Dear John,
I'd like to thank you for the
effort you have made to set out way in which messaging works in your practice
and you have asked for views as to how things could work better. I have
given a bit of thought to this question and I hope you will take what I
have written below as a sincere effort to progress this important debate in a
useful manner. If you do not believe that what I have written here is
sincere and genuinely motivated, I will cease and desist and let this debate
carry on, without me , because I believe it is time for action not words and I
believe that if the commercial (and not for profit) service comms providers
and the GP spokespeople could agree on a way forward, we'd make some tremendous
progress and quickly. So I hope that you'll hear me
out.
John you told
us that .......
My practice uses the following:
1) HealthLink transfers Frankston Hospital discharge summaries
which appear in my Medical Director (MD) holding file, and from
there get placed into the Letters tab.
2) eClinic downloads all Gribbles Pathology (and I think also radiology
results from their affiliated radiology mob, NMIG) to MD holding file.
3) Promedicus downloads MIA radiology reports to MD holding file.
4) emdata is a service that types up specialist reports from Southern
Eye Centre and forwards them by encrypted email to MD holding file.
5) Dorevitch Pathology use a program called Fetch (I think) which
somehow downloads results to the MD holding file - I'm not sure the
exact mechanism behind this.
6) Victorian Cytology Service also had their own program for
downloading there reports to the MD holding file, but I think that
they have now changed to using one of the other above systems.
7) Argus - this program enables me write a letter in the MD letter
writer and then click the email/send icon to send it (encrypted) to
a recipient who uses Argus. It also enables a specialist (or anyone)
using word or an EHR letter writer to send their reports (encrypted)
using Argus back to my MD holding file.
The above 7 systems are all working well :-)
But only Argus allows me to send referral letters from my MD letter
writer by the click of an icon to specialists, and also to receive
specialist
reports back into my MD holding file. Argus is here, it works, and it's
free. It is taking off in my Division.
Would someone like to advise a better system than Argus for the
purposes described above.
Thanks very much John for this useful
summary of messaging systems that deliver info to your practice. The fact
that you have a number of them co-existing on your system does not seem to be a
major issue for you, as you say, you are not quite sure who delivers what but
generally speaking, it all gets there. However it is understandable that
you should wish to reduce the number of parties involved because such
duplication is glaringly inefficient, in my view it also limits the amount
of future progress you can make ... forty parties to connect to, 40 pieces of
client software? I can also tell you without fear of contradiction that
none of the systems you are currently using fully conforms to the kind of
standards regime necessary to "scale up" to a fully paperless health system.
This statement includes what HealthLink is doing in this environment as
well.....
There appear to be three types of
system...
i) Those delivering messages for a single
service provider; Fetch (Sonic), E-clinic (Gribbles), etc
ii) Secure Person to Person Email
(Argus)
iii) Generalised messaging services with no
ties to service providers (in this case HealthLink) but in other parts of the
country Medical Objects as well and one or two others who are less well
known.
As far as Argus goes, let me say this, I
believe that Argus has creditably carved out a role for itself as a provider of
secure email between providers and I think it has a role in that area, I have no
problem with that. My only issues with Argus are;
(i) They are a commercial player, they
charge money for their services, I am sure their staff get remunerated according
to the success of the enterprise, other commercial enterprises invest money in
them and they should not try to think they are really any different
(IMHO).
(ii) SMTP/E-mail is not fit for all
messaging purposes and should not be portrayed as being so, it is not
scaleable. This has been demonstrated repeatedly and I do not propose to
go into this in detail here. But such as system has a place.
- Argus appears to be
forging itself a very useful place in secure provider to provider
communications by enhancing the way in which the sector can use
email.
As far as the single service
providers (who refuse to share a common conduit or one they do not control
by some means) I have what is no doubt a controversial view and one that
quite likely could viewed as self serving. My view is that those
organisations that wish to maintain their own systems prevent the emergence of a
competitive and useful communications infrastructure; a mechanism that in a
number of other countries is making a real difference to healthcare
delivery. While these organisations may think they have good reason to
maintain their own links rather than participating in a shared infrastructure,
they could instead be enabling development of a standards based messaging
infrastructure that would transform Australian primary care. By my
reckoning, some 200 million plus fully standardised messages should now be
exchanged between the systems of Australian GPs
annually. A highly competitive group of comms service providers
should be leading the development of web-services based architectures and
Australian GPs should be nearly paperless, just like their colleagues in
some other parts of the world.
What has yet to be widely understood is
that this is essentially a commercial/political issue and not a technical
one. The technical "birdsnest" that prevents progress is a direct result
of failure to adequately address the commercial/political issues. To
their credit, some of the "single service providers" plan to do
something about it, however, they are only belatedly doing so now because they
have viewed it as being in their (shareholders) interests not to for as
long as possible and they are now doing so before they are forced to by one
means or another.
OK, so enough about the politics, lets
discuss why your practice, on the Mornington Peninsula has six or seven
"downloads" but that with the exception of your new secure email capability, you
are probably not getting much closer to having a fully electronic practice after
a number of years in this position.
I believe I can speak authoritatively on
this matter as I am now advising two Canadian Provincial Governments about how
to align the planets to deal with this issue and as you are aware have had some
success in dealing with it in this part of the world... (yeah, yeah get on
with it)
OK.... The first and foremost issue
in Australia is I believe that the standards setting process has completely
failed us and more recently it appears to have been abandoned entirely
("Web services is the answer.... now what was the question
again????") . :-))
I believe that for various reasons, perhaps
not best debated here, the standards process has been hijacked by parties with
little or no interest in seeing sector-wide automation emerge. I have some
sympathy with "the powers that be" for pulling the plug on the
existing process for this reason. However, it is time that the people
that do want an automated sector i.e. GPs, service providers and Government (a
key beneficiary) grab the wheel and drive. That is what has happened
and continues to happen very successfully elsewhere.
Take the two key sets of Australian HL7
messaging standards; pathology and referrals/discharges.....
Pathology - implemented in a number of
different ways, each lab has their own HL7 format which doesn't work with the
others, GP systems vendors were not educated as to the importance of an
application acknowledgement loop, as a consequence, the small amount of so
called HL7 messaging going on is fairly dysfunctional, very little of it has a
proper HL7 acknowledgement loop, it shouldn't even be called HL7.
Referrals/Discharges has had similar issues.
The importance of end to end
acknowledgement is huge. An HL7 message must be acknowledged from
within the recipient's application, following processing and insertion into the
database. Today most of what is called HL7 is actually acknowledged from the
messaging application prior to going into the recipient's database.
The net effect of lack of standards is that
most of the messaging done around Australia is still done using PIT which has
very little value to the EMR and provides no leverage for adding further
functionality. Very few parties (if any) can justifiably go paperless and
the same old inefficient system rattles on year after year.
If the people that wanted things to
actually happen got together with those who know how to make it happen and
ran the standards process (instead of it being run by those that do
not want it to work), we could make things happen very fast indeed.
Until that time, your HL7 should
probably be renamed HL5 or HL6... (because HL7 it ain't) and
organisations such as HealthLink are forced to "tinker" with things like PIT
instead of being able to put a proper paperless environment in place.
Practices sink beneath a sea of paper, patient care languishes and the family GP
spends what should well-earned relaxation time doing paperwork, wrestling with
increasing amounts of red tape and becoming despondent about the future of
General Practice.
Studies have shown that use of multiple
non-standards based download systems inevitably result in approximately 0.1% of
messages being positively acknowledged with a transport level ack when the
message does not in fact arrive into the application. Now HealthLink
delivers 50 million messages annually, in NZ which is getting to be a paperless
environment. If we were using the systems prevalent in Australia (no
application level acknowledgements), we would "lose" 1,000 messages a
week! What would happen if the national immunisation register started
mysteriously losing messages or if the GPs of women being referred
for breast screening didn't get their mammography reports or if
patients getting their annual diabetes review were not followed up,
because ladies and gentlemen, that is exactly what would happen if each week
1,000 senders' systems were told that their messages had arrived safely when
they had not.
To sum up... the best way to sort out
messaging in Australia is for those who will directly benefit from data
communications standards to set them (with a small amount of expert help)
and then drive them through the adoption process by forcing their use by service
providers (properly not half-heartedly). Once there is exact agreement on
what those standards should be and no room for ambiguity in their adoption, and
a clear understanding of the importance of them, everything else will sort
itself out.
I believe that if five- ten GPCG
enthusiasts and representatives from the key comms vendors got together, we
could sort out the key HL7 standards and set an implementation timetable
in two meetings.... it ain't that damned hard?
Whaddya think John?
I look forward to your views,
Kind regards,
Tom Bowden
CEO HealthLink Ltd
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