive but cameras used for clinical purposes can be depreciated for taxation purposes and will ultimately cost you very little money.

3. Online Research Do some online research by visiting some of the wonderful digital camera websites such as Steve’s Digicams.

These websites have highly detailed reviews on a large number of recent and older models of digital cameras and list all the specifications of cameras as well as their good and bad features.

It can be difficult to interpret or understand some of the terminology but the sites listed below usually explain technical terms in ways that novices can understand.

If you have done your research on the web by reading reviews and come

QUICK CLICKS Steve’s Digicams www.steves-digicams.com Digital Camera Reviews and News www.dpreview.com The Imaging Resource www.imaging-resource.com Megapixel.net www.megapixel.net

to a choice between a few different cameras then the deciding factor may well be how the camera feels in your hand and how easy it is to use. This is an important issue and no matter how good a camera’s reviews may be, if it feels awkward or clumsy or unintuitive to use, you might not enjoy using it!

4. Camera Shops Visit some of the larger camera shops which have on display a wide range of different models of digital cameras ranging very cheap to outrageously expensive. Once you get the attention of a salesman and mention that you are interested in clinical photography let them first know how much you are prepared to spend on a camera so that they don’t try to tempt you with the most expensive gear in order to earn the best commission!

If you are allowed take some closeup photos with the camera which most tempts you and ask if you can view the images on a computer in the shop.

Alternatively, if you have a laptop, take it with you and ask to view the images on your laptop. The salesperson, sniffing a sale, may become very obliging!

5. Borrow A Friend’s Camera Try out other people’s digital cameras to see how well they work and how easy they are to use. This will be far

q A fixed-lens Nikon Coolpix 5700, used by the author for closeup photography.

less stressful and if your friends are particularly obliging you may be able to test the cameras in your own clinic, using your own computer.

6. Buyer Beware Online Watch out for cheap bargains as you may end up with an expensive “white elephant”. Buying a digital camera from a camera shop should provide security for those unhappy situations when a newly-purchased camera malfunctions and needs to be repaired or replaced under warranty. However, if one buys a camera more cheaply from an online retailer there is no certainty that such a vendor will provide satisfactory backup and it may provide greater peace of mind to pay a bit more for one’s purchase for this perception of support.

Online vendors can only sell cameras more cheaply because they don’t need to maintain expensive premises or employ salespeople. Commonly they import cameras cheaply themselves rather than buying their retail stock from distributors who will often provide repair and exchange services. Until now author has successfully resisted the temptation to save money by buying cameras from online vendors and has enjoyed excellent support from camera shop staff on those rare occasions something has needed fixing or exchange under warranty. The bottom line is “pay peanuts, get monkeys.”

7. Don’t Look Back Once you buy a camera, don’t look back. Just accept that no matter which camera you choose, it will become obsolete the moment you buy it. Newer models which are cheaper and have better/more features than the camera you’ve just paid for will be announced very soon. If you look at advertisements, the camera you have just bought will soon be available for half the price you paid for it or will no longer be available at all because it’s been superseded by a “better” model. Please accept these harsh realities and just get on with enjoying your new purchase.

The author has deliberately avoided recommending any specific brands or models of cameras as being particularly good for clinical work because it is virtually impossible to keep up with the outpouring of new models of digital cameras. However during discussions

30 PULSE + IT

FEATURES HISTORICAL NOTE As a historical note of interest, the digital camera first used for clinical purposes by the author was an Olympus Camedia 1000 which took (and still takes) fantastic images with a maximum resolution of only 0.875 megapixel resolution! The images taken with this camera still look quite good today even when compared with photos taken with 7-8 times the resolution. It is only when one tries to zoom in and examine these images in greater detail that one realizes the limitations of low resolution images.

with colleagues and while presenting talks on the topic of digital photography for doctors he is often asked about his personal choices of equipment for clinical photography and readers may also find this interesting. The author currently uses two digital cameras virtually every day in his clinical work - a Nikon Coolpix 4500 (solely for use with a Heine dermatoscope) and a Nikon Coolpix 5700 for general closeup work.

Both cameras are fixed-lens “prosumer” cameras and are now several years old and therefore quite seriously obsolete.

Fortunately the cameras seem unaware of this sad fact and still produce excellent digital photographs and, unlike their owner, have proven to be very robust with no obvious signs of ageing!

For holidays and other recreational purposes he uses his relatively new and very bulky Canon 20D digital single lens reflex with a Canon 50mm macro lens and a Sigma 18-200mm all-purpose zoom lens.

ACCESSORIES Memory Cards Virtually all digital cameras store their images on removable solid-state memory cards which come in different forms, capacities and speeds with which they can be read from or written to. It is now possible to buy memory cards with 16G capacity which have the capacity to store hundreds if not thousands of high resolution photos and prices for high capacity cards seems to fall as fast as the technology develops everlarger storage capacity. Nevertheless it is useful to have at least one spare high-capacity memory card because

p A high-speed memory card reader can significanly reduce image transfer time

most digital cameras come with quite low-capacity cards.

However, if one’s use of the digital camera is confined to clinical work and if clinical photos are immediately downloaded and incorporated into patient medical records then one memory card of even a modest size such as 256 MB may well be sufficient for that purpose. In fact, the author commonly uses a 32MB card to ensure that it there are not a large number of images on the card at any one time so that it takes very little time for the computer to see the images on the card (the more images on the card the longer the computer takes to “see” them all)!

High-Speed Memory Card Reader A lot of time can be saved by using a high-speed memory card reader to transfer images from the camera’s memory card to the computer instead of connecting the camera directly to your computer. Essentially one just removes the memory card from the camera after taking the photos and plugs it into the card reader which in turn is connected to the computer by either a USB 2 or a FireWire cable.

Many cameras only have a slow USB 1 port for connecting directly to the computer. Because digital images can be quite large (up to 14MB each with 10 megapixel cameras) it can take a very long time to transfer to the computer even just a few of these big images via a USB 1 cable. By contrast, card readers commonly have either USB 2 or FireWire connections with computers and this means images can be transferred up to

40 times as fast as USB 1 transfer rates.

This time saving is very useful in the context of a consultation and, unlike a doctor’s time, card readers are not very expensive. Of course one’s computer needs to have USB 2 or Firewire ports/ cards to make optimal use of a highspeed memory card reader!

External Storage Once the camera leaves the confines of the surgery it may not be possible to download images from the memory card once it’s full of images. So it is useful to own several memory cards. Another alternative, albeit expensive option, is to purchase a “digital wallet”, a generic description for a small portable device which incorporates a battery powered hard drive and one or more slots to accommodate the various formats of memory cards. This device can quickly download the images from the memory card and store them on the hard drive thereby allowing the card to be reformatted or cleared of its images so that more can be taken. The more expensive models of digital wallets have a viewing screen so that the images can be viewed, deleted, and even renamed. The images can eventually be uploaded to a computer for further use.

These devices are not cheap but can be invaluable if one takes one’s digital camera on an extended holiday sans computer!

Spare Batteries Sure as Murphy had a law, as soon as one goes to take a picture of a skin lesion just before excising it, the camera’s only battery is found to be as

PULSE + IT 31

FEATURES

p The author’s Nikon Coolpix 4500 fitted with a Nikon SL-1. Unlike a typical flash, this device emits light consistantly during operation. flat as a pancake and needs at least 90 minutes of charging!!! It’s important to always have at least one spare battery and to keep it charged. Some cameras can use standard AA or even AAA size batteries which are available virtually anywhere. However rechargeable batteries are more environmentally friendly! There are some cameras which have non-removable built-in rechargeable batteries and with these cameras one has to become disciplined to keep the battery charged all the time to avoid disappointment. For extended holidays in the outback or other remote areas far away from powerpoints it is handy to have a battery charger which can work plugged into the car’s cigarette lighter socket.

sufficiently reducing the intensity of the flash for close-up work. In these cameras the extremely high light output from the flash reflects back from a closeup object, completely overwhelms the light sensor and makes closeup pictures of skin lesions look totally white without any detail. Some of the more expensive “pro-sumer” digital cameras do have a “hot shoe” onto which an external flash can be mounted and some internal flash units can be controlled sufficiently to reduce the intensity of the flash so as not to overwhelm the camera. Most digital single-lens reflex cameras can use a flash unit specifically designed for closeup work (eg. a “ring” flash) but these flash units are nearly always unreasonably expensive.

Extra Lenses Owners of single-lens reflex cameras may choose to buy more than one lens and for clinical work a dedicated macro lens is an absolute necessity. They don’t focus in as close to the subject as many of the smaller and cheaper digital cameras but take extremely high quality photos which look as if they were taken much closer to the subject than indeed they were.

The author chooses not to use a flash unit and instead brings either a freestanding light or a cantilevered desk light closer to the patient. This has the advantage of being a cheap solution to provide adequate illumination and unlike a flash unit provides sufficient light for photographer to accurately focus on what may well be a very tiny object such as a tiny basal cell carcinoma.

Unfortunately this type of light source can still be intense and uncomfortably hot when it’s held close to the patient.

External Flash Unit Close up photography requires a good source of light. Unfortunately the built-in flash units in many digital cameras are quite useless for closeup photography because the cameras are incapable of

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Tripod This device can sometimes be a useful tool if one cannot maintain a steady pair of hands and if the ambient light is

so low that the camera’s shutter speed is too slow to prevent blurring of the image. Unfortunately tripods are slow to set up and one often has to move the patient to the tripod rather than bringing the camera to the patient!

SUMMARY Choose your camera wisely by doing some research in advance, then go to a camera shop to “play with” the small number of models you’ve narrowed the choice down to, and don’t be bullied into buying what you don’t want or need. Get extra batteries and memory cards and a fast card reader, and then go home and practice with you’re new “work tool”. Don’t look back and make sure you start saving for a better camera.

The author is a busy rural GP based in Castlemaine, Central Victoria and has been using digital cameras since 1998 to assist his work which increasingly involves the management of skin cancers and other non-malignant skin lesions. His group practice, currently with 7 GPs, has had fully computerized medical records since 1992.

IN OUR NEXT EDITION...

Look out for Daniel’s article on “taking good closeup photos” in the next edition of Pulse IT.

FEATURES

FIRST LOOK: TELSTRA MOBILE WIRELESS BROADBAND Simon James BIT, BComm Wireless networking has been rapidly adopted in homes and businesses across Australia, however it is only recently that “go anywhere” mobile wireless Internet options have become both reliable and affordable.

way to ensure the service will work reliably in your area. Fortunately Telstra offer a 10 day money back guarantee which can be used to gauge performance in the locations you intend to use their product.

Despite the companies perceived shortcomings, Telstra’s mobile wireless broadband offering stacks up favourably against the competition, especially for people who live or travel outside major metropolitan areas.

CLINICAL APPLICATIONS

I’ve been using Telstra’s mobile wireless broadband offering for the past three months to complement my existing wired Internet connections at home and work. While Telstra does have a USB modem, its bulk and requirement for mains power hamstring this as a mobile solution.

In addition to mobile web browsing and email, clinicians may benefit from flexible remote access to their central practice database. The ability to have twoway, real-time access to their practice software during home visits, ward rounds and other offsite engagements should improve both patient care and record keeping efficiency.

Even at locations with existing Internet access, the benefits of having a redundant connection not dependent on fixed lines cannot be understated.

COVERAGE & PERFORMANCE

COST

Telstra claims that its mobile wireless broadband technology can reach 98% of the population. It achieves this by using multiple networks to maximise both performance and coverage.

When compared to fixed line Internet solutions such as ADSL, cable and dialup, the price of the wireless broadband is relatively expensive. As such, I don’t recommend that this solution be used as an individual’s primary or sole Internet connection option.

In capital and other large cities with an established EV-DO network, theoretical download speeds up to 512Kb/s are advertised. In all other areas, the widely cast CDMA network is utilised, however theoretical speed degrades to around 100Kb/s.

As with all advertised Internet connections, we found actual performance didn’t approach the marketed figures. Despite this, connection speeds were more than adequate for email, web browsing, file transfers and remote access.

While Telstra does provide coverage guidance on their website, the fickle nature of wireless networks means that real world testing is the only definitive

The mobile wireless card retails for $299, and monthly plans range from $29 up to $109. Both time and data limited plans are available. As I’m largely deskbound in locations with ADSL, I’ve found the entry level 10 hours per month plan to be adequate. Like many ISPs, Telstra permit you to change plans at any time.

Simon James is the editor of Pulse IT.

QUICK CLICKS

Telstra Bigpond www.bigpond.com Whirlpool - Australian Internet Forum www.whirlpool.net.au

NEXT G As we prepared to go to print, Telstra announced its new mobile network dubbed “Next G”.

While this network will do little to appease people crying out for better fixed line services, it dramatically improves Telstra’s wireless broadband offering.

The Next G network uses High Speed Downlink Packet Access (HSDPA) that Telstra claims will give 98% of the population access to mobile wireless broadband at theoretical speeds between 512Kb/s and 1.5Mb/s, bursting to 3.6Mb/s in some locations.

Telstra claims that their new network’s capacity is far greater and expects to be able to provide speeds up to 14Mb/s as early as next year.

Telstra claims that the EV-DO and CDMA networks will be closed in 2008 when their new Next G network “is providing the same (or better) coverage and quality of service”.

Unlike its predecessor, a Telstra Next G mobile card allows international roaming in over fifty countries, albeit at the exorbitant rate of $16.50 per megabyte.

Existing users of Telstra’s Mobile Broadband card can upgrade to Next G capable hardware at no cost, although a commitment to remain on your existing contract is required.

As with the hardware they replace, the new mobile wireless broadband cards don’t come in an ExpressCard version. ExpressCard is a new laptop expansion interface (used in MacBook Pro and other modern laptops) designed to replace the antiquated PCMCIA technology.

PULSE + IT 33

FEAUTRES

FIRST LOOK:

WACOM INTERACTIVE PEN DISPLAYS Simon James BIT, BComm Many clinicians long ago accepted mice and keyboards as necessary parts of their work environment, however despite over twenty years of mainstream use, they have not proven suitable for all clinicians or all clinical environments.

While digital pen solutions have been available for many years, the software and hardware technology has matured significantly in recent times and many vendors are re-doubling their marketing efforts in the health sector. With a range of interactive pen displays (IPD), Wacom is one such vendor.

As it is the model Wacom is targeting at clinicians, I chose to evaluate the 15 inch DTI-520 (larger models are also available from Wacom including the 17 inch DTU-710 and the flagship 21.3 inch Cintiq 21U).

GETTING STARTED Setting up the DTI-520 was only marginally more complex than connecting a traditional monitor. In addition to the power and VGA monitor cables, a USB connection is made between the display and the computer.

USB ports on either side of the display allow a keyboard, mouse or other devices to be connected.

Once the supplied software driver is installed, the IPD functions as both a pen-based input device and a monitor.

An additional VGA port on the DTI520 allows the video signal to “pass through” to a second monitor. As this device is also marketed as an interactive whiteboard solution, it is likely this feature was included to allow a projector to be easily connected and used as a digital whiteboard.

In a clinical environment, this port could be used to allow the patient to view the

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doctor’s screen on a second monitor for demonstration or other purposes.

Unlike a traditional monitor, the DTI520 would typically be placed almost horizontally on the clinician’s desk. An adjustable stand allows the angle to be changed from almost horizontal to almost vertical. Alternatively, the unit can be mounted on a retractable arm to allow a full range of movement.

LEARNING CURVE For navigation purposes, the pen is used in much the same way as a mouse.

Tapping on the screen with the pen simulates a left mouse click and a programmable index finger button is used for the right.

As someone who has used keyboards and mice for over 20 years, transitioning to the pen driven system was an interesting experience. The concept of physically interacting with a monitor did take some adjusting to and initially I found myself reaching for my keyboard to perform well-practiced shortcut combinations. Fortunately I was able to retrain myself quickly and within fifteen minutes the new ergonomics felt natural and efficient.

HANDWRITING Wacom doesn’t ship handwriting recognition software with its IPDs, instead relying on popular third party solutions to extend the usefulness of the product. Interested to see how each platform would deal with my terrible handwriting, I spent equal time with the IPD connected to computers running WIndows XP machine and MacOS X. Windows XP Most users of Wacom’s IPD utilise the handwriting functionality included in Microsoft Office 2003. Most medical practices are likely to have this software

already and should only be required to follow a simple activation procedure to get it to work. Once configured, the user simply writes into an input panel, which then attempts to recognise and insert the text into the active text area.

Depending on the program the user is interacting with, drawings can also be inserted in a similar manner.

Despite the software not being able to learn or be trained (this is a feature of the soon to be released Microsoft Vista), I found the recognition to be acceptable initially, improving alongside my familiarity with the solution. To the delight of practice staff world wide, this software may actually improve clinician handwriting!

MacOS X MacOS X has handwriting recognition software built into the operating system, which can be configured using the “InkWell” System Preference (these options will only be visible when an IPD or graphics tablet is connected).

Despite being an early innovator in the field with the powerful but long defunked Newton PDA, Apple’s handwriting recognition didn’t impress me as much as the Microsoft offering.

The “gesture” system (which allows special symbols to be interpreted as commands) did allow corrections to be made easily, but the general accuracy of the software hampered my efficiency.

CLINICAL SOFTWARE While thoroughly testing specific clinical packages wasn’t a realistic goal in the brief time we had to play with the Wacom IPD, we did experiment with several popular solutions. In most cases text input could be achieved, however I felt that all packages would benefit from tighter integration with this and other digital pen solutions.

FEATURES VIEW OF VISTA Targeted for release in “early 2007”, the long-awaited upgrade to Windows, titled “Vista”, promises several improvements for users of Tablet PCs and other pendriven systems including Wacom‘s Interactive Pen Displays.

Prior to Vista, third party software or “Windows XP Tablet PC edition” was required to effectively use pen-based systems. In a move that is likely to improve uptake of penbased systems, Vista incorporates and extends the features found in the Tablet PC edition of Windows.

Training The handwriting recognition in Vista is significantly better than its predecessor, however its ability to learn the nuances of the user’s handwriting is likely to be the most well received improvement.

In addition to basic pre-training, Vista can be configured to learn from the user during routine tasks. By taking note of the corrections the user makes, Vista is better able to recognise these letters and words next time.

Most impressively, Vista’s recognition engine is context aware. This means that the sentence position and surrounding words assist Vista to better interpret the users input.

Flicks In what may make for amusing thirdparty viewing, Vista incorporates a gesture navigation system to allow the user to scroll around a page or trigger a macro using only the pen.

Aptly named “Flicks”, the user invokes this feature by rapidly flicking the pen in a pre-defined direction.

Auto-Complete While many doctors are already using macro software to assist with letter writing, Vista’s handwriting recognition software can automatically complete popular words and sentences, making input more efficient.

▲ Wacom’s flagship model, the Cintiq 21UX. When not being used for handwriting recognition, the Wacom pen simulates a mouse meaning sketches and diagrams can be created in any clinical drawing module.

SUMMARY The prospect of learning to type has proven to be a disincentive to computerisation for many clinicians.

While writing instruments have been around since the days of the caveman, present day techno-troglodytes have been let down by a lack of viable digital pen solutions.

The impending release of Microsoft Vista will give proponents of the pen something to cheer about, though ultimately the success of such devices in health will be heavily contingent on the levels of integration clinical software vendors are willing to provide.

While a keyboard can’t be completely jettisoned, Wacom’s IPD does provide an excellent hardware platform for desk bound clinicians that prefer pen based input.

Simon James is the editor of Pulse IT.

QUICK CLICKS Wacom - http://www.wacom-asia.com Apple InkWell - http://www.apple.com/macosx/features/inkwell/ Microsoft Vista - http://www.microsoft.com/windowsvista/

PULSE + IT 35

FEATURES

FILMLESS IMAGING TECHNOLOGY Simon James BIT, BComm

WHAT IS FIT? DDI Health working in collaboration with HCN has delivered an online imaging retrieval system dubbed Filmless Imaging Technology (FIT). Rather than the radiology provider generating a series of films or a CD, the images are made available via the Internet, direct to the clinicians computer.

To facilitate what DDI is marketing as “the last mile”, image streaming technology is used to great effect. [See Sidebar: Streaming Explained].

Using a broadband connection, images begin to appear in a matter of seconds.

As the user zooms in and pans around the image, each screen refresh is completed in a similar timeframe.

DELIVERY BENEFITS Internet based delivery of images has many benefits: • Turn around time is minimised, allowing images to be made available to the doctor as soon as the report is completed.

• The patient doesn’t need to take responsibility for their films, eliminating problems associated with them being forgotten or misplaced.

• Practices don’t have to store films, reducing the strain on typically overflowing practice shelf space.

• Clinicians can access the images from any room with an Internet-connected computer, eliminating the reliance on a light box.

VIEWING BENEFITS DDI touts the ability to view both the report and the image “in context”( i.e. simultaneously on one screen) as a significant benefit not available using traditional means.

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In addition to viewing the images on screen, the clinician has many display options not possible with film.

Brightness, contrast, magnification and orientation can all be easily adjusted with simple mouse controls. Colour inversion, annotations and bone density determination is also possible.

A unique URL is embedded in the report that loads the image using an identical interface to that presented in MD3.

Like the rest of the radiologist’s report, this URL should be shared only with authorised parties as it contains all the details needed to access the patient’s images.

MD3 INTEGRATION

COST

At the time of writing, Medical Director 3 (MD3) is the only practice software with DDI’s FIT solution tightly integrated.

If the radiology provider has FIT enabled, the images can be called up directly from the result screen, allowing for a seamless workflow. By default, the report is displayed side-by-side with the images, allowing the clinician to easily reference the report and show the image to the patient if appropriate.

As with existing radiology services, the radiology provider and patient bear the cost of the production and delivery of the clinical images. The only possible cost to the practice may come via an increased Internet data charge, though this can be mitigated by selecting an appropriate Internet plan with a large or unlimited transfer allowance.

A demonstration video highlighting this integration is available from the DDI website, as are sample radiology results that allow current MD3 users to view a selection of images.

SHARING IMAGES MD3 users can forward the radiologist’s investigation report to interested parties, allowing them to access images via Microsoft Internet Explorer 6.

Unfortunately other browsers (and hence operating systems) are not currently supported.

UPTIME FIT is reliant on having an active, stable Internet connection. In the unlikely event that your practice loses its connection, you will be unable to view the images.

While this is an unavoidable limitation of all web services, the proliferation of broadband and consumer demand for stable Internet connections should ensure downtime is rare. As Peter Weston of DDI explained, “the chance of Internet downtime is significantly lower than the chance of films being misplaced, forgotten or otherwise being unavailable when required.”

NAVIGATION TIPS The following tips will help you use FIT more efficiently: With the “hand tool” selected: • Left-Click + Drag: Moves image around screen • Right-Click + Drag left or right: Adjusts contrast • Right-Click + Drag left or right: Adjusts brightness • Left and Right mouse buttons + Drag up or down: Adjusts magnification

FEATURES STREAMING EXPLAINED Unlike most images displayed via the Internet which are heavily compressed, there can be no compromise on quality when dealing with radiological images.

Even on Australia’s fastest available broadband, downloading an entire CT study in full quality would take an age and consume significant disk space.

The use of streaming technology in DDI’s FIT allows the user to begin viewing images after a relatively small amount of data has been retrieved.

When you first view an image using FIT, only the data required to display the image at the initial magnification is downloaded. With a broadband connection, this usually happens in a matter of seconds. As you zoom in and pan around the image to view it in more detail, the additional data required is “streamed” to the client.

Regardless of magnification, each screen refresh completes in close to real-time.

In the case of radiological images, this technology can prevent large amounts of unnecessary data from being downloaded, even making the solution viable to clinicians using a dial-up connection.

Practices should note that Internet dependent solutions are rapidly growing in popularity (see page 26), meaning that Internet uptime will become increasingly important. The feasibility establishing a redundant Internet connection at your practice should be discussed with your IT provider.

providers offer DDI’s FIT solution, one imagines that MD3 will become a more compelling proposition for MD2 users.

FIT EVOLVED

Patient confidentiality needs to be considered and both the provider and the user will need to ensure adequate security safeguards to limit access to both the images and the reports.

Since Pulse IT first looked at FIT at the Sydney GPCE in late May, the DDI offering has undergone welcome cosmetic changes. With the assistance of an interface expert, DDI refined the navigation controls, making the program more intuitive and easier to use. Other important features have been added, including an indicator showing when data is being streamed. This is an important addition, and should ensure that clinicians make their assessments on completely loaded images, not on the lower resolution “interim” version displayed while the image is being refined.

CONCLUSION HCN is marketing FIT as a major feature only available in MD3. The steady stream of practices converting to HCN’s flagship product should encourage more radiology providers to consider implementing the DDI solution. Symbiotically, as more radiology

Because of its Internet lineage, it shouldn’t be technically difficult for other practice software vendors to integrate DDI’s solution into their products.

This system has significant benefits for both patients and clinicians in terms of rapid availability and user-friendly storage of all forms of medical imaging.

As end-users embrace this and similar solutions, this type of technology will become a standard in general practice.

Simon James is the editor of Pulse IT.

QUICK CLICKS DDI www.ddihealth.com.au HCN www.hcn.com.au Google Earth earth.google.com

▼ Fimless Imaging Technology (FIT) integrated into Medical Director 3.5

Google Earth (earth.google.com) Streaming technology isn’t limited to static images; audio and video are also possible. Perhaps the most impressive example of modern streaming technology is Google’s attempt to deliver the entire world to your desktop.

By stitching satellite images and aerial photography together, Google allows the user to browse the entire surface of the globe. The user can zoom in to street level with impressive quality in major cities.

As with FIT, the Google Earth client only downloads the images required to display the current field of view. As the user zooms in or pans around, the required images are streamed to the client computer from the server.

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EPIDEMIOLOGY

RECALL SYSTEMS Dr David Brookman MBBS, MHA, DipClinEpidem, FACRRM

WHY? Think of preventive health care as being provided on four levels.

• Primary - detection (screening for disease) • Secondary - earliest possible diagnosis to minimise risk of death and disability • Tertiary - rehabilitation - maximising support in the environment to keep people well • Quaternary - palliation - comfort and security when disease progress cannot be arrested.

Screening - Primary The general ethical principle of screening is that disease should be sought only if there is effective intervention available or possible. Hence screening for Huntington’s disease in childhood is currently not appropriate as no early intervention can be offered that will arrest the progress of the cerebral cell loss.

Generalised screening for uncommon illness is also not considered ethical on both cost effectiveness grounds, and in the induction of distress from the false positive pick ups.

In primary care, screening occurs in two ways: 1. Opportunistic screening where a test, or measure is performed where people present for another problem - the best example would be blood pressure checks.

2. Formal recall systems involve phone or mail, or email contact with a group of patients selected on the basis of risk.

Many practitioners do not believe they need to have a recall system as they have been implemented by government where necessary. E.g.

Immunisation is promoted through denial of some family benefits to children not

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immunised, and women are recalled for their PAP smears at appropriate intervals.

The immunisation scheme is quite effective, but people do slip through the net and you will need to know which of your patients has been denied effective prevention if they turn up with a risus sardonicus, or whooping cough.

Also people are misled into denying their children effective and appropriate immunisation by ignorant and hysterical publicity generated by people pushing a belief system and not scientific fact - you will need to address this issue with some people. The PAP smear system only recalls women who have already had a smear and who have elected to be on the system.

So what do you screen for? The RACGP red book fortunately provides an evidence based set of screening interventions which have been shown to be effective in reducing morbidity.

This can be obtained from the RACGP website so it is simply a matter of establishing polices for screening at your practice. You may also wish to implement screening for problems which are current but not yet supported by clinical evidence - an example of this might be recall of children for Meningococcal type C immunisation.

Detection - Secondary This is really an opportunistic activity. In the ideal practice every patient would have opportunistic anthropometry performed on every visit - it is managed in hospital emergency departments.

If your practice is financially able the practice nurse should review all incoming patients, measure and record their height, weight, blood pressure, UA, and BSL annually (subject to age variations). Other opportunistic measures can be conducted by the medical practitioners as needed.

Monitoring - Secondary Again the red book provides guidance on this. The major disease group of concern to Australia is diabetes and you are all well aware now of is required in the semi-annual, annual and biannual reviews of diabetic management. Others you may not consider are hypertension, glaucoma, hyperlipidaemia, drug abuse, depression, phobias, generalised anxiety disorder, vascular insufficiency, congestive cardiac failure, Parkinson’s disease and the like where intervention to improve functioning and retard the progress of the disease is effective.

Rehabilitation - Tertiary The aged care review is the prime example of this and most of you will have some means of identifying and screening your aged at risk people. The critical factors in this are the activities of daily living rather than disease states.

But you do not need to limit this type of review to the aged. Anyone with disability deserves regular review to ensure that they are not becoming socially isolated even if the government does not see fit to remunerate you for this. Most clinical computer systems have inbuilt aged care screening with flagging of the patient by age, and you may need to test your system to see if the same package can be used for younger people with established disability.

Palliation - Quaternary This is a primary care function which has been devolved to specialist and para medical teams in urban areas because of the perceived neglect of the area by primary care practitioners. In rural areas it is mainly a GP role. I am not aware of any screening instrument that examines the quality of life for someone where death is soon and predictable but I will keep searching and publish details in

EPIDEMIOLOGY a future Pulse IT article when I find one suitable. Areas that need to be assessed are: • Pain control • Bowel function • Appetite • Weight • Skin care • Socialisation • Diversion • Mood • Carer stress • Others (pruritus, dyspepsia, cough, dyspnoea, fragility.)

here. This is where your data quality is essential. With some computer systems it is not possible to store sociodemographic risk factors beyond age sex and ATSI status. You may wish to consider storing other data like family risk (disease specific), marital status, unemployment, existing disability, victim of abuse, etc. Medical director has a limited number of data fields available for this function and you can use them provided you are careful to eliminate typographical errors.

IDENTIFYING RISK GROUPS

It is necessary to seek the permission of the patient to store this data, some people are proud of their aboriginal

This is well set out in the red book and I will not repeat the recommendations

RECALL EXAMPLES The following recalls were performed from David’s practice in Cessnock.

1997: PAP Smear Recall Using Medical Director, demographic data (3300 records) was exported to a spreadsheet to identify gaps in data.

Missing dates of birth were obtained by reception staff and patient gender was checked. Congruity of first name was then checked against sex. Data was re-exported to spreadsheet and sorted on sex and birthdate (selecting ages 18 to 70) (750 records). Data was checked again in MD to ensure that the date of last PAP smear had been recorded.

Another spreadsheet was generated containing date of last smear, with sex equal to female. Age 18-70 was the sort criteria. 500 patients were identified for recall.

A mail merged letter was generated indicating that this was a review process to identify women who had not had a PAP smear with the last 2 years.

The letter suggested that: • Our records could be missing the data.

• Women may have had PAP smear done elsewhere.

• Women may have had hysterectomy.

They were advised that a female medical practitioner would be available weekly to conduct PAP smears if they did not wish to see a male doctor, and they were provided

ETHICAL ISSUES

with the contact number for the women’s health nurse.

They were asked to contact us if they had had a PAP smear done elsewhere and sign a permission note for us to obtain a copy of the result.

The total cost of the recall including postage and staff time was approximately $1100. Benefits included fully booked weekly women’s health sessions and better working relations with the women’s health nurse.

1998 Aged Immunisation Program We established a “Flu immunisation day” at our surgery for which extra support was arranged. Using a method similar to the previous example, all patients listed as being aged 65 or above were notified by mail that this day would be available for them to have their influenza immunisation. They were advised that the immunisation would be available on other days if they were unable to attend on that particular day.

Every person who attended was seen by the practice nurse who checked for intercurrent illness, and measured their height and weight. They were then seen by a medical practitioner who checked their blood pressure and provided the immunisation. The immunisation was recorded by one of the receptionists. Nursing home and hostel immunisations were conducted on the same day.

heritage, others have been victimised and do not wish to be a victim again, and people may not wish to face a genetic risk.

The method you use to contact people also needs consideration. Any mail should be marked “personal and confidential” and the content should be phrased in such a way as to not cause anxiety or stimulate paranoia.

Telephone calls are good, but avoid leaving messages as you cannot guarantee who will hear the message.

Email should not contain any private information unless you are prepared to encrypt everything individually.

This process enabled the practice to use its time most efficiently as it was in an area very short on medical practitioners, and it established an anthropometric data set for the aged.

1999 Aged Assessment Program The only instrument available was the DVA aged assessment forms.

These were copied and converted to electronic forms on a laptop but with the addition of the GDS, and MMS, and a medical history and examination adapted from other sources. All persons in the selected age group (75+) were identified and a mail merge generated.

The letter stated that the aged assessment was being offered as a new service funded by the HIC with the intention of providing services at home to people who needed them to prevent them from deteriorating to the extent where they needed nursing home admission. A consent form was attached and people asked to make an appointment for a home assessment. People were interviewed at home and the assessment recorded on the laptop. The results were printed and generated as a PDF file for electronic storage. A printed copy was provided to all patients.

This was before any support programs had been developed for GP’s and I found the home assessments most useful as it enabled me to judge on how well people were able to manage at home.

PULSE + IT 39

EPIDEMIOLOGY Remember that a public key system must be individualised - if you supply all your patients with the same key you are keeping security only for that cohort of patients and not between individuals in the group.

personalised letter quite easily in most office packages. I have also scanned my signature and use this at the bottom of the letter rather than have someone sign each one for me. Some offices also have letter folding machines.

Screening should only be performed where there is a well established effective (and proven) intervention available. The risk in the group needs to be sufficiently high to justify the expense of screening. Hence screening all women for BRAC1 is not cost justifiable even if prophylactic mastectomy can be offered, as the prevalence in the community is so low.

Window face envelopes are the easiest, but you can also use laser printed mail labels if you are careful to match the letter with the name on the envelope. Ensure there is a return address - any letters that are returned should be regarded as a signal that the patient is not longer active and they should be marked as such in your patient database. If the address is simply incorrect the inactivation can be reversed with correction when they visit next time but it avoids you wasting time and effort recalling them in the future.

THE PRACTICALITIES If your clinical system offers the capacity for selecting patients on demographic criteria it is relatively simple to generate a list of people. The system will also allow you to export to a mail merge or spreadsheet program. If you are to use the phone as the primary contact then produce a spreadsheet for your staff that lists the persons name, address, phone number, and some blank columns labelled first, second and third in which the staff can record the date and time they have phoned the person.

Some people prefer this as a printed list others are happy to use the spreadsheet function on the computer - negotiate this with your reception staff.

Mail merge is good where there are more than 50 people to contact. ����������������������������������� You can construct a mail merged

40 PULSE + IT

If your system does not provide this function it is slightly more difficult.

Export to a spreadsheet the entire active patient data set with any tags that indicate risk. In the spreadsheet eliminate any columns that will not be needed (Medicare number etc) but keep names, address, phone number and risk tags. To select your risk group simply sort the dataset on the risk criteria.

More advanced users may wish to use a database rather than a spreadsheet.

After the records have been sorted, scroll to the block of names that fulfill the criteria, select and copy to a new spreadsheet - this can be used as indicated above.

Some of the better clinical computer systems provide an inbuilt recall system based on criteria that you set.

The advantage with such systems is that they tag that patients have been recalled for some reason, this generates a warning message when they visit allowing the practice to follow up. If this is not provided the reception staff will need to tag the patients individually when the letters are sent, or phone calls made.

SUMMARY The clinical management software has improved vastly from when I conducted the recalls outlined on the previous page, but it demonstrates how with a bit of thought the capacity exists in all clinical software systems to generate recall programs. The idea is to provide a cost justified health improvement for the community in which you work. This may be through a more efficient way of delivering a service, or providing and publicising a new service.

Dr David Brookman has used Medical Director extensively to extract data for self directed clinical audit. He has a working knowledge of Profile and Genie.

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The National Primary Care Collaboratives (NPCC) program implements the Collaborative improvement methodology in Australian general practice; improving patient clinical outcomes, reducing lifestyle risk factors, helping maintain good health for those with chronic and complex conditions and promoting a culture of quality improvement in primary health care. The program currently focuses on three topic areas: • Diabetes Available from all good computer hardware suppliers.

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PULSE + IT 41

SHUTDOWN

BURNING DOWN THE MOUSE

Since I wrote my last article the whole flaming laptop battery issue hit the headlines. It received significant press coverage in publications ranging from IT magazines, down (or up depending on your persuasion) to ABC’s “The Chaser’s War On Everything”.

Initially the story revolved around some Sony-supplied battery cells sold in Dell and Apple laptops catching fire.

Dell and Apple blamed Sony, Sony attempted to shift part of the blame down its supply chain because of the way Dell and Apple “configure” its batteries.

Within a short space of time, nearly every major laptop manufacturer (including Sony’s own laptop division) became embroiled in the fiasco and the total number of recalled batteries is tipped to exceed 10 million (the largest recall in electronics history).

The root cause of the problem has been attributed to a crimping production process that left metal fragments loose in the battery cells. As a result, the affected batteries have a propensity to short-circuit, converting their stored energy to heat with spectacular results.

While the chance of a recalled battery combusting is statistically tiny, getting a free replacement battery is probably a worthwhile exercise anyway. Laptop batteries degrade over time resulting in diminished run time. Given the age of many of the recalled batteries, it’s likely that a new unit will provide up to an additional hour of portable use.

Have you checked that your machine is not one of the affected ones? Worth doing I would think!

42 PULSE + IT

In the lingering wake of this debacle, several leading laptop manufacturers including Apple, Dell, HP and Lenovo have committed to develop standards for lithium ion battery design, performance and safety. Given the fallout from the current recall, a standard is expected to be ratified quickly.

COME FLY WITH ME I was on a plane recently thinking about the possibility of a laptop catching fire during flight - it was a sobering thought.

Australia’s major airlines have also considered the possibility and issued statements indicating that passengers with affected laptop batteries would not be allowed to charge them during flight (an interesting proposition in itself).

the machine, and I was a bit nonplussed as the machine had been very reliable until then.

As I was sitting there pondering, the receptionist mentioned in passing that “you should have heard that black box when we came back from holidays. It sounded like a jumbo jet! And the room was sweltering!”

All the pieces fell into place. The room was not overly tiny, but being totally closed up for a couple of weeks with the server quietly humming away was enough to gradually heat the room to the point where the computer was struggling to cool itself. (The jumbo like noise was the server fans working overtime).

It’s not just dodgy batteries in laptops that you need to be mindful of. I have dealt with a couple of laptops where the sleep mode has not kicked in properly when the laptop lid had been shut.

Once it was a software configuration error and the other time it was a faulty closing switch.

While I seriously doubt the computer or surrounding paraphernalia could have caught fire, it isn’t outside the realms of possibility. In any case, the server required quite a spruce up to set it right again and I wouldn’t vouch for the long term prospects of that machine (or more importantly, its hard drives, where the digital practice lives).

In both cases the laptops happily powered up and proceeded to cook themselves in the confined space of their carry bags. One of them was mine, and I can tell you that when I got it out of the boot after driving for a couple of hours, it was so hot I was amazed that it hadn’t actually ignited!

Modern server hardware is designed for unattended continuous operation, however the environments they are placed in don’t always share the same qualities. If your practice closes for an extended break this summer, perhaps it would be worth giving your computers a holiday also?

ONSITE

To protect client confidentiality, Mr Fixit’s identity remains hidden.

As eluded to in my previous article, heat issues are not restricted to laptops. Just after the summer holidays this year I had a call from a clinic that had had weird failures and commotion on their server.

No one fessed up to doing anything to

QUICK CLICKS The Chaser Video Podcast www.abc.net.au/chaser/

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