Firstly, your latest post is a much better way to
win friends and influence people, Tom, compared
to the previous posts which only served to get people
off side.
Secondly, I forgot to add the communications
program (medcomms, I think) which transmits
data from my billing software to the HIC.
Also, to correct an ambiguity, I only meant to
ask if there was a better system than Argus
for transmitting referral letters from my EHR
letter writer to specialists (and hospitals), and
for receiving letters/reports back from specialists
and into my EHR ? ... This is the last "cog in the
wheel" needed to end scanning hard copy specialists
reports, which is very time consuming for my staff
(at least 3 hours = $100 per week per doctor),
and has other disadvantages such as using much
more storage space, less legible etc.
For all the lack of progress/development of HL7
standards, Argus seems to use whatever is presently
available and works well.
In the absence of a better alternative to Argus, I
will continue to promote it to the GPs and specialists
within my Division (and outside it).
If better alternatives are developed, then these can
supersede Argus at some future date. But there is
no reason that I can see to hang off any longer.
As a simple end user, I will leave others to comment on
the other more technical aspects of Tom's post.
John Mac
> Tom Bowden wrote:
> 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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