Pulse+IT - November 2007

PULSE IT Ã

AUSTRALIA’S FIRST AND ONLY HEALTH IT MAGAZINE

ISSUE 6: NOVEMBER 2007

NOW ENCOMPASSING AUSTRALIA’S ENTIRE HEALTH IT ENVIRONMENT

• GPs • Specialists • Practice Managers • Health Informaticians • Health IT Decision Makers

www.pulsemagazine.com.au

PULSE IT +

Publisher Pulse Magazine PO Box 7194 Yarralumla ACT 2600 ABN 19 923 710 562 www.pulsemagazine.com.au Editor Simon James 0402 149 859 simon.james@pulsemagazine.com.au

COVER STORY: PULSE+IT EXPANDED PAGE 06

Sub-Editor Erica McLellan Editorial Enquiries editor@pulsemagazine.com.au Advertising Enquiries ads@pulsemagazine.com.au About Pulse+IT Pulse+IT is produced by Pulse Magazine, the most innovative publisher in health. Over 15,000 copies of Pulse+IT are distributed quarterly to GPs, specialists, practice managers and the IT professionals that support them. In addition, over 8,000 additional copies of Pulse+IT are distributed to key IT decision makers in hospitals, day surgeries and aged care facilities. With a total circulation exceeding 23,000, Pulse+IT is not only the largest Health IT publication in Australia, but one of the highest circulating health publications of any kind.

Contributors Julian Flint, Dr John Goswell, Dr Terry Hannan, Simon James, Dr Heather Leslie, Jane London, Dr David More, Michael Murfitt, Dr Ian Reinecke and René Yim. Non-Commercial Supporting Organisations Australian College Of Health Informatics, Australian General Practice Network, Health Informatics Society Of Australia, HL7 Australia, National E-Health Transition Authority (NEHTA), The Royal Australian College of General Practitioners and Standards Australia (IT-014).

PAGE 32 PRACTICE HEALTH ATLAS Julian Flint outlines a tool designed to help practices improve patient care and achieve better financial outcomes.

PAGE 46 HOSPITAL COMPUTING Dr David More reflects on the causes of Health IT failure.

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 publisher cannot be held responsible for the accuracy of the information herein, or any consequences arising from it.

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

Copyright 2007 Pulse Magazine No part of this publication may be reproduced, stored electronically or transmitted in any form by any means without the prior written permission of the Publisher.

Subscription Rates Please visit our website for more information about subscribing to Pulse+IT.

PAGE 48 DESIGNING FOR TOMORROW Michael Murfitt encourages developers to be mindful of their systems’ inevitable obsolescence.

NEHTA PAGE 12

GPS PHOTOGRAPHY PAGE 20

RAID PAGE 30

SECURE MESSAGING PAGE 37

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

PAGE 12 NEHTA Dr Ian Reinecke outlines NEHTA’s National Product Catalogue and E-Procurement initiatives.

PAGE 16 AGPN Chris Scott outlines the Hunter Urban Division’s eHealth achievements.

PAGE 14 ACHI Dr Terry Hannan introduces the Australian College of Health Informatics.

PAGE 18 INTERVIEW: GENIE Pulse+IT checks in with Genie Solutions’ Managing Director, Dr Paul Carr.

PAGE 15 PULSE+IT SUBSCRIBER OFFER There has been no better time to subscribe to Pulse+IT, find out why.

PAGE 56 MARKET PLACE Australia’s most innovative and influential eHealth organisations.

PAGE 20 GPS PHOTOGRAPHY Dr John Goswell explains how to use GPS technology to get more from your digital photography.

PAGE 30 RAID René Yim discusses RAID, a preventitive backup measure for your practice server.

PAGE 46 HOSPITAL COMPUTING Dr David More reflects on the causes of Health IT failure.

PAGE 24 CONSULTING ROOM PRINTERS Simon James presents a consulting room printer buyers guide.

PAGE 32 PRACTICE HEALTH ATLAS Julian Flint outlines a tool to help practices improve patient care and achieve better financial outcomes.

PAGE 08 BITS & BYTES News from organisations operating in the eHealth sector.

PAGE 10 RACGP Jane London discusses the new RACGP online portals for practice managers and practice nurses.

FEATURES

PAGE 27 FIRST LOOK: GPCOMPLETE Simon James takes a look at practice software solution, GPComplete.

PAGE 37 SECURE ELECTRONIC MESSAGING WITH MEDICAL-OBJECTS Simon James demonstrates a working secure electronic messaging solution.

PAGE 48 DESIGNING FOR TOMORROW Michael Murfitt encourages developers to be mindful of their systems’ inevitable obsolescence.

PAGE 50 OPENEHR Dr Heather Leslie introduces the readership to openEHR.

www.pulsemagazine.com.au

STARTUP

PULSE+IT: 2007.4 Welcome to the sixth edition of Pulse+IT, Australia’s first and only Health IT magazine.

PULSE+IT EXPANDED Welcome to the sixth edition of Pulse+IT, Australia’s first and only Health IT magazine.

As our regular readers will note, we have increased both the page count and scope of Pulse+IT, with a view to better encompassing Health IT beyond the hardware and software found in specialist and general practices.

As part of this expansion, we have dramatically increased our readership base, many of whom will be receiving a complimentary copy of Pulse+IT for the first time.

A BRIEF HISTORY...

For the benefit of both our new and existing readers, allow me to bring you up to speed on where we have come from, and give you a hint of what’s to come...

Launched in August 2006, Pulse+IT was established as an Information Technology (IT) magazine specifically tailored for general and specialist practice.

While the response from readers in this part of the health sector has been positive, our ultimate goal has always been to provide an interesting and useful IT resource for all the relevant participants in the health sector.

SUBSCRIBING TO PULSE+IT To ensure you keep receiving copies of the printed version of the publication, and to gain unrestricted access to our electronic services, a subscription to Pulse+IT is required.

More details about our subscription packages, including information about our immensly popular iPod promotion, are available on pp15.

6 PULSE + IT

While the current state of the Health IT landscape may suggest otherwise, it is obvious that patients and their aliments are not confined to discrete parts of the health system. Further, rarely do GPs and specialists practise solely from their private rooms. The majority also spend time in either hospitals or aged care facilities or both. With these realities in mind, Pulse+IT will move forward with an expanded editorial scope, encompassing Australian Health IT wherever it is to be found.

Obviously it would have been possible to produce several sister publications focused on the IT found in hospitals, aged care facilities, day surgeries etc.

However, I strongly believe that holistic coverage of IT in the health sector through a unified publication will assist in the pursuit of a tightly integrated, cohesive Health IT environment, and ultimately, better outcomes for the sector as a whole.

In recognition of the support that our existing readership has given us since our launch, and ever mindful of the important role specialist and general practice is playing in the quest for a connected Health IT environment, we have no plans to dilute the historical editorial platform of Pulse+IT. Instead, we will broaden the scope of Pulse+IT by aggressively expanding the page count of the publication, ensuring that all readership groups will be provided with a substantial supply of quality Health IT content.

THIS EDITION Readers from general and specialist practice will be interested in our coverage of the RACGP’s new online portals designed for Practice Managers and Practice Nurses, the Hunter Urban Division’s eHealth initiatives, GPS photography, personal laser printers, RAID, the Adelaide Western GP Network’s Practice Health Atlas, Genie Solutions, GPComplete, and our

significant secure messaging article featuring Medical-Objects, MedTech32 and Medical Director 3.

This edition also covers openEHR, NEHTA’s e-procurement plans for the public health sector, the Australian College of Health Informatics, software change management, and the causes of hospital IT failure.

BONUS ONLINE CONTENT Despite increasing our page count and maintaining a high content-toadvertising ratio, we were unable to include all of our editorial submissions within the confines of this magazine.

Several quality articles had to be omitted, including organisational contributions from HISA, HL7 Australia and Standards Australia. In addition, feature articles encompassing the Vocera Communication System, document scanners, Microsoft Vista, and the Telstra Bedside Solution also had to be left out.

While we will endeavour to include many of these articles in the printed version of our forthcoming February 2008 edition, this content has already been made available at our website — I encourage you to take the time to check it out.

LOOKING AHEAD Before Christmas, we expect to complete a significant website redevelopment that will make our site more visually appealing, more functional, and most importantly, allow us to release content more frequently.

The next edition of Pulse+IT will be sent to subscribers in early February 2008. As always, in the run up to this edition, I look forward to your feedback and editorial suggestions, and wish you all the best for the Christmas period and beyond.

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

Advertisement

DHSMEC1

Authorised by the Australian Government, Capital Hill, Canberra.

BITS & BYTES EQUIPOISE INTERNATIONAL RELAUNCHES Equipoise International, the developer of the Totalcare suite of medical software has relaunched at the MedInfo 2007 conference.

Touting new corporate branding and a relaunched website, the Australian software developer is redoubling its promotion of Totalcare, the company’s integrated clinical, billing and patient management offering.

Designed with flexibility in mind, the Totalcare suite of products can be configured for deployment in GP and specialist practices, day surgeries, and larger hospital settings.

In addition to the relaunch of Totalcare, Equipoise has found time to establish a charitable initiative to encourage parents to read to their children.

The company has provided several thousand dollars worth of books to doctors who have committed to pass them along to patients with young children.

Equipoise International www.totalcare.net.au

GENIE INSTALLS ITS 1000TH SITE Genie Solutions, developer of the specialist and GP practice software product Genie, have recently installed their software in their 1,000th medical practice.

Established by then GP, Dr Paul Carr in 1995, Genie was originally developed as a Macintosh product directed at GPs. Genie was later ported to Microsoft Windows in 1999, allowing practices to run Genie on Mac OS, Windows or mixture of both systems.

Andy Matthews, Genie Solutions’ Victoria and Tasmania Sales Manager, recalls that before Windows compatibility was added, selling Genie to practices running Microsoft Windows was a difficult proposition.

“We didn’t just have to sell the Genie software, but often times had to convince the practice to replace their entire Wintel computer system with Apple Macintosh hardware.”

8 PULSE + IT

While Genie Solutions now has several hundred GP sites, the company has found greater success in the Specialist market. With customised modules for Obstetrics, IVF, Ophthalmology, Orthopaedics and other specialist disciplines, the company now boasts over 750 specialist customers.

Reflecting on his company’s success, Dr Carr said, “This is a tough industry, so it’s very satisfying to reach this milestone.

When I first started Genie Solutions I never really thought it would grow this big. However, after a small celebration, we are now focussed on our next goal of reaching 2000 sites by 2011.”

Genie Solutions www.geniesolutions.com.au

“IHE CD CHALLENGE” HOSTED AT THE RANZCR ANNUAL SCIENTIFIC MEETING The Royal Australian and New Zealand College of Radiologists (RANZCR) held their Annual Scientific Meeting in early October.

As part of this event, the college hosted an initiative focused on improving the way in which images are provided to clinicians on CD and DVD. While there are international standards defined, a variety of formats exist in Australian and New Zealand. The inconsistency between these formats is reported to be causing problems for both referring clinicians and radiologists.

Via discussions facilitated by the AMA, the RANZCR has been liaising with Orthopaedic and other procedural specialists in an effort to address this problem. The adoption by radiologists of image delivery solutions that are compliant with the IHE Profile for Portable Data for Imaging (PDI) was identified as part of a possible solution.

IHE is an international organisation established by healthcare professionals and the IT industry that seeks to improve the way computer systems used in healthcare share information.

Dubbed the “IHE CD Challenge”, radiology providers were asked to prepare a CD or DVD containing a routine CT brain study and knee x-rays.

Once submitted, disks were tested for compliance with the IHE PDI profile.

Of the 30 disks that were entered into the challenge, none were found to be fully compliant with the IHE PDI profile, however 2 disks were described as “coming close”. The organisers of the event were able to display images from all the media submitted, however considerable effort and IT expertise were required to get some disks to function as intended.

Dr Peter MacIsaac, Director of MacIsaac Informatics, was responsible for coordinating the challenge. Dr MacIsaac has been involved in the coordination of several interoperability initiatives including the successful MedInfo interoperability demonstration held in Brisbane in August this year.

Speaking after the event, Dr MacIsaac said, “The conference was a great opportunity to get the views of radiologists and also describe to them what is happening with their CDs out in the field. The results confirm the problems reported and indicated a need not only for CD standards but ways to tackle the upgrading of specialist’s and hospital’s IT systems to cope.”

As a follow-up to the IHE CD Challenge, the RANZCR has planed a 3 day workshop focussing on IHE, radiology profiles, cross enterprise document and image sharing (XDS and XDS-I) and PDI. The event will commence on 10th December, and will feature a keynote presentation from Mr Chris Lindop, the Co-chair of the IHE Radiology Committee.

This workshop will be preceded by an AMA-facilitated meeting, designed to better understand the needs of orthopaedic surgeons and other relevant clinician groups.

It is hoped that these workshops will lead to the formation of an IHE Australia/AsiaPacific branch and the implementation of IHE profiles in the region.

Integrating the Healthcare Enterprise (IHE) www.ihe.net IHE Australia www.ihe.net.au RANZCR ASM www.ranzcrasm.com

BITS & BYTES BEST PRACTICE RELEASES MEDICARE ONLINE FUNCTIONALITY Best Practice has released an update to their practice software suite under the moniker of version 1.6.0.395.

Most of the improvements to the software are contained in Best Practice Management, the company’s patient and practice management solution. Of these, the most signiďŹ cant enhancement is the addition of Medicare Online functionality (formerly HIC Online).

Bulk billing, DVA Paperless Claiming, and Patient and DVA Online VeriďŹ cation features are now available, with Online Patient Claiming functionality to be added in a future release.

The Medicare Online functionality has been available to Best Practice beta testers for some time, however issues with the Medicare Australia certiďŹ cation process delayed the ofďŹ cial release of the software.

The update was ďŹ rst made publicly available at the recently held Australian Association of Practice Managers conference in Hobart. The new version will be rolled out to existing Best Practice Management users throughout November, and will be available to new customers thereafter.

Dr Frank PyeďŹ nch, the company’s founder and lead developer, indicated that the addition of this long-anticipated

functionality is likely to increase adoption of Best Practice Management by existing users of his company’s clinical product, Best Practice.

Dr PyeďŹ nch also stated that he expects his company will enjoy increased enquiry rates from potential customers looking to migrate to a fully integrated practice software solution.

Best Practice www.bpsoftware.com.au

MAXON RELEASES NEXT G LAN SOLUTION Maxon have released a hardware router for Telstra and Bigpond Next G wireless broadband solutions. Dubbed the “Ethermax USB Docking Station�, the device is designed to bridge a Next G broadband wireless connection to either a single ethernet-connected computer or an entire ethernet network.

Maxon is a key supplier of Next G modem hardware to Telstra, manufacturing the Telstra Turbo Modem, the Bigpond Next G USB Mobile Card and the Bigpond Next G USB Desktop Modem.

APPLE SET TO UNLEASH LEOPARD On 26th October, Apple will release its sixth major iteration of Mac OS X. Code named “Leopardâ€?, the new operating system will come bundled with all new Macintosh computers. Alternatively, it will retail for $158 for a single licence, or $249 for a ďŹ ve user family pack.

Along with a heavy dose of eye candy, Leopard introduces some signiďŹ cant features to the already mature operating system. Among the most notable are “Time Machineâ€?, a realtime backup solution complete with versioning control, “Spacesâ€? for multipledesktop functionality, and “Quick Lookâ€?, a sophisticated ďŹ le-previewing tool. SigniďŹ cant improvements have also been made to “Automatorâ€?, Apple’s desktop macro development environment, and the powerful “Spotlightâ€? desktop search engine.

Apple claims Leopard has over 300 new features, however this tally includes a slew of relatively minor enhancements made to the operating system’s bundled application suite.

The Ethermax device retails for $299 and is available from Maxon’s online store.

Next G modem hardware and either a Bigpond or Telstra data plan is also required.

The system requirements for Leopard have increased beyond those required for Leopard’s predecessor, Tiger, however all Macintosh hardware released after 2003 with at least 512MB of RAM will be able to run the new operating system.

Maxon Australia www.maxon.com.au

Apple www.apple.com.au

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RACGP

MYGENERAL PRACTICE FOR PRACTICE NURSES AND PRACTICE MANAGERS Jane London

MY PRACTICE TEAM General practice is not just about GPs. Practice managers, practice nurses, and medical receptionists contribute significantly to the delivery of quality services in general practice. However, the ‘business’ of general practitioners is sometimes replicated in other general practice roles unnecessarily.

There are over 1,100 practice managers1 and 4,924 practice nurses2 active in Australian general practice. The general practice workforce is now approaching 75,000. While GPs within their role are well serviced by clinical and prescribing applications, practice managers and practice nurses only have access to waiting room/scheduling applications, some billing applications, and scant clinical resources. There are very few purpose built applications for practice managers or practice nurses.

The recognition of this gap by the RACGP has led to the development of a desktop portal for practice managers and practice nurses that will address issues of resource accessibility in general practice. The portal will offer a range of services and resources — a one-stopshop for their work needs.

The portal has been developed with funding from the Australian Government Department of Health and Ageing through a Managed Health Network Grant.

THE PORTAL The desktop portal for practice managers and practice nurses will use a client-server Internet desktopmanagement technology that facilitates integration of multiple information sources, networks, and technologies in a

10 PULSE + IT

simple, customised, centrally-managed information environment. The portal provides secure single sign-on access to the Internet, network, and local computer resources and technologies.

The single sign-on feature means that once all passwords are programmed into the system, logging on to the portal at the beginning of the day allows convenient access to all sites and resources that may need to be used during the day. The portal will facilitate standards-based applicationto-application messaging, allowing multiple information resources to share a common decision-making context.

Some of the Portal’s resources are explored below: Clinical Audit Tool A clinical audit tool will allow the interrogation of practice data under a number of clinical groupings. This tool will allow practices to explore where they are succeeding in the delivery of care, and where they may need to improve.

The ability to successfully identify gaps in delivery of care will enable practices to improve patient satisfaction and quality of care, strengthen their processes, and maximize various incentive payments.

GPDirect GPDirect is an e-procurement tool that can be used to order consumables, vaccines, and medical equipment. It simplifies and enhances ordering by allowing for product comparison, and shifts purchasing power to practices.

Stock purchased this way is provided by standard third-party distributors that many practices would currently use.

The ability to interrogate purchasing data will also be built into the system. This means that practice staff will be able to review their ordering history and further streamline their practice. For example, vaccine ordering can be explored to make sure that stocks are at maximal capacity, and minimise wastage.

Secure Vault Secure Vault is a program that allows the storage of personal and small business information in secure personal online ‘vaults’. This can include — but is not limited to — financial and accounting information, human resources, and small business incorporation documents. Any data exchange that occurs by using the program is transmitted using 128-bit encryption.

Other Resources, Tools and Links The prospect of incorporating a secure clinical messaging program into the new practice portal is currently being explored by a technical group. Along with this possibility, other practice process support items such as practice management resource kits, MBS Online, PBS Online, employment toolkits, and a number of other resources such as clinical and management links for practice nurses (e.g. wound management, diabetes management).

The RACGP will be conducting pilot phases over the coming months and launching the new general practice portals for practice nurses and practice managers in the New Year.

The MyGP Portal for Practice Managers and Practice Nurses is a companion to the existing MyGP Desktop portal.

Should you wish to find out more information about the portals, please contact Jane London at the RACGP. Jane London jane.london@racgp.org.au MyGP Desktop www.mygeneralpractice.org.au 1 - Figure provided by the Australian Association of Practice Managers 2 - Australian Divisions of General Practice. National Practice Nurse Workforce Survey Report. April 2006.

Manuka, Canberra: ADGP, 2006. www.tinyurl.com/23txbk

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NEHTA

E-PROCUREMENT IN THE PUBLIC HEALTH SECTOR Dr Ian Reinecke NEHTA is developing a National Product Catalogue (NPC) and an E-Procurement Solution to drive safety and quality improvements, and cost and process efficiencies across the national health sector supply chain.

The NPC and the NEHTA E-Procurement Solution will streamline the purchasing process of products in the public health sector through a fully automated, secure and auditable electronic transfer of healthcare product data. In addition to the anticipated safety and quality benefits these initiatives will deliver, an estimated $200 million in savings is expected to flow on from reduced errors and increased procurement efficiencies.

The NPC is a complete electronic source of information about medicines, medical devices and healthcare products, and provides a single source of product data for all procurement areas in the public health sector. The NPC now incorporates fields for the capture of important clinical information that was previously collected via the Australian Catalogue of Medicines (ACOM), which was funded by the Australian Government Department of Health and Ageing.

As of June 30, 2007 over 50 of Australia’s top medical and pharmaceutical product suppliers had populated the NPC, with many other companies in the advanced stages of adding their information. Since July 1, 2007 public health purchasing began incorporating the NPC as their primary source of purchasing data.

Major savings from the NPC will derive from the ‘one product, one code’ concept. The coding system used is a globally accepted standard and is proven in Australia, being the same as that used for retail products in major supermarkets. With this in place, the number of products incorrectly ordered because of identification errors will reduce significantly – errors that potentially delay the treatment of patients who need the right product in the right place at the right time.

12 PULSE + IT

Substantial savings will also arise from the NPC by removing the need for each of the literally hundreds of public health purchasing offices across Australia to maintain their own catalogue of product details. This duplication currently generates unnecessary overheads.

In terms of safety and quality in healthcare, the NPC lays the foundations for swift product recalls and precise product tracking so that flawed, out-ofdate or missing stock can be discovered and replaced before it is needed for use.

The second stage of the e-procurement strategy is the implementation of eprocurement facilities. NEHTA has developed a standardised e-procurement solution for the public health sector that will standardise and simplify purchasers’ processes, and assist all Australian health departments to develop a minimum e-procurement capability whilst supporting existing structures and process already adopted by suppliers and other stakeholders in the market.

To improve public health sector procurement analysis and reporting, NEHTA has also created business intelligence tools to provide a better understanding of procurement practices from overall healthcare procurement for a health department right down to product at item level transactions across all purchasing areas.

NEHTA’s approach to developing the specifications for business intelligence tools has built on structures and processes already operating in health departments and is based on learning from health departments, industry, international equivalent organisations, and appropriate local and international standards.

These tools will form the foundation for better business decisions as the public health sector captures more information electronically, and deliver the potential to identify and obtain significant savings through increased efficiencies.

Trials of the e-procurement solution using the NPC data have commenced in Western Australia through a Proof of Concept supported by NEHTA. Negotiations have also progressed with NSW to advance their solution for use of NPC Data in their health procurement processes. Most other States have indicated a willingness to begin using the NEHTA e-procurement solution in the next 12 months.

NEHTA currently has a number of additional projects underway to deliver secure, interoperable e-health systems, some of which are relevant to the work being undertaken in the Supply Chain area. This work includes: • Establishing an overall framework for interoperable e-health systems; • Standardising the terms and names used to describe medicines and other clinical information, such as diagnoses, procedures and therapies, in e-health systems; • Developing unique identifiers for individuals and healthcare providers as well as medicines and medical products; • Standardising the types and formats of health information to be collected in e-health systems; • Identifying a secure means of electronically transferring clinical information between authorised healthcare professionals; • Designing specifications for secure electronic health records; • Involving local and international standards organisations to support ehealth implementation; and • Developing the business case for a national system of shared electronic health records to be presented to COAG in 2008.

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

NEHTA www.nehta.gov.au

ACHI

THE AUSTRALIAN COLLEGE OF HEALTH INFORMATICS: AN INTRODUCTION Dr Terry J Hannan MBBS, FRACP, FACHI, FACMI Health Informatics as a discipline is not new. It has a history that dates from the mid to late 1960s. The early origins were most likely in France, with individuals such as Francois Gremy1.

Since then the essential role of health information in the delivery of health care has become increasingly apparent and important.

The 1991 publication by the Institute Of Medicine, summarised health informatics up to that time. This text was titled, “The Computer-Based Patient Care Record.

An essential technology for health care.” (Institute of Medicine, Committee on Improving the Medical Record.

Washington, DC: National Academy Press, 1991.)

This report spawned a series of texts on the many aspects of the use of computer-based technologies (electronic) that are components of what is now defined in terms such as the Electronic Medical Record, Electronic Health Record, Patient Health Record, etc.

The discipline of health informatics (sometimes referred to as medical informatics overseas) has evolved over time so that we now have three core aspects that define the importance of information management in health care: 1. Providing medical care can be defined as information management and therefore medical practice can also been defined as medical decision making. Information is thus key to all care delivery. (Biomedical Informatics, Shortliffe and Cimino 2006).

2. The communication of health information is based on the availability of an adequate medical record and the foundation for quality patient care

14 PULSE + IT

is information. This information must be comprehensive, accurate and up-tothe-minute.

3. To improve care you must be able to measure it and this is not possible using predominantly paper-based record systems. (W. Tierney, Regenstrief Insitute) Also, you manage what you measure. (Brent James IHC, QMMP project. Chicago, Illinois. 1989).

ACHI is a child of this emerging, but already robust scientific discipline, and was inaugurated in 2002 with its original Fellows and Members being drawn from those who had established ‘histories’ in this field. Its creation also reflected the need for a stronger academic scientific arm for health informatics within Australia, with a view to building on the strong record of the Health Informatics Society of Australia (HISA).

ACHI can therefore be seen as a distinct but integrated organisation within health informatics structures in Australia.

Ongoing professional cooperation between these two organisations and other informatics groups must occur for future successful health informatics projects to occur. With these professional interactions the knowledge and experiences of health informatics can be linked to health care management based on the Electronic Health Record and can be disseminated to industry, governments, health care institutions, medical colleges, clinicians, researchers, patients and health care funding organisations. This will facilitate the development and uptake of the Shared Electronic Health Record and all the required interoperability standards.

The College continues to grow in membership and now has 44 Fellows and Members thus expanding its

research and knowledge resources. Its members are recognised internationally for their quality research and knowledge in this discipline.

The primary missions for ACHI are to: • Act as the peak reference body for health informatics in Australia; • Foster professionalism in the health informatics community through a commitment to quality, standards and ethical practice; • Build a community of practice in health informatics, embracing the multidisciplinary nature of the field; • Work to enhance the national capacity in health informatics in research, education and training, policy and system implementation; • Support individual health informaticians through mentorship and the development of career paths; • Represent the health informatics community through advocacy and constructive interaction and linkage with government, industry, academia and other professional organisations; and • Work as agents of change in the health system by encouraging the appropriate and innovative use of health informatics concepts or technologies.

Dr Terry Hannan is the President of the Australian College of Health Informatics.

ACHI Website www.achi.org.au ACHI President - Dr Terry Hannan terry.hannan@dhhs.tas.gov.au ACHI Hon Secretary - Heather Grain H.Grain@latrobe.edu.au 1 - www.imia.org/history.html

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HUNTER URBAN DIVISION OF GENERAL PRACTICE: IMPROVING PATIENT OUTCOMES

BY DELIVERING IM/IT SOLUTIONS Chris Scott BSc (hons), G Dip Comp App DIVISION PROFILE Based in Newcastle, The Hunter Urban Division of General Practice (HUDGP) employs over 250 GPs, 95 Nurses and 60 head office staff. The region HUDGP covers includes both rural and urban general practices. The 450 GPs that are supported by the HUDGP service a population of approximately 500,000 people.

The HUDGP Information Management and Technology (IM&T) team supports 119 practices, providing over 1,000 direct services per year. Services provided include help desk support for hardware, networking, communications, data modeling and other related IT services.

CONNECTIVITY In 2005, the HUDGP partnered with Internet service provider, Pacific Internet to roll out a secure and reliable broadband network across the region.

The network is enormously popular among local GPs. 89 practices within the region now use the PacNet Broadband Network with many using fully managed Cisco 877 Routers, which provide intrusion detection and prevention services.

Firewall configurations are backed up and for those managed by the HUDGP any changes in firewall configuration are reported to HUDGP IM&T staff for immediate investigation.

Through collaborative arrangements, the GP Access After Hours Service was set up to operate 5 clinics on Hunter New England Area Health Service (HNEAHS) premises offering after hours GP services to the local population. The after hours service allows patients to talk with a nurse located in a call centre who organises a bulk-billed appointment with one of 250 doctors rostered at five clinics in Newcastle, Lake Macquarie and Maitland.

16 PULSE + IT

HUDGP after hours clinics have been connected to the Area Health Service Patient Administration System via an eGate HL7 interface. This HL7 interface is designed to preserve data quality and synchronize patient records (HUDGP’s database contains over 120,000 patient records). The Division also supports the NSW Electronic Health Records project for managing patients with chronic and complex care requirements.

ADVANCED SUPPORT The roll-out of the broadband network has allowed the introduction of a remote IT support system, Citrix GoToAssist. This has enabled IT problems to be fixed promptly, thus maintaining business continuity in the GP practice and reducing travel for IT personnel by 30%.

The HUDGP identified that electronic access to clinical information stored remotely would greatly benefit service provision. With this in mind, the HUDGP ran a pilot of Citrix GoToMyPC Corporate Edition, a centrally managed remote access system.

Survey results to date indicate that this system is easy to use and saves an average of 2.25 hours per week of GP time. Remote access was reported to improve patient care and was found to provide options to improve work lifestyle and improve Practice efficiency. The survey responses also show that remote access allows GPs to improve their time management.

CLINICAL MESSAGING The Division is currently rolling out a clinical messaging system, which will create an infrastructure of enormous public value. At this time, 400 GPs and Specialists are connected. The project is to be implemented over three phases and is expected to connect nearly 2,000 health professionals:

• Phase 1 - Sending consultation summaries from our GP Access After Hours Clinics, Psychology Services and Best Practice Rehabilitation to GPs. • Phase 2 - Sending consultation summaries from Specialists, Allied/ Community Health and Area Health Services to GPs. • Phase 3 - GP referrals sent electronically to Specialists, Allied/ Community Health and Area Health Service Specialists and Clinics.

This project has immediately provided evidence of improved services in the delivery of health care to patients.

Where consultation summaries were once faxed, they are now sent via the broadband network and integrated into the patient’s electronic record within the GP practice. The broadband network, in conjunction with Medical-Objects’ software and its three level acknowledgement system, ensures summaries are received quickly and securely. This has reduced clerical overhead costs at the GP practice.

CHALLENGES AND THE FUTURE Clinical data is inherently complex and privacy concerns will continue to present as a challenge to future e-health advancements. The HUDGP believes that Divisions provide the right infrastructure to achieve successful outcomes in e-health projects and this requires significant commitment from government.

The HUDGP will continue to be at the forefront of collaborative services aimed at improving services and providing practical outcomes for the community and for GPs. Chris Scott is the Chief Information Officer at the HUDGP. Starting from this edition, the Australian General Practice Network will contribute regular articles on Information Management and eHealth.

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INTERVIEW

INTERVIEW: GENIE SOLUTIONS Pulse+IT checks in with Genie Solutions’ Managing Director, Dr Paul Carr.

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

Genie Solutions produces the original Genie for general practice, and Genie SP for specialists. Users can select their particular specialty, and the program adjusts, hides, and shows a variety of features pertinent to the selected specialty. In particular, there are modules for Obstetrics, IVF, Orthopaedics, and Ophthalmology. It is also popular amongst plastic surgeons and dermatologists because of the handling of digital photographs, and a Lesions module for the excision of skin lesions. The handling of procedures and quotes makes it attractive to all other procedural specialties.

For GPs, it incorporates health assessments and management plans, a diabetic and other disease register, NPCC reporting and appointment analysis, as well as the usual clinical and prescribing capabilities using MIMS Integrated Plus as the source for all medicines information.

the Australian market do pretty much the same thing to some extent, but when demonstrating Genie to practices I am frequently surprised to see that it’s the simple things that excite them, like the ability to print and store preoperative quotes, handle pre-payments, automatically include assistants’ fees in invoices, change a banking record from Cash to Cheque without having to delete the payment and start again, print or email theatre lists, and send SMS reminders.

Practice managers like being able to automatically update new fee schedules via the Internet, particularly the private fund schedules.

They also like being able to leave a halffinished letter open while they create an appointment or an invoice, without having to save it first.

These are all small things that our users have suggested over the years, but they can save a lot of frustration and wasted time.

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

Pulse+IT: What platforms does Genie run on?

The principal reason that practices buy Genie is our reputation for good support.

Whenever a practice switches to Genie from another program, the number one reason given is poor support from their current vendor. Genie has grown to be the largest specialist vendor purely by word-of-mouth recommendations. I’ve always believed that if we provide a good program with good support, then the sales will follow, and that has proven to be the case. We hardly ever advertise because our existing customers are great advocates for Genie. We try hard to maintain good business relationships with all our customers and, in some respects, to engender a feeling of an exclusive “club” of Genie users.

Mac OSX and Windows, or a combination of both on a network.

It originally started as a Macintosh program but was ported to Windows in 1999. Today, our user base is 25% Macintosh and 75% Windows. Many practices use a combination of both Macintosh and Windows machines in their networks. It’s quite useful being cross-platform because it means that a Mac-centric doctor joining a Windows-based practice doesn’t have to learn how to use Windows, and vice versa. The Macintosh platform is also a wonderful niche for us, because it’s no secret that Macintosh users are very passionate about their chosen platform. We understand their passion and are committed to providing a great experience with Genie on both Mac and Windows.

Second, it’s often just the little things. All the practice management programs in

18 PULSE + IT

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

There are 38 built-in conversions which includes all the major programs available in Australia, although MD3 is still only a partial conversion because of the encryption HCN use in some tables.

We don’t convert billing data from any program as it’s just too different for each program. Usually, practices just run the old program for a couple of months, receipting outstanding accounts until they are down to a level where they can be transferred manually.

Pulse+IT: How is the data conversion performed?

Conversions are usually performed by our own staff at the time of installation, or the day before. Genie is installed on the computer hosting the program to be converted. In some cases eg MD2, it’s just a matter of clicking a “Convert” button and going for a coffee. In others, it’s necessary to create an ODBC source first. In some cases, we do the conversion at our own offices and deliver the converted data on the day of installation.

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

Healthlink, Argus, 2Hippo, ePIT, AllTalk, Division Report and Medical-Objects.

This is one of our major areas of interest.

We see this integration as being of increasing importance in the next few years. We are at the forefront of development in this area, and have been working closely with these vendors to provide seamless integration of electronic communications.

Pulse+IT: How does Genie handle photos and scanned documents?

Digital photos can be extracted directly from the camera and automatically linked to a specific patient. Alternatively,

INTERVIEW they can be saved to a directory on disk and then assigned to the relevant patients.

Scans are handled in the same way, i.e. scanned and linked automatically to a particular patient, or scanned in bulk to a holding directory and linked to multiple patients from there.

In fact, any type of document can be linked to a patient record. All images and documents are stored in a folder hierarchy on the server, where each patient has their own uniquely named directory. Anything placed in a patient’s folder, whether manually or automatically by Genie, is “linked” to the patient. On a network, Genie scans or extracts a photo initially to the client machine, and then copies it across the network to the patient’s folder on the server. Once it’s in there, it’s available to all the other clients on the network.

When a user clicks on the image, Genie uses FTP commands to copy it from the server to the client, and then displays the local copy. This can then be manipulated, annotated, or otherwise modified, and saved back to the server.

Interesting photos can be saved to an “Album” for storage in case you want to use them for a presentation. Or, in the case of plastic surgeons, to show new patients the expected results of surgery.

Pulse+IT: How is training and support provided?

Onsite training is provided at the time of installation and, if feasible, a couple of weeks after installation for follow-up questions. Ongoing support is provided by phone, fax, email, and by the Internet-based Genie Message Board which allows conversations between users and staff. This is also a searchable database of problems that other Genie users may have encountered, so our users can often find the answer to any problem they are having here.

Pulse+IT: How many people make up the Genie team?

There are 19 in all. 14 at our head office in Brisbane, 3 in Melbourne and 2 in Sydney. In addition, there are independent distributors in South Australia (Konos Koncepts) and Western Australia (Assured Technology). The Melbourne office looks after Tasmania,

and Brisbane looks after the Northern Territory. That’s the theory anyway. In practice, we often fly someone from Melbourne to Cairns, or Sydney to Hobart, depending on availability. There are also several practices in London, New Zealand and Spain who are supported via email, phone, and the occasional visit.

Pulse+IT: Overview your pricing structure.

Initial installation includes the software price, the first year’s annual support fee, and the installation and training.

For the average 3 workstation practice this works out to around $3800 + $1800 + $1700 respectively. The ongoing annual fee is $1800 for a 3 user system. Software price increases by around $800-$1000 for each extra workstation.

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

MIMS Subscription, around $230 for a single doctor. ICPC Subscription for GPs and non-procedural specialists, $200 initially and then $100pa thereafter.

These are both optional. Genie Solutions has a distribution license for ICD10 coding, so this is provided free of charge to procedural specialists. Genie does not use Microsoft SQL so there are absolutely no other networking costs, no matter how large the network.

We don’t usually charge for data conversions unless it is one of the more complex conversions, or it’s from a program which we haven’t previously encountered.

Pulse+IT: How frequently does Genie release program updates?

Every 2 months approximately.

Pulse+IT: Is professional IT assistance required to perform these updates?

Not usually. Fee schedules, MIMS, ICPC and ICD10 updates are just a one-click procedure which are downloaded via the Internet and automatically imported into the program. Updates of the program itself are also automated to the extent that a user on a client machine simply selects to apply an update which is then downloaded via the Internet, automatically copied to the server, quits

the server, applies the update and then restarts the server. So usually it’s just a matter of click a button and then stand back.

Pulse+IT: How many practices are currently running Genie?

We are expecting our 1000th site to be installed in the first week of November, which will be a pretty exciting milestone for us. Gallons of champagne are being chilled as we speak. We usually install around 20-25 new sites each month.

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

ECLIPSE is the main priority at the moment, but we’re also spending a lot of time on fine-tuning electronic communications between GPs, specialists, and hospitals. The next version also has an option to use an updated interface with a more standardised look and feel to buttons.

We’re also doing more and more with web services to deliver information and updates to our customers. In particular, we maintain a database of providers in Australia on a web server, including address, phone numbers, provider numbers, specialty, and preferred method of communication. Our users have access to this database so that when we install a new site, we can immediately populate their address book with every GP or specialist in their vicinity. And in the next version, when searching for a referring doctor or specialist, Genie will offer to search the web server if they don’t exist in the local address book, allowing the practice to download their details automatically.

Our users keep this database up to date themselves by periodically uploading their own address books to our web server.

In the next few months we’ll also be integrating Genie with the Clinical Audit program developed by Pen Computer Systems, which will allow our GP users to analyse their clinical data in detail, and help to improve chronic disease prevention and management.

Genie Solutions www.geniesolutions.com.au

PULSE + IT 19

FEATURES

AN INTRODUCTION TO GEO-PHOTOGRAPHY Dr John Goswell MBBS DipObs RACOG

GREAT HOLIDAY! So you’ve returned from a wonderful holiday. You had a great time, and have lots of photos to remind you. Chances are that you used a digital camera and took twenty times the number of photos that you would have taken with a film camera.

Digital photographs offer many advantages over film. They can be reviewed on the spot to ensure that “what you saw is what you got”. They can be edited. Botched photos can be discarded without wasting film and the cost of developing. No longer do you have to wait a week for the photos to return from the developer.

There is one important thing, however, that digital photos will not allow you to do, and that is to write on the back of the photo to record the date, the place, and the subject.

Wouldn’t it be good if we could do something similar with our digital photos?

Even better, what if the camera did this for us automatically? Well, to a large degree it can. Not only can the time the photograph was taken be recorded, but also the exact location. Such information is recorded within the image file as Exif (EXchangeable Image File Format) data.

EXIF Most digital image files store information about the photograph itself (called metadata). To be useful this information needs to be readable and ideally needs to be in a standard form. Most camera manufacturers use the Exif data standard, which allows metadata to be encoded in JPEG and TIFF files. Exif metadata may include: • Date and time.

• Camera information (aperture, ISO, shutter speed, focal length, metering mode).

20 PULSE + IT

• A thumbnail image.

• GPS (Global Positioning System) data including latitude, longitude and altitude.

• Image descriptions and copyright information.

• Makernotes (this is used by manufacturers to encode extra information).

Viewing this information is surprisingly easy. In Windows, one needs to select the photo in Windows Explorer or in Windows Picture and Fax Viewer.

Right-clicking the mouse brings up a menu from which the user can select “Properties”, then “Summary”, then “Advanced”. A significant amount of information about the photo can often be found, however this method does not display GPS data.

There are dedicated, stand-alone Exif viewers such as Opanda IExif, and add-ons for Mozilla Firefox and Internet Explorer, which display Exif data on rightclicking the image. Two of these are Exif Viewer and Kuso Exif Viewer.

Mac users (10.4 and above) have access to Exif data through the Finder’s “Get Info” window, Apple iPhoto, or shareware programs such as GraphicConverter.

LOCATION, LOCATION, LOCATION So how does one get the location (GPS) data into the digital image file? There are four general solutions: 1. Use A Camera With An Inbuilt GPS While there were some early models that did this, and some current highend models used for surveying, there are surprisingly few cameras with this functionality today.

There are some recent mobile phone/ camera combinations, such as the HP hw6915 sport GPS, and there are also some car navigation systems that

include a camera that will add the GPS co-ordinates, including Navman AIOs (N40i, N60i). However, these systems do not take the high-resolution photos to which most digital photographers are now accustomed.

2. Connect A GPS Unit To The Camera Some cameras allow data from a GPS unit to embed location data into the image file at the time the photo is taken.

Such models include Ricoh’s Caplio 500SE (which embeds data wirelessly from a nearby Bluetooth GPS unit) and the Nikon D300 (via an adaptor cord purchased optionally). Wireless Bluetooth solutions are obvioulsy preferred as a cabled arrangment adds bulkiness to the camera.

3. Add The Location Information Manually Some software products, such as RoboGeo, allow you to do this, either by typing in the GPS co-ordinates or by clicking on a location on a map.

While this may be viable when working with one or two photos, it becomes tedious to calculate positions for multiple photographs.

4. Syncronise Your Camera And GPS On Your Computer This solution is often the most practical, and the author’s preferred GPS photography method.

Under this arrangement, the photographer uses a GPS device to record his/her movements whilst shooting the photos. Operating independently from the camera, the GPS unit simply logs the latitude and longitude at regular intervals (e.g. every 15 seconds), and the exact time of each log entry. This “tracklog”, is later transferred to the photographer’s computer.

Because the photographer’s camera will have recorded (into the Exif data of

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FEATURES each image) the time that the photo was taken, it is easy for computer software to look at this time recorded (in the tracklog) and match it with the corresponding latitude and longitude.

This location information is then added to Exif metadata for that image.

Because the timestamps are the only information used to perform the match between the image and the GPS data, this approach requires that the camera’s internal clock be accurately matched to the GPS unit’s own clock before GPS photography commences.

WHERE TO START? If you have a GPS unit that can record tracklogs, and if this can be connected to your computer, then you already have most of what you need. On your next excursion try the following: 1. Turn the GPS unit on and allow it to get a satellite fix.

2. Set the camera time to exactly match the GPS time.

3. Set the GPS to record a tracklog based on 15 second intervals.

4. Carry your GPS unit with you whilst taking your photos.

5. When you have finished taking your photos, save the tracklog on the GPS. 6. Load the photos to your computer, and import the tracklog from the GPS. 7. Use a program such as RoboGeo to add the GPS data to the photos (geo-tag).

RoboGeo is available as a fully functional free trial; however, the program adds random inaccuracies to the GPS data until you pay for a licence.

RoboGeo has good features and is quite easy to use.

An alternative is the free program Grazer. It could not be simpler, and works well, but is light on extra features.

One downside of the program is that it does not give error messages when something goes wrong.

AND NOW THE EASY SOLUTION Using a GPS unit is OK for those who have one and have taken the time to learn to fully use it. For most of us however, a simpler solution is needed.

This is where GPS data loggers come in.

Data loggers are units dedicated to recording GPS tracklogs. They are typically small and will usually function

22 PULSE + IT

longer than most GPS units on a single charge/set of batteries. The process simplifies to: 1. Synchronize the times for the GPS data logger and the camera.

2. Turn on the data logger and take it with you when photographing.

3. Upload your photos to your computer.

4. Plug in the data logger and run its software.

Examples of GPS data loggers include Sony’s CS1, GisTeQ, iBlue 757 Pro 32, GlobalSat DG100, TraCKsTICK II, WinTec WTC-200 and ITrekZ1.

AND NOW THE FUN There are several fun, interesting, and

useful things you can do once the Exif data is imported: Locate Where The Photo Was Taken Using Exif Viewer in the Firefox web browser, one can pin-point the location for any geo-tagged photo on a Google Earth map (right-click, select “View image Exif data”, scroll to “GPS Info” and select “Google Maps”). Other software can also be used such as Picture Motion Browser1or PhotoTrackr2.

View A Map Of Where You Went The path that you and your data logger followed can be plotted on a map.

The location of each photo can also be highlighted and linked back to the image, adding context to the photo.

Below - Opanda IExif shows the Exif (image meta-data), including the GPS information.

Bottom - A photo of an orchid that has been ‘stamped’ with Exif data by RoboGeo, including the data and time the image was taken, as well as the precise location.

FEATURES Stamp Your Photos With Exif Data The location and time a photo was taken can be ‘stamped’ onto the visible image using RoboGEO.

CONCLUSION

View A Slideshow Of Your Trip Programs like PhotoTrackr can play a slideshow of your images while displaying a map showing where each photo was taken.

Improvements in photo quality and falling costs have caused the uptake of digital cameras to surge in recent years. The increased popularity of these devices has resulted in an explosion in the number of complementary products and services designed to extend their usefulness — GPS related solutions being one of the more interesting categories.

Upload Your Photos To The Internet PhotoTrackr directly enables uploads to Google Earth and locr. Once done, others can view the photos based on geographic location. Photos can also be uploaded to Flickr in order to “share your photos with the world”.

Combining GPS devices and related software with digital cameras adds another dimension to modern-day photography. The technology is readily accessible, adds value to your photographs, and most importantly, is enjoyable to use.

Below - A satellite image displaying the route travelled by the photographer (in blue) while using a GPS data logger, as well as markers indicating where each photo was taken. As indicated, thumbnails of the photos corresponding to the markers can also be displayed.

Bottom - A map showing the route (in purple) taken by a photographer while using a GPS data logger. PhotoTrackr software was used to generate this image.

Dr John Goswell is a solo GP from Maitland, NSW, having worked in general practice for twenty years.

He has an ongoing interest in medical IT, authoring The Doctors’ Reference Site (www.drsref.com.au) and running the Nat-Div Mailgroup (www.gp.org.au).

He is the chairman of the Friends of Werakata National Park (www.werakata.org.au), and is documenting the Park flora and fauna photographically. He is currently finishing the first of hopefully a series of CDs on local vegetation habitats (The Kurri Sand Swamp Woodland).

To complement this article, Dr John Goswell has written detailed reviews on the Sony CS1 and the GisTeQ data loggers. Due to space restrictions, these articles could not be included in this printed edition of Pulse+IT, however they have been made available at the Pulse+IT website.

Opanda IExif www.opanda.com/en/iexif Exif Viewer tinyurl.com/2hr3o3 KUSO Exif Viewer tinyurl.com/3yb5b2 iPhoto www.apple.com/iphoto GraphicConverter www.lemkesoft.com RoboGEO www.robogeo.com Google Earth earth.google.com Locr www.locr.com Flickr www.flickr.com 1 - Picture Motion Browser is supplied with Sony’s CS1KA data logger.

2 - PhotoTrackr is supplied with GisTEQ’s data logger.

PULSE + IT 23

FEATURES

CONSULTATION ROOM PRINTERS Simon James BIT, BComm

INTRODUCTION While secure paperless correspondence is slowly starting to become a reality, doctors are unlikely to be able to cease printing documents in their consultation room any time soon. Bowing to this unfortunate reality, this article seeks to provide guidance to practices looking to install new printers in their consultation rooms.

While some of the material presented in this article will apply equally to reception and administration settings, most practices would be better served by deploying larger, more robust printers in these areas, the likes of which will be discussed in future articles.

KEY CHARACTERISTICS When looking to purchase a printer for a consultation room, there are several key characteristics to look for: Trays, Trays & More Trays The most tangible way to reduce the time clinicians spend printing documents in their consultation room is to minimise the need for them to have to physically handle different types of paper for scripts, pathology and radiology requests, and other document types.

There are three basic approaches that can be used to achieve this: 1. Reduce the number of paper types used by the clinician.

2. Install multiple printers, each loaded with a different paper type.

3. Install a printer with multiple paper trays.

Given that Option 1 will depend heavily on the pathology and radiology facilities the doctor refers patients to, and Option 2 doesn’t scale well and is likely to be undesirable for ergonomic reasons, the deployment of a single printer with multiple paper trays will usually be the

24 PULSE + IT

most viable method of reducing the time spent manually inserting the requisite paper into the printer. A printer with three paper trays could, for example, allow scripts, pathology request forms and plain A4 paper to be permanently stored in the printer and intelligently selected by the clinical software when required.

Time To First Page While the top speed of both laser and ink jet printers continues to improve steadily, the fact that many printers suitable for consulting rooms can print 20 to 30 pages per minute is largely irrelevant.

Rarely do doctors need to print large, multi-page documents. Instead, the vast majority of jobs sent to a consultation room printer are one or two pages in length, e.g. a referral letter, specialist report, script, or a pathology or radiology request.

Because of this usage pattern, purchasers should look for printers with a fast “time to first page”. The reader should note however, that as with most performance guidance quoted by manufacturers, these times are clocked under ideal circumstances and tend to be slightly optimistic.

Total Cost Of Ownership While the purchase price of a printer is easy to measure, determining the ongoing cost of running the device requires slightly more effort.

Armed with an approximation of the number of pages the printer will output each year, would-be purchasers should be mindful of the cost of toner per page, and also the cost of replacing the printer’s drum unit. Warranties, the location of service centres, and whether scheduled maintenance needs to be performed should also be considered.

BONUS CHARACTERISTICS While certainly not as important as a fast print speed or multiple paper trays, the following features are worth pursuing if they won’t dramatically increase the purchase price of the printer: Networking Having a network interface in a consultation room printer would usually not be a critical requirement, as in most cases, the printer will be sent jobs from a computer via a USB cable. However, having a network interface, or the option to add one at a later date, increases the utility of the printer.

Duplexing The capacity to print on both sides of the page should not been seen as a critical requirement for a consultation room.

However, duplexing functionality is now a fairly common inclusion for printers priced in the $300 - $500 range and may be attainable without extra expense.

MacOS X & Linux Support While it is likely that your practice currently runs a flavour of Microsoft Windows, the increasing popularity of the MacOS X and Linux alternatives is worth considering when buying printers and other hardware. Within the useful life of your new printer, the IT landscape promises to be markedly different to the present day. As such, opting for a printer that is compatible with MacOS X and Linux will ensure that a change in operating system won’t require you to replace your still-functioning printer.

THE CONTENDERS When searching for printers that meet the key characteristics outlined earlier, it will become apparent that there are only a few laser printers on the market that both fulfill the key requirements, and are affordably priced. While it wasn’t feasible to consider all of the potential candidates in this article, three printers

FEATURES Kyocera FS-1030D

Brother HL-5240

Brother HL-5250DN

Canon LBP-3300

Pages Per Minute (A4)

22

28

28

21

Time To First Page

10 seconds

10.5 seconds

10.5 seconds

11 seconds

Time To Second Page

13 seconds

12.5 seconds

12.5 seconds

15 seconds

Native Print Resolution

1200dpi x 1200dpi

1200dpi x 1200dpi

1200dpi x 1200dpi

600dpi x 600dpi

Standard Paper Capacity

250 + 50

250 + 50

250 + 50

250 + 1

Optional Paper Capacity

250

250 + 250

250 + 250

250

Maximum Paper Capacity

550

800

800

500 + 1

Output Bin Capacity

250

150

150

125

Speed

Paper Handling

Connectivity USB

Yes

Yes

Yes

Yes

Parallel

Yes

Yes

Yes

No

Network (Ethernet)

Optional: $141 (IB-21E)

No

Standard

Optional: $209 (NB-C1)

Standard

No

Standard

Standard

Misc Features Duplex Mac OS X Support

Yes

Yes

Yes

No*

RAM (Base / Max)

32MB / 288MB

16MB / 528MB

32MB / 544MB

8MB / 8MB

Pages Per Cartridge

7200 (TK 120)

7000 (TN 3185)

7000 (TN 3185)

6000 (CART 308 II)

Cost Per Cartridge

$140

$129

$129

$169

Pages Per Drum Unit

100,000

25,000

25,000

Not Available

Cost Per Drum Unit

$295

$235

$235

Not User Serviceable

Cost Per Page

2.2 cents

2.8 cents

2.8 cents

Not Available

Printer

$394

$349

$449

$349

Extra Tray

$195 (PF-17)

$199 (LT 5300)

$199 (LT 5300)

$299 (PF-35)

Total Cost Inc Extra Tray

$589

$548

$648

$648

Running Costs

Purchase Price

Above: A table showing the various characteristics of several printers considered to be potentially suitable for deployment in a doctors consulting room. “Time To First” and “Time To Second” page were benchmarked by using a stopwatch to record the time taken for Genie 7.4.7 to print typical one and two page referral letters. All prices shown have been collected from Australian-based online stores and should be treated as approximations only. * A Japanese CAPT driver for the Canon LBP-3300 is available for MacOS X, however it is not officially supported in Australia.

were obtained and tested, namely the Kyocera FS-1030D, the Brother HL-5240, and the Canon LBP-3300.

Kyocera FS-1030D The Kyocera FS-1030D is the fourth revision in Kyocera’s popular 1000 series.

The printer ships with a 250 page paper cassette, and a 50 page multipurpose tray. A second cassette can be added, allowing three different types of paper to be available to the clinical software without manual intervention. It is worth noting that Kyocera has used the same optional paper tray since the FS-1000

(the great, great grandfather of the FS-1030D). While there is no guarantee that future Kyocera printers in this series will continue to use the same paper tray design, it does mean that there will be a large pool of second hand paper trays and printers available to users, should they experience an equipment failure outside of the two year warranty period.

As the “D” in the name implies, the FS-1030D has built-in duplex functionality, allowing the user to print on both sides of the page without having to manually flip paper over. The printer features an

expansion slot that allows a network card to be added, allowing customers to purchase the printer with a network card pre-installed, or purchase and install one themselves at a later date.

The printer uses a drum rated for 100,000 pages, which, when factoring in all running costs, gives it the lowest total cost of ownership of all the printers referenced in this article.

One downside with the FS-1030D is the fact that when paper is inserted in the multipurpose tray, all print jobs are printed to this tray, regardless of

PULSE + IT 25

FEATURES the tray the clinical software tells the printer to draw paper from. This issue can be addressed using a one-time configuration procedure, however the ability to switch from “bypass” to “cassette” functionality using the driver software would be a welcome improvement.

Brother HL-5240 / Brother HL-5250DN For the purpose of this article, the author was provided with a Brother HL-5240 laser printer. Brother also retails the more expensive Brother HL-5250DN, which adds a duplexing unit, more RAM, and a network interface to the feature set of its sibling. The printing mechanism and all other features are identical across both devices.

Building two, non-upgradeable printers serves to lower production costs slightly, however this approach means that customers will need to decide at the time of purchase whether they will require networking and duplexing capabilities, both at the time of purchase, and into the future.

This minor quibble aside, the HL-5240 is an excellent printer, sporting a fast time to first page and high multi-page speeds.

The printer has the option of not one, but two extra paper trays, meaning a total of 4 different paper types can be made available without manual intervention.

As a bonus, each of these paper cassettes features a gauge indicating the amount of paper contained within.

Canon LBP-3300 Unlike the Kyocera FS-1030D and the Brother HL-5240, the Canon LBP-3300 does not have a multipurpose tray to compliment its built-in paper cassette and duplexing unit. While it does allow the manual insertion of paper via a “transactional” front-loading slot, the use of this paper path requires that users manually hand-feed pages into the slot.

The Canon LBP-3300 produces high quality results at acceptable speeds.

It can be upgraded with an optional network card, and a second paper cassette can also be installed.

Unfortunately, the fact that manual intervention is required to use the transactional paper feeder limits the printer’s suitability for use in a consultation room. Its lack of MacOS X support and its fixed drum architecture count against it further.

CONCLUSIONS This article has highlighted some of the key characteristics to look for when purchasing a laser printer for deployment in a consultation room setting. Among these characteristics are the ability to add multiple paper trays, a fast “print to first page” time, and a low total cost of ownership.

While historically, multi-tray laser printing solutions were expensive, costs have fallen to the point where all practices can now quickly recoup the initial investment through efficiency improvements.

The printers discussed in this article from both Kyocera and Brother are excellent options for a consulting room. Because of their slightly differing feature sets and prices, the author found it difficult to rank these printers for all situations with conviction.

If duplex and network functionality aren’t important to your practice, the Brother HL-5240 is likely to an appealing choice. With the option for a total of four paper trays, it also has the ability to deliver the greatest efficiency improvements over the course of its lifetime.

If network or duplex functionality is required, the Brother HL-5250DN is well priced, as is the Kyocera FS-1030D when the total cost of ownership is considered.

Simon James is the Editor of Pulse+IT.

Detailed reviews of all printers mentioned in this article have been made available at the Pulse+IT website. A review of a business inkjet, namely the HP Officejet Pro K5400 is also available.

Brother www.brother.com.au Canon www.canon.com.au Kyocera www.kyocera.com.au

Faster. Smarter. Stable. Ad-free. And more intuitive at your fingertips. The evolution of Australia’s fastest growing GP software continues as Best Practice Management now goes live with Best Practice Clinical. With companion software, Top Pocket – for your PDA – Best Practice gives you the unique, fully integrated whole-of-practice software suite you’ve been waiting for.

26 PULSE + IT

Call, write or email for a FREE Demo CD of the lot. Best Practice Software PO Box 1911 Bundaberg QLD 4670 Ph 07 4153 1277 www.bpsoftware.com.au

FEATURES

FIRST LOOK: GPCOMPLETE Simon James BIT, BComm INTRODUCTION GPComplete is a fully integrated practice management solution designed specifically for general practices. It is developed by The Practice Management Software Company, and was first released in 2003.

The company claims that GPComplete is different from other practice management or clinical records systems, because it is not features-based, but workflow-based. It seeks to reduce the amount of time required by the doctor, practice manager and receptionist to complete the tasks they perform repetitively throughout the course of their day.

GPCOMPLETE DIFFERENCES The appointment screen is the ‘home’ for the entire system, and for every staff member. The doctor can open a patient file from here, the receptionist can bill and the practice manager can perform searches and see the day’s financial performance to-date.

A patient file can be opened by different staff members at the same time. A doctor can be entering notes for a patient while the receptionist edits their address and the practice manager handles their account.

The system includes all the components of a modern practice management and clinical records system, and runs off a single, open source database.

A sophisticated internal messaging system allows users to send short notes to each other. These messages can be linked to patient records, adding context to the message and allowing the recipient to open the relevant patient file easily. The messaging system is tracked by an audit log, and all notes that reference a patient are listed in the patient’s clinical record.

GPComplete allows keyboard shortcuts (hot keys) to be allocated to common functions, allowing the user to design their own way to navigate around the system. These shortcuts can be defined globally, or on a per user basis.

DOCTORS GPComplete includes features common to most clinical packages, allowing clinicians to print scripts, pathology and imaging request forms, record and review the medical, family and social histories, enter clinical notes, generate recalls and reminders, scan and store documents and images, import electronic pathology and radiology results, and generate letters using sophisticated templates.

The system allows the clinician to review old notes whilst entering new ones and multiple patients can be opened at the same time. Encounter notes can record not merely the ailment but the severity and nature of the ailment.

Appointment durations can be customised and can be set as short as 5 minutes, allowing for maximum flexibility.

PRACTICE MANAGERS A reporting wizard enables virtually any variable within the system to be reported on. Reports can be custom-created, saved, automatically run on pre-defined schedules and emailed to pre-selected recipients.

A central library and a Document Intray store practice documents, journals and other materials scanned or emailed.

These can be shared or kept private.

Document and Pathology Intrays download files and assign them to doctors.

RECEPTIONISTS An “Intelligent Billing” system remembers the practice’s top 10 billing profiles,

each of which can be given nicknames (e.g. ECG) to allow for easy selection.

GPComplete contains a wide selection of Medicare Australia Online features, including ACIR, Bulk Bill, DVA, Patient Claims and Eclipse. Paperless DVA Claiming is currently under development, and will be released after the recently changed DVA specifications are crystallised.

GPComplete can be configured to prompt staff for a password before performing routine tasks. This feature allows an accurate audit trail to be developed, even in settings where several staff switch between multiple computers e.g. the practice reception.

TECHNICAL INFORMATION GPComplete is built on client-server architecture and is designed to run on the open source Firebird database engine. The program has modest technical requirements, requiring that only 256MB RAM and Windows XP be installed on the client computers.

The GPComplete server does not require a specialised server operating system (e.g. Windows Small Business Server), and will function with only 512MB RAM. It is possible to run the client interface on the server to minimise the number of computers required, however a dedicated server will provide better performance in larger practices.

In addition to running on Windows XP, GPComplete is compatible with both Terminal Services and Vista.

TRAINING, INSTALLATIONS & SUPPORT Practices switching to GPComplete receive onsite training and assistance with the installation of the software.

Clinical data can be converted from

PULSE + IT 27

FEATURES Medical Director 2, Medical Director 3, MedTech32 and Best Practice.

Like most practice software solutions, GPComplete does not migrate financial data, requiring practices to “run down” their old billing package (i.e. outstanding invoices are receipted in their old billing package, while new invoices are generated in GPComplete).

The installation and training of all staff can usually be performed in a day, with training tailored specifically for GPs, practice managers and receptionists.

GPComplete contains a built-in manual, with customer support facilitated by telephone, email and remote access.

COSTS The GPComplete software costs $500 for a site licence. In addition, an annual support fee is charged, the amount of which is determined by the number of doctors in the practice. The first doctor’s annual fee is $500, the second is $450, with each subsequent doctor increasing the total due by $400. The annual fee for a part-time doctor is $250. No additional costs are levied on licences for receptionists and practice managers.

If a GPComplete staff member is required to travel to perform the installation and training, associated costs are passed on to the customer. The only additional cost most practices will incur

is for the MIMS drug database, which is sold separately.

It is worth noting that because the Firebird database engine is free, no underlying database software licences are required to run GPComplete, minimising the total cost of purchase and ongoing ownership.

Simon James is the Editor of Pulse+IT. GPComplete www.gpcomplete.com.au MIMS www.mims.com.au

GPCOMPLETE CASE STUDY: MUDGEERABA BULK BILLING MEDICAL CENTRE The Mudgeeraba Bulk Billing Medical Centre is located on the Gold Coast, QLD. Its patient base primarily consists of retirees and families, both young and established.

The practice has two GPs, a part time practice nurse, four receptionists (with two on at any one time) and practice manager, Kerrie Poncet.

Each GP in the practice has a PC, with two computers located at reception. Ms Poncet uses a laptop, allowing her to station herself at different locations within the practice as well as offsite.

The practice has four printers and a scanner, with the whole network connected to the Internet via broadband.

THE OBJECTIVES While the practice had long been computerised, Ms Poncet believed that adopting a fully featured, integrated practice software solution would assist the practice to achieve increased workflow efficiencies.

“Our objective was to eliminate small, time-consuming hurdles and get faster patient administration through our practice.

We have no shortage of patients, but I was convinced we could speed up processing at the front desk and even do this with positive effects on our customer service.”

It was also important to address the needs of both the administrative staff and the clinical staff, Ms Poncet says.

“One of our GPs works particularly fast, and it was important they weren’t hamstrung by the system. We need to be able to keep up with them administratively. There were a lot of ordinary things that needed to be done much better and more flexibly... Cancel a claim and re-bill, issue medical certificates, look at the billings of the day at a glance.”

After considering several packages, the practice adopted GPComplete in January 2007.

28 PULSE + IT

CHANGING SYSTEMS Adopting the new system was not as painful as Ms Poncet expected, saying she found the onsite training to be very effective.

“They’d come and sit with each GP in turn, individually, and go through the system. That’s pretty good. It meant the staff were up to speed straight away. There was little downtime.”

The data’s integrity was completely retained in migrating to the new system. No new hardware was needed, and the practice continues to run in a Windows XP environment.

Ms Poncet was also positive about the quality of the support provided post-installation by GPComplete’s developers, The Practice Management Software Company.

“Their response time is fast. We’ve gone from 4 days to 3 rings.”

RESULTS TO-DATE Having used the system for nearly a year, Ms Poncet believes the change to GPComplete has been overwhelmingly positive, describing the system as fast, easy to navigate, stable and flexible.

“Under the old system, we occasionally lost money. I’m probably owed thousands. I get paid for everything now, nothing is lost.”

She went on to say that her pursuit of increased workflow and billings has been very successful.

“Going from a paper-based system to our computerised system, we jumped from 30 appointments a day to 40 per GP. With GPComplete, we’re jumping from 40 to 60 appointments a day. That’s an astonishing increase in our workflow and billings.”

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FEATURES

AN INTRODUCTION TO RAID René Yim BEcon, BEng (Aeronautical) INTRODUCTION Most medical practices are well aware of the importance of performing daily backups. Unfortunately, while these are of great importance in the event of a data disaster, they do nothing to minimise the likelihood of data corruption or loss occurring in the first place.

The installation of a Redundant Array of Independent Disks (RAID) is a preventative technical solution that can minimse the chance of data loss and increase practice server uptime and clinical data availability.

RAID is a term that describes storage schemes that divide and/or replicate data across multiple hard disks. RAID combines multiple physical hard disks and presents a single logical unit to the operating system and applications by using specialised hardware or software.

RAID CONCEPTS There are three key concepts that the readers need to be aware of: • Mirroring – the duplication of data to more than one disk.

• Striping – the splitting of data across more than one disk.

• Parity Data – extra data written to disk to facilitate error detection and correction.

COMMON RAID ARRANGEMENTS There are several different ways to setup a RAID system, each configuration offering different combinations of performance and data redundancy.

The three most popular configurations (referred to as levels) are outlined below: RAID 0 Under this arrangement, data is striped over two or more disks. This arrangement results in improved disk performance, as it is possible to read and write parts of a file to different disks in parallel.

Assuming identical disks are used (highly recommended), the amount of available storage is determined by the

30 PULSE + IT

total capacity of the disks used in the array.

It is important to note that no extra data protection is provided by RAID 0 systems. Given that the failure of any disk in the RAID array will result in data loss, probability dictates that such an arrangement is less reliable than a single disk system.

Because of its properties, RAID 0 is commonly used where disk performance is paramount, and data redundancy less important. As such, RAID 0 systems are not suitable for medical practices seeking to improve the reliability of their server.

RAID 1 RAID 1 is a data mirroring scheme that utilises two or more disks to store multiple copies of the same information. The duplication of data provides obvious redundancy, and prevents data loss in the event of a disk failure. As each disk in the RAID set contains the same data, the effective storage capacity of RAID 1 systems is equal to the size of the smallest disk in the array. Compared to a single disk arrangement, RAID 1 offers a slight increase in read performance, as data can be retrieved from either disk. Unfortunately, this gain is offset by marginally slower disk writing performance.

Requiring just two disks, RAID 1 is both cost effective to implement and offers improved redundancy.

RAID 5 Conceptually harder to understand than RAID 0 or RAID 1, RAID 5 systems use striping in conjunction with parity data to provide a good mix of performance and redundancy. RAID 5 require a minimum of three disks.

If a disk fails, calculations based on the distributed parity data on the remaining disks mean that data would still be available to the users. A second disk failure however, will result in data loss.

RAID 5 combines good performance, good fault tolerance, high capacity and storage efficiency, making it a suitable but expensive solution for hosting clinical software databases.

NESTED ARRAYS RAID levels can be nested together so that a master array can use other arrays instead of single physical disks. Nested RAID systems are usually signified by joining the numbers indicating the RAID levels together, either directly or by using a “+”.

Nested RAID systems are usually deployed in an effort to boost the performance of a RAID arrangement designed for redundancy, such as RAID 1 or RAID 5. RAID 0 is the most commonly combined RAID arrangement because of its high-performance characteristics.

Two examples of nested RAID scenarios are outlined below: RAID 0+1 Under this arrangement, two or more striped arrays (RAID 0) are connected using a mirroring array (RAID 1). This RAID setup provides fault tolerance and improved performance, but increases complexity compared to the RAID sets of which it consists. Four or more disks are required to establish a RAID 0+1 system.

The arrangement can survive a single disk failure without data loss, at which point the system assumes the properties of a single RAID 0 system. Unless the compromised disk is replaced, a subsequent disk failure will result in data loss.

RAID 1+0 Under this arrangement, two or more mirrored (RAID 1) arrays are connected using a striped array (RAID 0). RAID 1+0 has similar performance and slightly better redundancy properties than RAID 0+1.

A RAID 1+0 array can sustain multiple disk failures, so long as all disks in one

FEATURES of the stripes are not compromised.

It requires a minimum of four disks to establish.

IMPLEMENTING RAID RAID can be implemented using specialised hardware, software, or the RAID functionality built into most modern operating systems. Disks can be housed either inside the computer, or within external disk enclosures.

Hardware RAID A hardware RAID controller is simply an expansion card that is inserted into a slot on the computer’s motherboard. These cards are specially designed to perform parity calculations, come equipped with high-speed connectors for multiple hard disks, and offer many other features.

RAID controller cards are available in port configurations that support either internal hard disks, external hard disk enclosures, or a combination of both.

Software RAID Another option involves connecting the hard disks to the Serial-ATA ports found on modern computer motherboards, or optionally, installing a Serial-ATA card into an available motherboard expansion slot and plugging the hard disks into the ports on this card. As with dedicated RAID controllers, these Serial-ATA expansion cards are available in configurations that support internal hard disks, external hard disks, or a combination of both.

Unlike dedicated RAID controllers, SerialATA cards and the ports found on most motherboards do not have the ability to create RAID sets themselves. Instead, they are reliant on the server’s operating system or a third-party software solution to arrange the connected hard disks into the desired RAID arrangement.

External Disk Enclosures External disk enclosures are selfcontained units that simply contain a power supply and space for hard disks.

Some units also contain a RAID controller card, allowing the disks installed in the enclosure to appear outwardly as a single disk, negating the need for any additional configuration to be performed on the computer.

External disk enclosures can be hooked up via a USB port, or via a number of other connection types such as FireWire, SCSI or Serial-ATA. While USB and FireWire are suitable interfaces for external backup solutions (whether they be a RAID or a single disk product), Serial-ATA is the most suitable interface with which to connect a RAID solution hosting live practice data.

REBUILDING AN ARRAY Redundancy-enabled RAID solutions provide the ability for the system to continue functioning, even when one of the disks in the array has failed. When this occurs however, performance is adversely affected and the array is described as operating in a “degraded” state.

If a failed disk is replaced with a functioning disk, the hardware or software controller will proceed to rebuild the RAID set, restoring full redundancy capabilities to the system.

This restoration process can be timeconsuming, and while the array will function properly during this time, the performance will be diminished.

Although replacing an internally installed hard disk is relatively straightforward for an IT savvy person, external disk enclosures that feature hard disks mounted in trays or drawers simplify

the task to the point where even the most technologically shy practice staff member could be trained to perform the process unassisted, or guided through the steps involved over the phone by an IT support professional.

Excess disks in certain RAID arrangements can be designated as “hot spares”. When such a disk is available, the RAID controller can automatically start rebuilding the system, minimizing the amount of time that the array is vulnerable.

DO I STILL NEED TO BACKUP? While the use of an appropriate RAID scheme can reduce the risk of hardware related data loss, it certainly does not completely mitigate it. Further, RAID does not protect against user error (e.g. the accidental deletion of files), nor from corruption caused by application software or the operating system. As such, the existing backup arrangements practices have in place still need to be followed.

CONCLUSIONS RAID has long been used by large organisations to maintain high levels of server availability. Recent improvements in storage technology and the falling cost of hard disks and associated hardware now make RAID easily accessible to small businesses, and ideal for deployment in medical practices.

Practices that do not yet enjoy the data protection that RAID delivers are advised to discuss the feasibility of implementing an appropriate RAID system with their IT support professional.

René Yim has a background in data analysis and is presently involved in managing risk for a financial institution.

Below - Graphical representations of three popular RAID arrangements. RAID 0 stripes data over two or more drives, improving performance but not redundancy. RAID 1 mirrors data on two or more drives for the purpose of increasing redundancy. RAID 5 stripes data over three or more drives, distributing parity (redundant) data across all drives in the RAID set. [Images sourced from Wikipedia]

PULSE + IT 31

FEATURES

THE PRACTICE HEALTH ATLAS Julian Flint BHSc, CCNA

INTRODUCTION

DATA COLLECTION

The Practice Health Atlas (PHA) is a process that creates a decision support tool. It has been developed by the Adelaide Western General Practice Network (AWGPN) over the past three years.

Once the formalities have been completed, the requisite information is collected from the practice. This consists of three main data sets:

General practice data is collected by a trained representative of the Division and then analysed, synthesised with other data sets, and a comprehensive report is produced for the practice. The thrust of the PHA is towards managing patients with chronic disease through better utilisation of the chronic disease item numbers, as well as improving the quality of clinical data. The practice can then act on the implications of the PHA Report, with assistance from its Division. The PHA process is intended to be performed on an annual basis, as this time frame usually allows practices to see measurable changes in practice epidemiology and key financial indicators.

THE PHA PROCESS Once a practice expresses an interest in having a PHA report conducted for their practice, the next stage involves a process of consultation to inform the practice exactly what information is collected and how this information will be used. The information flow is strictly between the practice and the Division.

It is not shared with any third parties and, in fact, access to a practice’s PHA is strictly limited within the Division to those involved in its construction.

Privacy and confidentiality agreements between Division and practice are signed, as well as an official enrolment form. This states that the practice acknowledges that it is aware of what a PHA is, that they have read and understood the Division’s privacy policy, and that they agree to have the relevant data collected, aggregated, and analysed.

32 PULSE + IT

1. De-Identified Clinical Data This is collected using an extraction tool especially built for the PHA by Pen Computer Systems. The output of this tool is a de-identified data set, which mainly consists of patients’ chronic disease diagnoses, most recent clinical measures (e.g. HbA1c, cholesterol), and demographics. The data is de-identified to the postcode level, meaning that only the patients’ postcodes of residence, their age, and their gender are collected in addition to this clinical data.

2. Billing Data As the PHA is chronic disease-focussed, the billing pattern for the relevant chronic disease Medicare items numbers including GP Management Plans (GPMPs) and Team Care Arrangements (TCAs), are collected (i.e. the number of items and dollar amounts).

3. Marketing Information This consists of a photograph of the practice (sometimes with all of the staff gathered out the front!) and information about the practice. This information includes the practice’s opening hours, names and professions of practice staff and special interests. As the PHA is done annually, this section is quite popular with practices who have had the PHA done a second time - they can compare to the previous version and then reflect on the changes over the year, similar to a yearbook!

The collection of the data is usually done with minimal effort required from the practice staff, so the PHA construction process is not considered an imposition on the practice’s time. Collection of the billing data is usually the most time consuming activity because there are a

range of billing programs in the General Practice environment, some with advanced search capability; others with more primitive functionality.

CONSTRUCTING THE PHA The construction of the PHA takes place at the Division and is done using the Microsoft Office suite (i.e. Access, Excel and Word) and MapInfo Professional GIS (Geographical Information Systems) software.

The AWGPN PHA training program provides the Divisions with the requisite skills and templates to produce the PHA. Basically, the practice data is entered into different parts of the template. “Fine tuning” of the maps and business modelling is required to ensure presentation quality is high. Construction historically took between half a day and a full day depending on the speed of the operator and the number of interruptions they face. With mapping automation recently introduced, this time should be reduced to a couple of hours. Some of those already trained can do a PHA in approximately 3 hours without the automation.

Other aspects of the PHA are now automated to the stage where the bulk of the PHA construction can be handed to an admin person. The fine tuning and analysis can then be done by someone with more specialised informatics skills.

PHA ANALYSIS The PHA consists of two main components: 1. Epidemiology And Mapping In this section, the practice’s clinical data is synthesised with Census data and presented in graphical format. The practice can then see the postcodes from which their populations are drawn and how this compares with market share (i.e. the total number of people residing in those postcodes).

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FEATURES Practices can also see the socioeconomic status of their patient population, this having important implications for billing and services delivered. In addition to the census comparison and exploration of the patient populations, the “Epidemiology and Mapping” section also maps the practice’s patient populations, i.e. the regular patient population and also the populations with chronic diseases. An example of a chronic disease map can be seen in Figure 1, a practice’s Cardio Vascular Disease (CVD) population.

The range of major chronic diseases are mapped – Diabetes, CVD, Asthma, Diabetes, Mental Health, Coronary Obstructive Airways Disease (COAD), and Bone Diseases.

Practices find this section very interesting — often it matches their perception of the practice population, and sometimes it can enlighten or surprise them.

Certainly in most cases this is the first time that the practice has viewed their population in such a way.

2. Clinical And Business Modelling Following on from above, this section takes the chronic disease figures and other key information (for example, number of patients aged between 45 and 49) and, in consultation with the practice, a business modelling exercise is undertaken.

It poses the question: “If you were to apply the CDM item numbers to X percent of your patients identified within the clinical records with each chronic disease, what could be your opportunity income from care planning activities and improved patient outcomes / well being?”.

The modelling is applied to the available chronic disease item numbers such as

Figure 1: An example of a chronic disease map showing a practice’s CVD population. This details the concentrations of the practice’s CVD population by postcode.

PHA TECHNICAL INFORMATION What is the software used by the PHA? A range of software products are used in the production of a PHA. The extraction of the de-identified data is done by a .NET-based tool that has been developed by Pen Computer Systems. The majority of the querying, modelling, and charting is done using the Microsoft Office suite – Word, Access, and Excel. The mapping is done using MapInfo Professional, typically version 8.5 or 9. As the mapping is quite straightforward, this can be done with any GIS program capable of thematic mapping.

What practice software is the PHA compatible with?

The information required for a PHA comes from both the billing and clinical systems. The former is queried manually, so any billing system is suitable for a PHA. In terms of clinical software, currently the extraction tool works only with Medical Director 2 (MD2) or Medical Director 3 (MD3), so a full PHA can only be done for practices using this software (a less detailed version is possible however). Currently the AWGPN is working on extraction tools for other clinical programs to widen the scope of the PHA. How automated is the PHA construction process?

Once the data is collected, the PHA construction process is automated to the extent that it can be done in approximately half a day. Most of it can be done within approximately 2 hours, and this component can be performed by an administration assistant with minimal training. The analysis and fine tuning of the final document can then be performed.

How long does the PHA extraction tool take to run?

This is a function of such factors as the number of patients in the database, the speed of the computer running the extraction tool, and the number of results recorded for each patient.

A database with 10,000 patients will take approximately 15 minutes on MD2 and 5 minutes on MD3.

34 PULSE + IT

FEATURES Item description

Actual Earned * (A)

Estimated Total Value ^ (B)

Estimated Potential New Income (B - A)

$24,230

$24,230

EPC Health Assessment Items

EPC Chronic Disease Management (CDM) Items GP Management Plan & Team Care Arrangement and Reviews Diabetes GPMP/TCA/Review

$1,015

$28,968

$27,953

Asthma GPMP/TCA/Review

$1,077

$25,624

$24,546

Mental Health GPMP/TCA/Review

$150

$30,322

$30,172

CVD GPMP/TCA/Review

$283

$6,146

$5,862

$69

$1,867

$1,617

$428

$9,231

$8,803

Sub-Total

$3,023

$102,157

$98,954

Practice Incentive Program SIP Items

$2,536

$16,087

$13,551

Total

$5,558

$142,474

$136,734

COAD GPMP/TCA/Review Bone Disease GPMP/TCA/Review

Current Utilisation

Potential Utilisation

Item

Description

No. claims #

721

Preparation of a GP Management Plan by a GP

7

10990

Bulk-Billed Service Commonwealth Concession Card holder incentive

725

Review of a GP Management Plan by a GP

10990

Bulk-Billed Service Commonwealth Concession Card holder incentive

723

Coordination of Team Care Arrangements by a GP (formerly item 720)

10990

Bulk-Billed Service Commonwealth Concession Card holder incentive 3

727

Coordination of a review of Team Care Arrangements by a GP (formerly item 724)

10990

Bulk-Billed Service Commonwealth Concession Card holder incentive

0

8

0

Total

Actual earned (A) $772

$0

$243

$0

$1,015

No. of patients

Freq. per annum +

Unit Price* ^

Est. total value (B)

Est. potential new income (B - A)

118

1

$124.95

$14,744

$13,972

61

1

$6.05

$369

$369

59

1

$62.50

$3,688

$3,688

31

1

$6.05

$188

$188

74

1

$98.95

$7,322

$7,079

38

1

$6.05

$230

$230

37

1

$62.50

$2,313

$2,313

19

1

$6.05

$115

$115

$28,968

$27,953

Top: A summary of the practiceâ&#x20AC;&#x2122;s current utilisation of the chronic item numbers (on the left hand side of the table) versus their potential new income were they to utilise the chronic disease items to a greater extent. Above: Underlying each line on the summary table at the top of the page is a detailed table, which has an item-by-item breakdown for each of the diseases. The above table shows the Diabetes GPMP/TCA item breakdown.

PULSE + IT 35

FEATURES GPMPs, TCAs, and Service Incentive Payment (SIP) Cycles of Care. A comparison between current and potential utilisation of these items is made. Based on this business modelling, the Division would then discuss with the practice various options open to them e.g. bringing on board a practice nurse, investing in infrastructure and the like.

The business modelling in this section is quite flexible, with each item (or group of items) able to be individually modified. This allows the user to tailor the modelling to: 1. Suit the practice’s capacity to perform those items.

2. Set the utilisation of given item numbers to a realistic level.

The aim of the business modelling is to be realistic and conservative, so the resulting potential income is actually attainable for the practice.

THE PHA AND PATIENT CARE The PHA can assist the practice with their ongoing patient care. At the basic level, it indicates the quality of the data within the clinical database. By mapping the

pattern of the various chronic diseases, as well as making comparisons with national benchmarks, the practice can see quite quickly whether they have more or less patients with a particular chronic disease than expected. If the numbers are less than expected, does this mean that the practice is not attaching diagnoses to the patients as part of the consultation?

In terms of enhancing the care of patients with chronic diseases, the PHA has the potential to have practices change their business and clinical system to be more “geared” towards applying the CDM item numbers to patients with chronic diseases and improving the quality of their clinical information.

SUMMARY The PHA is an evolving general practice decision support tool with multiple potential uses. Among the GPs and staff engaged to date, it has demonstrated its potential to develop a professional culture around quality health data, the utility of integrating and synthesising data with various other sources, and as a driver of innovation in health care service delivery. It requires little technical

input, time or effort from the practice staff. A practice interested in having a PHA done should contact their Division for more information.

While the PHA is excellent at indicating the direction and potential of any business/clinical change, it is certainly not a “silver bullet”. Ultimately it is up to the practice to enact change to meet the implications and modelling of the PHA. For more information, please contact Julian Flint at the Adelaide Western General Practice Network or visit the Health Atlas website.

Julian Flint julian.flint@awgpn.org.au Health Atlas www.healthatlas.org.au MapInfo www.mapinfo.com Pen Computer Systems www.pencs.com.au

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FEATURES

SECURE ELECTRONIC MESSAGING WITH MEDICAL-OBJECTS Simon James BIT, BComm

INTRODUCTION This is the third article in a perpetual series of technical demonstrations designed to assist medical facilities to better understand secure electronic communication.

Like its predecessors, this article demonstrates a secure messaging scenario using software that is available now, namely MedTech 32, Medical Director 3 (MD3) and Medical-Objects.

The first article in this series demonstrated the transmission of an electronic referral from a general practice running Genie, to a specialist practice using Medtech Mercury. Healthlink was used to transport the message between the two practices.

The second article demonstrated the transmission of an electronic referral from a general practice running Best Practice, to a specialist practice using Zedmed.

Argus was used to transport the message between the two practices.

This article consists of three sections: 1. A brief description of the software and companies referenced in the article.

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

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

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

IT TAKES THREE TO TANGO The demonstration in this article is

framed around the transfer of a discharge summary from a GP After Hours Clinic (GPAHC) to the practice of the patient’s usual GP. Readers may be interested to note that the secure messaging demonstration presented in this article draws heavily from a real-world GP after hours clinic discharge summary initiative, namely the one established by the Hunter Urban Division of General Practice for their GP after hours clinic in Newcastle.

There are three software applications used in the scenario presented in this article: 1. The sender’s clinical software.

2. The recipient’s clinical software.

3. The messaging software.

The Sender’s Clinical Software For the purpose of this demonstration, MedTech32 will be the software used to generate the discharge summaries at the GPAHC. MedTech32 is a practice software solution that integrates clinical, billing and patient management features.

Medtech32 is developed by MedTech Global, a New Zealand based company with Australian offices in Melbourne, Sydney and Perth. The company’s recent acquisitions of CompuDoc and the publicly listed Australian Healthcare Technology Limited (developers of RX) have grown MedTech Global’s Australian user base dramatically, the company now claiming to service the second highest number of practices in the country.

The Recipient’s Clinical Software For the purpose of this demonstration, Medical Director 3 (MD3) will be used as the clinical software to receive the discharge summaries from the GPAHC.

MD3 is developed by Health Communication Network (HCN), Australia’s market leading provider of clinical and practice management software to GPs and specialists. HCN’s head office is located in Sydney, with satellite offices in Bundaberg, Perth and Melbourne.

The Messaging Software Software from Medical-Objects has been chosen to transport the message between the GPAHC and the usual general practice of the patient that presented at the GPAHC. Medical-Objects is a medical software company specialising in secure messaging and decision support solutions. The company is headquartered in Buderim, QLD. Medical-Objects has a range of messaging and related clinical products, Medical-Objects Messenger Real Time (RT) has been chosen as the software application to transport the message.

This product is also dubbed “Capricorn”, a name that, for the sake of simplicity, will be used throughout this article when referencing the software.

Capricorn is designed to run as a local HTTP server within the medical facility’s LAN. The software offers message sending and receiving, provider lookup and SNOMED-CT terminology query functionality. Capricorn has the ability to receive and transmit via HL7 LLP (TCP/ IP), SMTP, and SOAP web services, in addition to common file drop interfaces.

The software can be installed as a background service, or as a tray icon application on Microsoft Windows 95, through to Microsoft Windows Vista.

Native MacOS X & Linux versions are in the pipeline, and will supersede the current Medical-Objects Java based download client.

PULSE + IT 37

FEATURES SETUP Following are the steps that need to be performed before a site running MedTech32 can send a secure electronic After Hours Consultation Discharge Summary (HL7 REF^I12) via Medical-Objects to a site running MD3.

Please note that while these instructions are specific to MedTech32 and Medical Director 3, practices using other clinical software should be able to apply significant parts of the information presented to their own circumstances.

1

Install And Configure Medical-Objects Before the transport of the message can take place, Medical-Objects software needs to be installed at both the GPAHC and the recipient GP’s clinic.

The installation and configuration for both the sending and receiving site are outlined below: Sender 1. Visit the Medical-Objects website to apply for an installation token and submit your details for inclusion in the provider directory.

2. Download the Capricorn installation package from the Medical-Objects website. This installer is approximately 5MB and should not take long to download using a broadband Internet connection.

3. Start Capricorn and enter the issued registration token into the setup screen.

4. Enter your passphrase and use the key generation tool to create encryption keys for your practice.

5. Capricorn should now be running.

If prompted, unblock your Microsoft Windows personal firewall to ensure that Capricorn can function properly.

No incoming ports need to be opened on your LAN firewall.

6. Capricorn now needs to be configured to correctly process incoming messages and acknowledgement files (ACKs) from sites that have received your practice’s outgoing electronic correspondence. To do this, rightclick on the Capricorn tray icon and select “Configure”. Select “Integration Options” from the list on the left, then set the “ACK Management” fields to match the paths shown in Figure 1.

All other settings can be left with their default values.

7. On the left of the screen, click “Server

38 PULSE + IT

Above - The Capricorn Integration Options window showing the directory where incoming ACKs (to files sent out by the GPAHC) will be dropped by Capricorn. Below - The Capricorn Server Parameters window the configuration to allow incoming messages to be passed to MedTech32.

2

FEATURES Parameters” and specify the message output directory.

8. A message queue now needs to be established to process the HL7 file exported by MedTech32. To do this, click “Add” to create the queue, then click “Setup” to add the required

Message Decorators to the queue.

Capricorn Message Decorators are designed to address a range of common syntax problems found in HL7 messages that are not compliant with the AS4700.x specifications. In the case of the exported MedTech32

HL7 file, three Capricorn Message Decorators are required to address AS4700.x non-compliance issues.

The Message Decorators used in this scenario are shown in Figure 4.

Recipient 1. Steps 1-5 demonstrating the setup of Medical-Objects at the GPAHC need to be repeated on the MD3 server at the recipient general practice.

2. Once Capricorn is installed on the MD3 practice server, the software will detect the input, output and acknowledgement (ACK) directories, which speeds up the installation and configuration process considerably.

3

4

Above Left - The Capricorn Manage Queue window showing the MedTech32 message queue, including its base directory. Above Right - The Message Decorators installed in the MedTech32 message queue. These are required to fix some non-compliance issues present in the HL7 messages generated

by MedTech32. Below - A Capricorn log window showing the successful auto-detection of the various message directories used by Medical Director 3.

5 PULSE + IT 39

FEATURES Had the messages in this scenario been compliant with the AS4700.x specifications, the message queue would require a single entry, i.e. the “Route with Capricorn” script. This entry is responsible for encrypting, digitally signing and transmitting the message.

Configure MedTech32 To Send Messages MedTech32 now needs to be configured to interface with Capricorn. To do this: 1. From the “Tools” menu, select “Message Transfer”, then “Message Transfer Utility”.

2. Click “Add A New Configuration” to create a new message rule and open the “View Configuration” window.

3. Enter the details shown in Figure 6 into the fields in the window.

It should be noted that: 1. The “File Send Path” in Figure 6 should now match the directory set in the “Base Directory” in Capricorn as shown in Figure 3 on page 39.

2. The “File Receive Path” needs to match the “Folder to save external ACKs for PMS” field in Figure 1 on page 38.

6

Above - The MedTech32 Message Transfer Utility showing the reciprocal settings for Capricorn.

Below - The Investigations Tab from the Medical Director 3 Options window. The “Generate ACK files” checkbox should be ticked to ensure that the sending site receives notification of the successful transmission of their correspondence to the recipient running MD3.

Once these directory paths are entered, the interface between MedTech32 and Capricorn is established, allowing HL7 messages and ACKs to flow between the two software products.

MedTech32 can be configured to import and export messages on a predefined schedule. To configure the scheduler: 1. From the “Utility” menu, select “Scheduler”, then “Start Scheduler”.

2. From the “Utility” menu, select “Configure Scheduler”.

3. Click the “Add Task” button.

4. Enter “Medical-Objects” as the name of the task, then specify when you would like the task to run.

5. Click the “Browse” button and navigate to the “MsgTran.exe”.

6. Append a space, followed by a capital “A” to the path to the “MsgTran.exe”, i.e.: C:\<path>\MsgTran.exe A

7

This step is necessary to ensure that the Message Transfer Utility runs automatically after being opened by the scheduler.

7. Click the “OK” button to save the configuration.

The configuration of MedTech32 to send HL7 files and process the corresponding incoming ACKs is now complete.

Configure MD3 To Receive Messages As Capricorn has been configured to use the default Medical Director 3 message directories, it is likely that no configuration will need to be performed within the Medical Director 3 program. It is worth checking however, that Medical Director 3 is configured to export acknowledgment files on the successful

40 PULSE + IT

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FEATURES import of an incoming HL7 message. To do this: 1. From the “Tools” menu, select “Options”.

2. Click on the “Investigations” tab.

3. Ensure that the “Generate ACK files” checkbox is ticked.

4. Click “Save” to close the Options window.

The configuration of MD3 to receive incoming HL7 files and return ACKs to the sender is now complete.

DEMONSTRATION Having now presented an overview of the steps required to configure both MedTech32 and MD3 to communicate using HL7 messages via Capricorn, this section demonstrates a practical application of the technology.

Meet The Doctors Dr Seeya Layta is a GP who works at the local Division of General Practice After Hours Clinic (GPAHC). The GPAHC runs MedTech32.

Dr Regular Practitioner is a GP who works at the “Regular GP Clinic”. His clinic runs MD3.

The Scenario Miss Bianca Test presents at the GPAHC and is seen by Dr Seeya Layta. Bianca informs Dr Layta that she has been experiencing severe chest pain and nausea. Dr Layta examines Bianca, prescribes some medication and instructs her to make an appointment to see her regular GP later in the week.

Dr Layta writes summary consultation notes in MedTech32, and transmits a secure electronic discharge summary to Dr Regular GP. The electronic communication interactions relating to Dr Seeya Layta’s discharge summary to Dr Regular Practitioner are outlined in detail below: 1. Exporting The Letter From MedTech32 Using exactly the same steps as would be performed when creating a printed letter, the discharge summary is created.

When the letter has been completed,

the user clicks on the “Send Via” pop-up button at the bottom of the screen.

“Message Transfer” is then selected from the list of options. A window is presented, allowing the user to specify: 1. The recipient.

2. The messaging software to be used to transmit the document.

3. The message type.

The user then clicks “OK” to accept the details, then “OK” again to prepare and export the document, ready for electronic transmission.

The next time MedTech32’s pre-defined message import/export schedule runs, MedTech32 will deposit the discharge summary as a HL7 file into the directory shown in Figure 6 on page 40.

2. Sending The Message Almost instantaneously, Capricorn detects that a new file needs to be sent and performs the Message Decoration steps as specified in the MedTech32 message queue. After correcting any non-compliance issues, the message is

Below - The discharge summary as it appears in MedTech32 prior to being sent electronically. To send the discharge summary electronically, the user simply needs to select “Message Transfer” from the “Send Via” pop-up button at the bottom of the screen.

42 PULSE + IT

FEATURES both digitally signed and encrypted to ensure that the contents of the message cannot be intercepted by a third-party during transmission.

The Medical-Objects messaging system utilises clinician provider numbers to identify senders and recipients. As Capricorn uses the provider number embedded in the exported MedTech32 HL7 message, it is therefore important that the MedTech32 provider address book be accurately maintained.

In the event that the recipient has not received electronic correspondence

During this process, the HL7 envelope is modified to ensure that the discharge summary displays as intended once imported into the recipient’s clinical software.

from the GPAHC before, the Medical-Objects provider directory is interrogated by the Capricorn software and the information required to correctly transmit the HL7 file retrieved. Once the credentials of the recipient have been established, the message is sent directly to the recipients installation of Capricorn, a process that is completed within a matter of seconds.

4. Importing The Message Into MD3 To import the HL7 file into MD3, users simply follow the same steps used to import pathology and radiology results:

3. Receiving The Message At the “Regular GP Clinic”, the HL7 message is unencrypted and deposited into the default MD3 incoming message directory shown in Figure 5.

1. From the “Investigations” menu, select “Download”.

2. Select the appropriate doctor from the list.

3. Double click on the record to review

Below - The discharge summary as it appears in Medical Director 3. Note that the rich text formatting present in the original discharge summary was removed during the MedTech32 HL7 export. By removing the formatting information, the HL7 file is more likely to be compatible with other clinical systems. The amount of disk space required to store the letter is also minimised, ensuring the clinical database doesn’t grow unnecessarily large.

PULSE + IT 43

FEATURES

GP AFTER HOURS CLINIC

MedTech32 Database

File System

INTERNET

Capricorn

REGULAR GP CLINIC

Capricorn

File System

Medical Director Database

MT32 Letter

“MT32 Schedule”

MT32 HL7

< 1 second

MT32 HL7

< 1 second

Secure HL7

< 1 second

Transport ACK

Secure HL7

< 1 second

Absorbtion ACK

MD3 HL7

“F4”

MD3 Letter

HL7 ACK

HL7 ACK

HL7 ACK

Secure HL7 ACK

Secure HL7 ACK

MT32 Letter HL7 ACK

HL7 ACK

< 1 second

< 10 minutes

< 1 second

< 1 second

< 1 second

“MT32 Schedule”

Above - This diagram outlines the journey of a HL7 discharge summary from the GP After Hours Clinic to the Regular GP Clinic. Three levels of acknowledgement are shown, namely the “Transport ACK”, “Absorbtion ACK” and the “HL7 [Application] ACK”. The HL7 ACK shown in blue provides end-to-end accountability, while the Transport and Absorbtion ACKs assist with the tracking of messages through the system. All messages sent between the two installations of Capricorn across the Internet are digitally signed and encrypted to prevent unauthorised viewing.

44 PULSE + IT

FEATURES the discharge summary and action it accordingly.

5. Returning The ACK To The Sender When the HL7 file is imported from the file system into MD3, an acknowledgement file is generated. Capricorn detects the presence of this ACK, digitally signs and encrypts it and sends it back to the GPAHC’s Capricorn installation.

6. Importing The ACK Into MedTech32 When the Capricorn installation at the GPAHC receives the ACK file, it unencrypts it and deposits it into the directory specified in the “File Receive Path” field shown in Figure 6 on page 40.

The next time MedTech32’s pre-defined message import/export schedule runs, the ACK is imported into the database and matched against the original outgoing discharge summary. The status of individual messages can be displayed visually by selecting “Message Transfer” from the “Tools” menu, followed by “Messages Lodged”.

This window displays the time the correspondence was created by the clinician, the time it was exported from MedTech32 as a HL7 file, the patients name, the recipients name, the message type, and most importantly, whether the correspondence has been acknowledged as having been received by the recipient.

COSTS Under Medical-Objects’ pricing model, the sending party bears the cost of the secure electronic communication (i.e. there are no costs involved with receiving messages).

There are several pricing options available to larger health organisations (e.g. pathology labs, radiology providers, hospitals), however specialists who send correspondence using Capricorn are charged a flat rate of $450 per year. This fee covers the software, all message charges and remote support. Specialists with more complex needs, such as diagnostic image delivery, or Specialists operating from large sites should contact Medical-Objects for further pricing information.

There is no charge levied on GPs for the use of the Medical-Objects software or the network.

CONCLUSIONS While the scenario presented dealt with the transfer of a discharge summary from a GP after hours clinic to a general practice, the Medical-Objects product suite can be used to transfer a range of other clinical correspondence, including GP referrals, pathology results, radiology reports and specialist reports.

It should be noted that while Capricorn has been demonstrated alongside MedTech32 and MD3, Capricorn’s Message Decorators allow the software to function with many other clinical products on the market.

As has been demonstrated in this article, secure electronic communication is possible using technology currently available to general and specialist practices, and other health care facilities.

Unfortunately, there remains a wide variation in the quality of the HL7 message generation capabilities of the various clinical packages on the market.

Compounding the problems that flow from this inconsistency, the message import and display functionality of clinical systems also differ significantly.

While the message decoration techniques highlighted in this article do facilitate the circumvention of these problems to a large extent, ultimately, clinicians and their patients will be best served if clinical software developers place a priority on improving the HL7 capabilities of their products with a view to having them certified by the Australian Healthcare Messaging Laboratory (AHML).

Simon James is the Editor of Pulse+IT.

AHML www.ahml.com.au HCN www.hcn.com.au Medical-Objects www.medical-objects.com.au MedTech Global www.medtechglobal.com Standards Australia www.standards.org.au

ACKNOWLEDGEMENTS In addition to negating the need for printing, scanning, paper handling and postage costs, one of the main benefits provided by a properly implemented secure electronic messaging solution is an automated audit trail. Acknowledgements (ACKs) play a crucial role in the creation of these message audit trails. As shown in the diagram on page 44, three ACKs feature in the transmission of the HL7 discharge summary from the GP After Hours Clinic to the general practice: Transport ACK A “transport” acknowledgement is generated by the recipient’s Capricorn installation on receipt of an incoming message. This is sent to the sender’s Capricorn installation, indicating that the discharge summary has been committed to the recipient’s hard drive.

Absorbtion ACK An “absorption” acknowledgement is generated by the recipient’s Capricorn installation the instant the discharge summary is removed from MD3’s incoming message directory in the file system. Under normal circumstances, this will take place when MD3 imports the discharge summary from the file system into its database. This ACK is transmitted to the sender’s Capricorn installation to indicate the high likelihood that their discharge summary has been imported into the recipient’s clinical software.

Application ACK An “application” acknowledgement is generated by the recipient’s clinical software, namely MD3. It is deposited into the MD3 ACK directory the instant the incoming discharge summary is imported into MD3. The recipient’s Capricorn installation then transmits the ACK to the sender’s Capricorn installation, which then deposits the ACK into MedTech32’s incoming ACK directory. Once the ACK is imported into MedTech32, the sender of the discharge summary has infallible proof that their correspondence has been imported into the recipient’s clinical software.

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FEATURES

HOSPITAL COMPUTING: WHY IS IT SO HARD? Dr David G More MB, PhD, FACHI All over the country it seems we have Hospital IT projects that are struggling to actually get started (e.g. WA, SA and to some extent QLD), are running very much behind the initially planned time lines (e.g. NSW and VIC), or are failing to satisfy their users (almost everywhere).

The first thing to be said about this situation is that we are not alone.

In 1998, Scott Silverstein M.D. launched a Web site devoted to shining light on healthcare IT failures. Hospital leaders, IT vendors and the media have swept the topic under the rug, he says. “IT failure is a serious problem, but people are reluctant to study it,” says Silverstein, the director of the Philadelphia-based Institute for Healthcare Informatics at Drexel University College of Information Science and Technology. “We like to talk about success, not failure.”

The website now covers over thirty project which would appear, by all accounts, to have come seriously adrift!

Why is it that these projects seem to go badly so often – especially in the public sector? I would suggest there are a range of reasons: First, many believe a key point is that managerial and organisational instability is a major cause of failure. I agree this is really important and, indeed, when one reflects on the Public Health Sector it is really a relative rarity to have an Area Health Service CEO or CIO serve out their full five year contract. This flux is due, in part at least, to a combination of Government and Ministerial changes, changing policy priorities, some being perhaps promoted beyond their capabilities and the unexpected events that precipitate management change.

Conducting any significant project in the absence of continuing stable senior management support is a recipe of disaster.

Second, especially in the public sector, there is often a disconnect between

46 PULSE + IT

the managerial responsibility placed on a project manager and the freedom to act they are accorded. At times this leads to the “wrong” staff being retained in roles for which they are no longer suited, to the detriment of the project as a whole. The disconnect (and budget inflexibility) also often leads to difficulty in attracting and retaining suitably skilled staff as well as excessive delay in staff acquisition. The other problem that is almost universally encountered in Hospital projects in my experience is the “drip feed” of funds and the difficulties in getting suppliers paid. More than once I have seen competent project managers just resign in disgust when they realise they have neither the spending authority, money or the staff to deliver the project they are required to make happen.

Third, because executive health-care management are often uncomfortable regarding many aspects of Health IT, frequently associated with a fairly limited understanding of what is required, at an executive level, for project success, the quality of project sponsorship and support is less than is needed. Senior executives, like everyone else, prefer to stay within their “comfort zone” and, if the Health IT project is not within that zone, real difficulties are almost inevitable. The project manager has a difficult responsibility to carry the project sponsor along on the journey, and to make it clear what they must do for the project to be a success on their watch.

confident the system will work for them and be convinced of its value and utility, or the project will be at extreme risk before it even starts.

Sixth, there is a real tendency to underestimate the complexity of and the effort required to implement say a new laboratory or patient management system – to say nothing of clinician facing systems such as Computerised Physician Order Entry or Computerised Nursing Documentation which involve virtually all key staff changing the way they work.

Careful planning and an really adequate emphasis on education and change management are vital, as is developing real clinician ownership of the project.

Seventh, is it clear that all organisations need to develop organisational competence and teamwork with Health IT. I think the best way to do this is to choose one or two easily “doable” projects and get them done on time and within budget. Only once this capability is proven should an organisation try the larger and more complex implementations. Success, as they say, builds on success.

Fourth, clinicians inevitably see a new system as a very low priority in their “caring for their patients” activities. This will lead to all sorts of difficulties with change management, training and effective use of a new system, unless both executive management are fully committed and real “clinician” evangelists and enthusiasts are recruited to work with their peers.

Eighth, it is clear that when implementing systems in hospitals size really does matter. It is a relatively straightforward process to put basic systems in a 100 bed regional hospital in 3-6 months with very little difficulty. The 1000 bed tertiary teaching referral hospital is a horse of a totally different colour. The budget is likely to be in the millions, the complexity of what is needed much higher, and the work practices more entrenched. All this means both risk and duration are much higher. Additionally these organisations cannot be fed a ‘one size fits all’ solution.

The systems that are deployed must not only be flexible, but be flexibly implemented in consultation with ALL involved.

Fifth, involvement of all relevant categories of clinicians in the selection and, later, configuration of systems is crucial. The clinicians really have to be

Last, it is vital to work hard to develop an open and frank relationship between the system vendor and the organisation which is implementing the new system.

No contract will prevent a disaster, but working to ensure a constructive, frank and balanced relationship will make a huge difference.

If all this is taken into account – and experienced project managers are engaged and then supported a good outcome is more than possible. Other factors that can increase the likelihood of success are: 1. Making sure a strong educational project that gets to all the hospital’s staff is conducted early to explain to everyone involved what is needed from them and how their lives will be easier once implementation is complete.

2. Preparedness on the part of both executive and technical management to seriously address issues raised by grass roots staff and to ensure there are real working processes to gather honest feedback before problems fester and then spin out of control.

3. Making sure that consultation is more than token. There is a tendency for project managers to exhibit a rigidity regarding goals and processes, that often means some involved get the feeling that their being consulted is little more than an unnecessary formality.

4. Being prepared, from time to time, to offer small incentives to reward success, and to acknowledge that change is never easy with some fun and interesting occasions, awards etc.

5. Working to identify the inevitable “organisational opinion leaders” that exist in all large organisations outside the formal hierarchy and work very hard to have these people on side and supportive.

If you ignore any of these points you do so at your peril!

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

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

Dr Scot Silverstein’s Website tinyurl.com/2e9ysb Dr David More’s Health IT Blog www.aushealthit.blogspot.com

GPCOMPLETE COMPLETE GPCOMPLETE GPCOMPLETE

FEATURES

CHANGE DEFENCE: DESIGNING FOR TOMORROW Michael Murfitt

While I have spent most of the past 33 years in health IT, I have had several interspersed ‘sabbaticals’ into other business areas, which included ship building, financial management, public utilities, accounting and stock brokerage. These have helped to balance my perspectives as to the relevance and impact of IT on these industries, as well as my main interest, public health.

move from one need to another in this case? Firstly, ensure that all lookup tables have a boolean column to denote ‘redundancy’. For the sake of our example we will call our column “deprecated”. Our existing list item Alpha has become redundant so we mark the deprecated column as true.

New items Beta and Gamma are added appropriately to the lookup list with deprecated value of “false”.

Achieving something really tangible in healthcare with software is a tough gig.

The environment is unlike anything else in business enterprise. One of the standout differences between healthcare software versus business applications is the likelihood of change. Healthcare software applications are regularly subjected to functional inadequacy and/or redundancy due to the ongoing evolution and change to treatment regimes. One day there is a new type of diagnostic procedure to accommodate, the next there is a new standard definition affecting the breakdown of an entity status. It is impractical and fiscally inefficient to be running off for programming changes every time one of these events occur.

When the application runs, the query to populate the list control is qualified by “where deprecated=false”, so that Alpha will not appear, but Beta and Gamma will. This prevents item Alpha being selected inappropriately. But what do we do if we wish to view a screen of data where Alpha was selected as the value at that time? Remember, with most combo boxes and especially web page pulldown controls, you cannot even display an item if it is not in the list.

Over the past ten years I have been involved with several developments where attempts were made to take an approach with software design that could accommodate change without resort to constant programming changes. The advent of object-oriented programming with event-driven operating systems has made this much easier to achieve.

Let’s look at a very simple example. A very common type of data item is a selection from a list, most commonly provided by a pull-down combo box.

A situation can arise where there is a need to subdivide an existing item into two separate items. In this case it is likely to be impossible to convert the existing combined value into the two new component values. How do you

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To get item Alpha to display, we have to put the item in the list. Easy - in the code that synchronises the data value to the control, you raise an event when the data value cannot be matched to any item in the list. I call mine a “syncFailure” event, which also returns and exposes the value of the foreign key that caused the event to be raised. The event code then reads the database lookup table for an entry to match the key argument, and if found, adds the details to the bottom of the existing selection list, then calls another synchronise method on the list. This causes item Alpha to appear selected in the list and allows the user to change the value to any other, including the new Beta and Gamma items, as well as allows re-selection of item Alpha.

However, once another value is chosen and the record written to the database, item Alpha would no longer appear the next time the parent data record was revisited.

From personal experience this simple approach has been worth it’s weight in gold. However, it is necessary to use a

development tool that supports objectoriented methodologies, eliminating several popular current products. I have been involved with other approaches to the same problem, including the qualification of date ranges to qualify lookup values. The complexity of the implementation tended to detract from the result.

From a philosophical perspective, I have always found that there is more than one way to solve a problem or a challenge (the “skinning of cats” comes to mind here). I am always attracted to the simplest solution, as this is usually the most robust and reliable method.

Many of my colleagues seem to differ in opinion, preferring to use the most complex methodology to prove how ‘smart’ computers can be.

Another strategy for “change defence” is to re-examine the definition of an application’s entities. Too often there is undue emphasis placed on today. Let us look at a second example of how to improve this situation.

The result of a specific diagnostic test is an integral component of any treatment regime application. The most common scenario is where the name of the specific test is put into a lookup table entry (e.g. blood test, pap smear, biopsy) and matching results for each test are created. However, every time either a new test is required or a structural change to an existing one is needed (i.e. two result values provided instead of a single value), some amount of programming is required to implement the change. But if the definition of the diagnostic test is taken to an abstract level, the need for reprogramming can be eliminated.

This is done by simply defining that any diagnostic test comprises a procedure, an “origin” (i.e. site or source) and one-to-many results where each result can be either a number, a list pick, an image, text (short or memo), letter, 3 part

FEATURES boolean value (true/false/neither, yes/ no/neither, positive/negative/neither), date, or time value. For procedures where the “origin” is obvious (e.g. blood test) then an origin of ‘Implied’ can be used.

It is not difficult to write a module for an application that allows the user to define any new test, or modify an existing one, with the latter including the ability to remove a result (with deletion of existing data), add or insert a new result, or change the sequence and other result attributes.

Other obvious data attributes can be added to suit. For example, number range checking, future date inhibition, use of “common” lists across many tests, mandatory flags, default values, etc - you can go ballistic! This is not too difficult really, and once done you have a design that can be applied to pathology tests, imaging, ultrasound, investigatory surgery, etc.

In my own domain, I have also extended this approach to drug administration, treatment “events” and prognostic factors. In practice, it has empowered

the application user and removed the need for expensive time delaying reprogramming. Most business processes in a hospital environment can be broken down to an abstract level - including numbering and identification systems - which moves us to our third and last example of “change defence”.

When a patient receives treatment at a hospital, whether as an inpatient or an outpatient, there is a need to record numerous identification numbers.

There are two obvious primary numbers (i.e. Unit Record and Medicare) but there can be several others, such as referring hospital UR number, health fund membership number, DVA number, trial number, etc. By taking a simple abstracted approach, you can define functionality that will allow any formal numbering system to be created and used, even extending its use into patient search functionality. The simple abstracted elements are just “number value” (alphanumeric), “category” and “organisation” (if not implied).

When developing healthcare software in the 1980s, it was always a case of replacing a manual system with a

computerised form, rather like shelling peas. There was nothing like the complications that are encountered when a project is formed to migrate an application to a replacement.

One large dataset that I am involved with is currently using its third form of application software, and that is now over 8 years old and in need of urgent upgrade. Computer systems are often “designed” without any design consideration that they in turn will become redundant within a few years.

It has an unusual influence on one’s approach if you design a new or updated application with a view that what you are creating will in turn be obsolete within a relatively short space of time. And isn’t that the ultimate change?

Michael Murfitt has been practising as a Health IT professional since 1974.

He has been running his own business, Thunderbird Software, since 1998 and works in Ocean Grove, Victoria.

Michael Murfitt michael@thundersoft.com.au

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FEATURES

OPENEHR: THE WORLD’S RECORD Dr Heather Leslie MBBS, FRACGP, FACHI

In a world where connectivity reigns, our health information is largely still caught up in silos and, in the main, is not shareable by clinicians. Shared electronic health records (SEHRs) are increasingly needed to provide timely, comprehensive and coordinated healthcare. Over many years there have been ongoing and thorough attempts to achieve the sharing of health information in order to support the improvement of health outcomes, but this incremental approach, gradually building on previous experience, has not been wholly successful. Progress has been made; however despite enormous investment and resources, the solution has been more difficult than most ever anticipated. Healthcare provision does not seem to fit into the same kind of data sharing model that has been successful in other domains, such as banking or financial services.

In order to support interoperability of health information, SEHRs need clinical content to be standardised. This supports standardised communication of complex health information between systems and the opening of these vertical domain and organisational silos, allowing accurate and semantically computable health information flow.

Inevitably the shared clinical content specifications begin to influence the information models within clinical applications. openEHR is an electronic health record architecture based on many years of research and development, and is designed to work in partnership with all vendor systems, organisations and providers to facilitate semantic interoperability of health information. It is a comprehensive and transformational solution, which applies to the capturing and sharing of information from the most complex and dynamic knowledge domain – health.

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WHY ARE HEALTH RECORDS SO DIFFICULT? The problem is twofold – firstly, the evolving clinical needs and requirements for a SEHR are difficult to pin down, and secondly the technical issues related to a SEHR solution.

Why are clinical requirements so difficult to capture and transform into an electronic health record (EHR)? Certainly no-one will argue that our experience of healthcare delivery is changing – hospital in the home projects; supported self-management; patient requests for access to GP and hospital clinical records; personal health records; service coordination; clinical care plans; preventive health priorities... The list goes on, mirroring the rapidly evolving change in clinical EHR requirements needed to support these new paradigms of healthcare delivery. These new ways of delivering care require a coordinated approach – healthcare providers need to collaborate efficiently in real time, which is not adequately supported by traditional methods, such as meetings and phone calls. We really need an interoperable and integrated patient record in which all healthcare providers can participate, within a framework providing governance, authorisation and security measures.

The clinical knowledge domain is very complex and dynamic, so any clinical system created using traditional software development methods (embedding the clinical knowledge directly into proprietary application code and databases) has an uphill battle to deal with the changes. Considering the time it takes for a clinical application to be developed, it may already be out-of-date at its launch! The inherent difficulties in updating knowledge structures that are hard-coded into the application and database inevitably

lead to a gradual deterioration of the integrity of the system.

Clinical decision support is another difficult area; there is a lot of discussion about it, but there is very little real computerised decision support happening in practice. Certainly, each clinical system has some that are custom built – usually limited to allergy and drug interaction alerts and a reminder system – but generally there has been very little general progress in this area. Why is clinical decision support (CDS) still largely found only in the academic domain, and not implemented in production clinical systems? We already have clinical guidelines and other resources that are approved and used in paper formats – why are they not integrated in our clinical desktop applications?

The answer is multi-factorial. Things that have blocked progress include ownership and sharing of intellectual property, licensing problems etc, but the main issue is to do with practical implementation and cost. An approved guideline can be transformed into some proprietary computable format, but then it has to be able to integrate into every other clinical system – lots of interfaces have to be built, paid for, and maintained. This is a nightmare. Another approach is for each system developer to take a guideline and integrate it into their system as best they can. This introduces variability and the potential for significant quality and liability issues to arise.

Silos of proprietary information cannot talk to each other without mappings and necessary assumptions. Such transformations inevitably compromise the quality and integrity of the information being shared, thus creating more threats to patient safety. It is only through use of a common logical clinical

FEATURES content model reflected in our EHRs and CDS systems that the guidelines can be created once according to this agreed model, and can be integrated meaningfully and accurately with the clinical information systems to give us quality clinical decision support at the point of care.

From a technical point of view, the current reality around the world is that the majority of vendors are competing to build the greatest and ‘best of breed’ clinical software applications, but all are doing it in their own proprietary way. The software may have a rich functionality and a great user interface, it may do a great job in the clinic, hospital, or network on which it is installed, but how does it share clinical data? Some software applications may be able to share with the same system in another geographical location because they share a common data structure, but most cannot easily share with the system of another vendor.

Current clinical applications can usually send or receive point-to-point messages using a format, which is known and agreed and based on a standard such as the Health Level 7 (HL7) version 2. The software may also incorporate a terminology to assist in capturing and storing common clinical concepts. However, there is a common misconception that if we simply have a messaging standard paired with a terminology, then we have ‘achieved interoperability’.

A NEW PARADIGM FOR ELECTRONIC HEALTH RECORDS Most of us mistake the software program for the electronic health record; in fact in the USA the term “EHR” means a clinical application. The openEHR approach asserts that it is not the application, but rather the data (or health information), which makes up the health record. And further, that it is a common and agreed structure of that data that makes the electronic health record of any use for computing in health.

In order for two clinical systems to be able to share health data unambiguously, such that clinicians can read it and the computer can compute with it, more is required. This semantic, or knowledge-level, interoperability, based on a common and coherent clinical model, is an absolute requirement

for truly shareable EHRs and valuable complementary functionality, such as clinical decision support and workflow/ care planning. Further, it is only when this clinical content structure is agreed at a local, regional, national, or international level, that true semantic interoperability can occur at each of these levels. The broader the level of clinical content model agreement, the broader the potential for semantic health information exchange.

While an increasing number of health informatics experts agree on this view of the problem, incremental work towards EHR standards based on messaging paradigms, such as HL7 v3, have only had limited degrees of success. At an international level, there is increasing concern that this incremental approach to SEHRs may not be able to solve the issues of semantically interoperable EHRs. Remember that Einstein argued: “We can’t solve problems by using the same kind of thinking we used when we created them.”

We need semantic interoperability for our SEHRs and in order to achieve this we need a transformational change.

We need to use a different paradigm.

The openEHR paradigm has been collaboratively developed, reviewed and refined to realise a collective vision of a high quality, internationally interoperable EHR.

WHAT IS SEMANTIC INTEROPERABILITY? Let’s be clear about what semantic interoperability means. According to Walker et al1, Level 4 interoperability, or ‘machine interpretable data’, comprises both structured messages and standardised content/coded data. In practice, it means that data can be transmitted and viewed by clinical systems without need for further interpretation or translation. This is a basic foundation for a truly shareable EHR and for functionality such as clinical decision support.

For clarity, existing HL7 v2 messages probably fit into Level 3 of Walker’s conceptual framework – ‘Machine organisable data’ which comprises structured messages but unstructured content. According to Walker, a Level 3 message “requires interfaces that can translate incoming data from the sending organisation’s vocabulary to

the receiving organisation’s vocabulary; usually results in imperfect translations because of vocabularies’ incompatible levels of detail.” We cannot directly compute on a Level 3 message – it requires interpretation or transformation before the computer can use it. HL7 v3 goes a step further with an underlying semantic model. The problem has been that using this in systems has proved very difficult. The HL7 CDA, chosen by NEHTA for communication in Australia, bypasses some of the difficulties by at least enabling us to share documents that we can read. However, more is needed to achieve semantic interoperability.

WHAT IS OPENEHR? openEHR2 is a set of open specifications for an Electronic Health Record (EHR) architecture – but it is not a software application. Its design purpose is to enable semantic interoperability of health information between, and within, EHR systems – all in a non-proprietary format, avoiding vendor lock-in of data.

All clinical knowledge concepts are captured in a structured way - known as archetypes – outside the software.

The types of archetypes support the recording required for common clinical activities, with some of the key building block archetypes comprising observations, evaluations, instructions and actions. Data built according to these are stored in an EHR in larger ‘composition’ structures, which have their own archetypes.

Compositions are comparable to a document that results from a clinical event e.g. a consultation record or a discharge summary. Archetypes can be simple, such as temperature, blood pressure or diagnosis, or complex, such as capturing the risk to a fetus if the father has a grandmother with Huntingdon’s chorea. The archetypes contain a maximum data set about each clinical concept, including attendant data required such as: protocol, or method of measurement; related events; and context that is required for the clinical data to be interpreted accurately.

The creation of archetypes and templates is almost purely a task for clinicians – openEHR archetypes put clinicians in the driver’s seat, enabling them to create the breadth, depth and complexity of the health record

PULSE + IT 51

FEATURES to suit their needs for direct healthcare provision.

Aggregations of archetypes are combined in openEHR ‘templates’ in order to capture the data-set corresponding to a particular clinical task, such as an ICU discharge summary or antenatal visit record. When clinicians look at templates, the information contained within them inherently makes sense and doesn’t require significant training for interested clinicians to be able to create templates for their own purposes – be it domain, organisation or purpose specific. Templates can be used to build generic forms to represent the approximate layout of the EHR in a practical sense, and these can be used by vendors to contribute to their user interface development.

Both archetypes and templates can be linked to terminologies or contextually appropriate terminology subsets that will support appropriate term selection by healthcare providers at the point of data entry. openEHR is rapidly gaining international momentum, supported by evidence from current high profile implementations of the openEHR specifications such as in the UK NHS Connecting for Health program.

WHO IS OPENEHR? The openEHR Foundation owns the intellectual property of the openEHR architecture specifications. The Foundation is a not-for-profit company, with the founding partners being University College London (CHIME) and Australian company, Ocean Informatics.

The specifications are the result of over 15 years of research and international implementations, including the Good European Health Record (GEHR), and the collaboration of an international community of people who share a common goal – that of the realisation of clinically comprehensive and interoperable electronic health records to support seamless and high quality patient care.

The registered online community has over 1000 members from 75 countries with many actively participating in debate and contributing to ongoing openEHR development from both technical and clinical perspectives.

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WHAT IS OPENEHR USED FOR? openEHR is a specification for secure, shareable health information and provides a foundation on which to build interoperable, modular software applications. These, in turn, can support distributed clinical workflow, such as care plans.

The openEHR specification can be implemented in a number of ways: • Scalable EHRs – from Personal Health Records to small/medium/large organisations to regional or state clinical record systems and on through to National e-Health programs; • Message-based, web-service, middleware applications; and • Integrating existing clinical systems, including virtual federation of data for research or public health purposes.

However, while it has much in the way of additional functionality, it is important not to lose sight of openEHR’s raison d’être – semantic interoperability, or more simply, a truly shareable Electronic Health Record.

HOW IS OPENEHR DIFFERENT? There are many aspects of openEHR which clearly differentiate it from other EHR models: 1. Open Source Initiative The openEHR specifications are freely available under an open licence.

2. Separation of the Technical and Clinical Domains The openEHR design is markedly different to traditional EHR development - it is a 2 level information model. These 2 levels allow a clear separation of the technical reference (i.e. data) model on which software is based from the clinical knowledge itself. The appeal of this new design is that the technical components of the EHR can be kept quite separate from the dynamic clinical knowledge model. In practice, the technicians manage just the technical aspects, while the clinicians are critical in the development of the clinical archetypes and templates that shape the nature of their EHR. 3. Purpose-Built EHR The design of the reference and archetype models support many unique openEHR features required for robust clinical record keeping, clinical business

process and medico-legal compliance, such as: distributed versioning and merging of EHR records, including audit trails; a strong history and event model for complex observational information; and archetype-driven semantic querying. openEHR design supports configurable security, anonymous EHRs, fine-grained standards-based privacy, digital signing, and access auditing.

4. Knowledge-Enabled Clinicians are able to contribute actively and directly to the development of the clinical knowledge models that underpin their EHRs. Archetypes can be revised and versioned to reflect the rapid and varied changes in health domain knowledge.

5. Terminology Agnostic openEHR connects flexibly to any or all terminologies through either archetypes or templates. Terminologies such as SNOMED-CT are leveraged when used alongside archetypes, with the archetype clinical model providing context to minimise the need for post-coordination and complexity.

Archetypes and terminologies are not competitive, but rather complement each other.

6. Semantic Querying Archetypes, in combination with terminologies enable powerful possibilities for semantic querying of repository data – whether for individual usage or for population research.

Archetype-based querying enables true longitudinal processing of health data, regardless of the originating system.

7. Language Independent There is no language primacy in archetypes; they can begin in any language and be translated to multiple other languages. Translation enables the same archetype to be used in different countries, with data created in one language to be interoperable with systems developed and used in other languages. Archetypes are currently available in English, German, Turkish, Dutch, Swedish, Farsi, Spanish and Portuguese.

8. Sustainable Reference Model The openEHR reference model has been rigorously engineered over the past 15+ years as the foundation for a comprehensive health computing platform. It consists only of generic data

FEATURES types, structures and a small number of generic patterns, resulting in a small, stable and sustainable information model for IT people to maintain.

This approach allows a clinical data repository to act as a future-proof data store, totally independent of software applications and technology change.

In practice this means that no software application changes, or redeployment, are required when new or revised archetypes are published to reflect changing clinical knowledge. As a result, life-long, application-independent health records are possible for the first time.

9. Ease of Implementation openEHR is comparatively easy to implement: • there is little infrastructure required; • the software required is small, due to being based on a compact and stable, object-oriented reference model; and • the clinical models (archetypes) can be developed separately from the software application.

10. Ongoing Development and Enhancement Based on feedback from its international collaborators, openEHR is undergoing continuing development, with ongoing maintenance and releases of specifications and software.

11. Governance of Shared Content Archetypes are created once, and if broadly agreed upon, they can become

the basis of consistent sharing of data content between systems, providers and even other countries. While archetypes can be designed and used by a given solo practitioner/researcher or locally within an organisation, the power of archetypes becomes more evident the more broadly they are shared. All systems that use the same archetypes – even across country borders and terminologies – will be able to interoperate.

The openEHR Foundation is in the process of developing an ontologically-based international, open source archetype and template repository3. This is being supported by a governance framework which will facilitate archetypes to be submitted for international clinical review, and publication. It comprises a complete archetype and template lifecycle and version management repository and supporting processes to allow countries, regions, organisations or vendors to freely download and utilise these commonly agreed archetypes in their clinical systems. Archetype libraries can also be set up at domain, organisational, regional, or national levels.

12. Collaborative Development The openEHR development to date has been the result of interested and motivated volunteers from a broad international community of clinicians and software engineers. Formal and rigorous processes have underpinned its progress and both Architectural and Clinical Review Boards, comprising world

experts in their fields, have had oversight of the overarching strategy, process and governance.

Standards are not rejected in the openEHR approach; they are just not a part of the development process. In comparison to a traditional standards-based approach, openEHR development has been relatively rapid and pragmatic, rather than being held back by the slower process of ‘design by committee’. In fact, the recent European CEN standard for EHR extracts (EN13606) has been based on an earlier version of, and a subset of, openEHR. In addition, openEHR’s Archetype Definition Language (ADL), has recently been accepted as an International Standards Organisation (ISO) committee draft, for consideration as a standard.

WHERE IS OPENEHR BEING USED? openEHR is being used in both active research and commercial activities4.

Research on openEHR is being conducted in Sweden, Australia, United Kingdom, USA, Sri Lanka and Spain.

Commercial development is occurring in Australia, United Kingdom’s NHS Connecting for Health, Netherlands, Belgium, Sweden, Turkey and the USA. The United Kingdom’s National Health Service (NHS) Connecting for Health program has just commenced a formal clinical modelling program using openEHR archetypes and templates to provide a common and agreed clinical content on which to base its clinical applications. In a pilot

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FEATURES early in 2007, content developed for NHS Maternity and Emergency domains were provided to vendors for implementation in new clinical application development5. These archetypes are available in the public domain, and have undergone broad internal review by expert clinicians prior to being approved for NHS usage.

The Emergency templates developed reflect the top 10 presentations to an Emergency Department – including chest pain, shortness of breath and collapse. The Maternity templates followed the clinical journey of a pregnant woman – from a prepregnancy consultation and antenatal visits, through to capturing the labour and delivery record, including Partogram data. Each template is

made up of a variable number of archetypes – ranging from a few simple templates containing only 2 or 3 archetypes through to complex templates containing up to 80 discrete clinical concepts.

CURRENT OPENEHR STATUS AND SUPPORTING TOOLS 1. openEHR Specification The latest openEHR Specification (Release 1.0.1) was published on 15 April 2007.

2. Clinical Content Development of archetypes and templates has gained significant momentum in the past 12 months:

Below: An openEHR template for recording an antenatal consultation.

Archetypes As a result of initial Australian modelling work and, more recently, within the UK NHS, there are now approximately 250 archetypes.

Templates Over forty distinct templates representing clinical needs in Emergency and Maternity were developed over a short time period in March/April 2007.

3. Commercial Tools Currently there are a number of commercial tools supporting the open source openEHR implementation. The major tools to date are developed in .Net and Java. Australia’s Ocean Informatics6 has developed a suite of products supporting openEHR implementation in .Net, while Sweden’s Linkoping University has developed an Archetype Editor in Java and Cambio Healthcare Systems7 have an early Java kernel.

The Ocean Informatics .Net products include: • Clinical Knowledge Suite: o Archetype Editor (open source) and Template Designer, including semi-automated screen form construction based on templates; o Terminology Toolset – including a caching terminology server and subsetting tool, incorporating SNOMED-CT in the first instance; and o Archetype-powered Query Designer.

• OceanEHR platform – including a universal data repository, demographic service binding, generic EHR Viewer; and data integration & transformation services.

• Archetype/Template Library Service as an online template and archetype repository.

GET INVOLVED WITH OPENEHR Membership of the openEHR community is free and open to everyone via the openEHR website8. It assumes a commitment to a common vision for high quality, interoperable EHRs, and a willingness to share ideas and experience. All levels of interest and contribution are welcome – from novice to expert. The lists range from discussion on technical, clinical and implementer mailing lists through active development of archetypes, templates

54 PULSE + IT

FEATURES and tools, to review and critique of clinical content models and technical specifications. Whether you are a clinician, patient advocate, vendor or provider of health care you, have a role in the development of what is becoming known as ‘the world’s record’.

Dr Heather Leslie worked as a General Practitioner for 15 years until 2000, and has been involved in the design, implementation and support of both primary care software and personal health records. Dr Leslie is currently Director of Clinical Modelling at Ocean Informatics.

Dr Heather Leslie heather.leslie@oceaninformatics.com

4 - For more details, see: http://tinyurl.com/2vnd93

1 - Walker J, Pan E, Johnston D, AdlerMilstein J, Bates DW, Middleton B. The Value of Health Care Information Exchange and Interoperability. Health Affairs 2005 Jan 19: http://tinyurl.com/3yqhbn

5 - For more details of the NHS clinical modeling work, see: http://tinyurl.com/39wdwo

2 - For more details, see: www.openEHR.org

7 - For more details, see: http://tinyurl.com/3aovgt

3 - For more details, see: www.archetypes.com.au

8 - For more details, see: www.openEHR.org

6 - For more details, see: www.oceaninformatics.com

Below: An openEHR archetype for recording alcohol use. The creation of archetypes and templates is almost purely a task for clinicians – openEHR archetypes put clinicians in the driver’s seat, enabling them to create the breadth, depth and complexity of the health record to suit their needs for direct healthcare provision.

PULSE + IT 55

MARKET PLACE

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FUJI XEROX AUSTRALIA

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ArgusConnect provides and supports software that enables doctors and healthcare organisations to exchange clinical documents securely and reliably.

2HIPPO

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2Hippo uses modern software and methods to deliver intelligent digital communication solutions to healthcare professionals that reduce medico-legal risk and operating costs.

Dimension Data is a specialist IT services and solution provider, helping clients plan, build, support and manage their IT infrastructures.

2Hippo provides secure messaging, automatic address book management, automated appointment management (one way and two way SMS/email), and fax services.

BEST PRACTICE

Contact 2Hippo for solutions that meet the needs of your busy practice.

Best Practice sets the standard for GP clinical software in Australia offering a flexible suite of products designed for the busy GP practice, including:

AGFA HEALTHCARE

P: 03 8808 4000 F: 03 8808 4413 E: bronwyn.saville@agfa.com W: www.agfa.com/healthcare Contents: 2-3 Agfa HealthCare, a member of the Agfa-Gevaert Group, is a leading provider of IT-enabled clinical workflow and diagnostic image management solutions,and state-of-the-art systems for capturing and processing images in hospitals and healthcare facilities.

Agfa HealthCare has over a century of healthcare experience related to diagnostic imaging and has been a pioneer on the healthcare IT market since the early 1990’s.

The business group is a leading actor in the development of e-health solutions, including Electronic Patient Record technologies, for governments and regions.

Agfa HealthCare today employs 5,700 staff members, with sales offices and representatives in over 100 markets worldwide.

56 PULSE + IT

Fuji Xerox helps organisations take control of their documents, manage costs and improve productivity.

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• Best Practice Clinical (“drop-in” replacement for MD2) • Integrated Best Practice (clinical/management) • Top Pocket (PDA companion software for Pocket PC)

Dimension Data’s Healthcare Collaboration Suite consists of four integrated clinical solutions that provide faster, smarter healthcare with the ability to direct, locate and prioritise information for clinicians and their patients. As a result, hospitals realise improved staff productivity, reduced capital and operating costs with extended systems, and significantly enhanced quality of care and services.

GENIE SOLUTIONS DOCSTOCK

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COACTIVE EVENTS

With more than 12 billion pages produced on Xerox technology in Australia annually, whether you’re in an office, print room, commercial printer or publishing environment, we have the experience and knowledge to design and implement a document solution for you.

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P: 07 3720 2801 F: 07 3720 2802 E: info@geniesolutions.com.au W: www.geniesolutions.com.au Contents: 21 Genie is a fully integrated appointments, billing and clinical management package for Specialists and GPs. Genie runs on both Windows and Mac OSX, or a combination of both. With over 1000 sites, it is now the number one choice of Australian specialists.

Genie has 38 built-in data conversions covering all the major practice and clinical management systems in Australia.

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Nuance’s Dictaphone Healthcare Solutions Division is a leading provider of speech recognition, dictation and transcription solutions for the healthcare industry.

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Locum replaces traditional paper records with a robust electronic filing system that manages patient information and improves the efficiency of medical practice.

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GPCOMPLETE

P: 1300 794 471 F: 07 5569 2648 E: sales@gpcomplete.com.au W: www.gpcomplete.com.au Contents: 47 GPComplete is the first software explicitly geared to reducing the time taken to perform common tasks in your practice, and has been shown to increase workflow by as much as 50%. It combines electronic health records, practice management and Medicare Australia Online functionality, all built on a single, open source database.

Australia’s largest effective secure communication network.

• Fully integrated with leading GP and Specialist clinical systems • Robust; Reliable and Fully Supported Join the network that more than 60% of GPs use for diagnostic, specialist and hospital communications.

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HL7 SYSTEMS & SERVICES P: 0412 746 457 F: 02 9475 0303 E: admin@hl7.com.au W: www.hl7.com.au

HL7 Systems and Services is a leading Australian specialist consultancy focusing on healthcare system interoperability.

HISA

HCN

Member 2007

The Health Informatics Society of Australia (HISA) aims to improve healthcare through health informatics.

HL7S&S has a comprehensive track record in successfully undertaking projects for Federal and State Health agencies, Standards Australia, private hospital groups and other healthcare organisations locally and overseas.

HL7S&S has special interest in GP and Specialist data communications.

Health Communication Network (HCN) is the leading provider of clinical and practice management software for Australian GPs and Specialists.

HCN focuses on improving patient outcomes by providing evidence based software tools to health care professionals at the point of care.

GPA

P: 1800 188 088 F: 1800 644 807 E: info@gpa.net.au W: www.gpa.net.au Contents: 36, 41, 53 GPA ACCREDITATION plus has given general practitioners a reliable alternative in accreditation.

GPA is committed to offering a flexible accreditation program that understands the needs of busy GPs and practice staff. GP is the only only accreditation provider that assigns an individual quality manager to support your practice with accreditation.

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HEALTH PHONE

P: 02 8875 7977 F: 02 8875 7777 E: sales.au@healthphonesolutions.com W: www.healthphonesolutions.com Information at the Point of Care Healthphone Solutions is in the business of helping its customers improve the management of their healthcare operation by providing information at the point of care, wherever and whenever they need it.

INTRAHEALTH HL7 AUSTRALIA P: 0412 746 457 F: 02 9475 0685 E: chair@hl7.org.au W: www.hl7.org.au

HL7 Australia is the local representative of the global Health Level 7 standards organisation. The HL7 standards are widely used in Australia to interconnect computer systems in hospitals, laboratories as well as GP and specialist practices.

HL7 Australia supports the local user and implementer community with standards, education and implementation support.

P: 02 9956 3827 F: 02 9901 3705 E: trevor.obryan@intrahealth.com W: www.intrahealth.com Contents: 9 Intrahealth is a major supplier of healthcare software. Out leading edge solutions offer a family of products for use by healthcare professionals at the point of care.

Profile is a fully integrated financial, clinical and appointment practice management system used by GPs and specialists.

• Excellent robustness and reliability.

• Powerful reporting / data extraction.

• Extendable and customisable.

• Multi site access.

• 3 tier architecture.

• Load balancing redundancy.

PULSE + IT 57

MARKET PLACE

MOTION COMPUTING

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MEDICAL-OBJECTS

P: 07 5445 5037 F: 07 3221 0220 E: info@medical-objects.com.au W: www.medical-objects.com.au Medical-Objects is a medical software firm specializing in secure standards based clinical messages and applications of messaging.

This includes integration to other clinical systems, clinical tools through to high-end decision support.

MIMS AUSTRALIA P: 02 9902 7760 F: 02 9902 7701 E: info@mims.com.au W: www.mims.com.au Contents: 11

To cope with the demands of practicing healthcare in the real world, you need fast access to a pure source of knowledge.

MIMS is essential knowledge that Australian health professionals can trust, distilled down to crucial facts and easy to use.

Because of the rapid flow of information today, you can count on MIMS being up-to-the-minute with regular updates through print, CD ROM, PDA, online or integrated into your clinical software.

And because it is generated by a local Australian editorial team and backed by global resources, you can be sure MIMS is always relevant to your needs.

Look for the MIMS logo. It’s your guarantee of the knowledge you need in healthcare today.

MOBILE COMPUTING

P: 07 3839 4321 F: 07 3939 1251 E: info@mobilecomputing.net.au W: www.mobilecomputing.net.au

58 PULSE + IT

Motion Computing is a mobile computing and wireless communications leader, combining world-class innovation and industry experience enabling professionals in vertical industries such as healthcare, field sales/service, government and education to use computing technology in new ways and places.

Marketed through an experienced worldwide reseller network, each Motion Tablet PC is built to customer specifications.

NEHTA

P: 02 8298 2600 F: 02 8298 2666 E: admin@nehta.gov.au W: www.nehta.gov.au

POWERHEALTH SOLUTIONS

P: 08 8410 6404 F: 08 8410 6403 E: paul.venables@powerhealthsolutions.com W: www.powerhealthsolutions.com PowerHealth Solutions specialise in decision support, performance monitoring, and patient billing software for hospitals, health departments and other healthcare organisations.

E: john.kingsley-jones@oracle.com W: www.oracle.com.au Oracle’s business is information - how to manage it, use it, share it, protect it. For 30 years, Oracle - the world’s largest enterprise software company - has provided software and services that help organisations get up-to-date and accurate information at the lowest cost. The right information leads to good decisions - and good decisions lead to good business.

That’s why successful enterprises rely on Oracle for their information needs.

Oracle brings comprehensive, end-to-end solutions to the healthcare industry to support best practices and decrease costs. Oracle’s healthcare-specific industry applications help ensure quality care and decrease patient safety concerns through the integration of clinical data and the ability to analyze patient-specific information.

P: 02 9237 6000 F: 02 9237 6091 E: healthinformatics@standards.org.au W: www.e-health.standards.org.au Standards Australia Limited is recognised by the Government as Australia’s peak standards body.

It develops Australian Standards of public benefit and national interest and supports excellence in design and innovation through the Australian Design Awards program.

Using the latest mainstream technology, our high quality affordable solutions are guaranteed to deliver positive return on investment, regardless of your organisation size.

Using the latest mainstream technology, our high quality affordable solutions are guaranteed to deliver positive return on investment, regardless of your organisation size. Our software solutions are flexible to suit your needs — with onsite implementations, web-based hosted services and outsourced services.

WACOM

P: 02 9422 6700 F: 02 9420 2272 W: www.wacom.com.au Contents: 13 Wacom is the worldwide market leader in graphic tablet technology and interactive pen displays.

The National E-Health Transition Authority is responsible for developing key national health IM&ICT standards and specifications.

ORACLE

STANDARDS AUSTRALIA

For practices looking to move toward a paperless office system, Wacom has a number of solutions that are intuitive and easy to use.

EQUIPOISE INTERNATIONAL

P: 07 3252 2425 F: 07 3252 2410 E: sales@totalcare.net.au W: www.totalcare.net.au Contents: 29 Founded in 1994, Equipoise International’s focus has been the development of best of breed medical management systems.

We are a proudly Australian based and owned company, with a shareholder base including clinicians, employees, and private investors.

Our flagship product - the Totalcare suite of medical software - has been in continuous development for over 12 years.

Totalcare reflects our philosophy of providing comprehensive, flexible and reliable solutions to our clients, backed by a personal, knowledgeable support team. We seek to excel in all our interactions, and to provide not just superior software, but superior service.

ZEDMED

P: 03 9818 5488 F: 03 9818 5499 E: sales@zedmed.com.au W: www.zedmed.com.au For 30 years Zedmed has been one of Australia’s most innovative and successful, fully integrated practice management and clinical record solution providers.

• Fast • Stable • Innovative • Secure The new generation of medical software.

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