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Wednesday, February 14, 2007

Guest Article on Secure Pathology Messaging III - The AAPP Perspective.

Ann Webb, Deputy CEO of the Australian Association of Pathology Practices has written another contribution to the secure messaging discussion, from their perspective. This adds another view to the discussion for all to consider.

Ann writes:

In a guest blog by Dr Ian Colclough (see the entry for February 1, 2007) there were a number of references recently to the position held by pathology laboratories with respect to electronic messaging. It was felt by the Australian Association of Pathology Practices (AAPP) that a clarification of that position may be helpful.

Members of the AAPP provide more than 90% of community pathology services in Australia. The AAPP has a working group in health informatics and has supported standards development in this area for more than 10 years.

Among these standards were the Australian standards that Dr Colclough references for the implementation of HL7 v2.3.1. Indeed the Standards Australia Working Group that has carriage of the AS4700.2 and HB262 was formed through the efforts of AAPP member’s and in 1996 after formally reviewing the available messaging standards (including EDIFACT and PIT) unanimously endorsed the adoption of HL7 and immediately set about producing an Australian implementation guide.

This was first published in 1998 five years after PIT, a simple document format, was developed and adopted by pathology practices to get electronic messaging started in Australia. The structure for reports provides for the transfer of both atomic results and a rendering to ensure that the intended pathology report is conveyed with high fidelity.

Pathology practices have since been involved in a number projects to test and improve these messaging standards including communications with cancer and communicable disease registries.

The AAPP endorses ‘AS4700.2-2004 Implementation of Health Level Seven (HL7) Version 2.3.1 Part 2: Pathology orders and results’. Furthermore member practices currently provide significant volumes of electronic messaging to GPs, Specialists, and hospitals using these standard messages. The Pathology Practices are not the source of delay in widespread standardisation and would be pleased to move their customers to this mode of messaging now. The report receiving systems however have to be capable of managing these messages properly. That PIT is provided at all by AAPP member practices is because that is what their customers have asked for.

The AAPP continues to work closely with Standards Australia and NEHTA to establish the infrastructure that Australia needs for connected health care.

-----------------------------------------

Thanks Ann!

David.

6 comments:

Teki said...

Is AAPP willing to disclose the details of links between commercial (ie, for-profit) pathology and the cancer registries? I guess not, since they would be commercially sensitive. So, then, can the disease registries disclose how they are accepting personal details, largely without informed consent? If the transfer of information is deemed to be required by law, then there should be no harm in telling the public how it works, should there?

Dr Ian Colclough said...

The Australian Association of Pathology Practices (AAPP) should be complimented for clarifying its position on secure messaging through the commentary provided by the Deputy CEO of AAPP, Ann Webb.

The pivotal points made by Ann are:

1. “The AAPP endorses ‘AS4700.2-2004 Implementation of Health Level Seven (HL7) Version 2.3.1 Part 2: Pathology orders and results’.”

2. “The Pathology Practices are not the source of delay in widespread standardisation and would be pleased to move their customers to this mode of messaging now.”

3. “The report receiving systems however have to be capable of managing these messages properly.”

4. “That PIT is provided at all by AAPP member practices is because that is what their customers have asked for.”

Some additional clarification is required.

Is it ‘their (AAPP) customers’ who are asking for PIT? (4)
-or-
Is it that the Clinical Desktop Vendors (report receiving systems) are telling their customers to ask for PIT?
-or-
Is it that the Clinical Desktop Vendors are unwilling or unable to provide the system capabilities to enable the messages to be ‘handled properly’? (3)
-or-
Is it that none of these parties - the pathology practices, the report receiving practices, the Clinical Desktop Vendors - are prepared to pay for or share the cost of the changes required to enable the messages to be ‘handled properly’? (3)
-or-
Is it that one or more of these three parties believe that Government should contribute to underwriting the cost of the changes, either in whole or in part, via grants, incentive payments or some other mechanism?

Who stands to gain the most from bringing about ‘the widespread standardisation’ that enables ‘report receiving systems’ ‘to be capable of managing these messages properly’? (2, 3) Clearly, everyone will gain; but, without doubt the one that stands to gain the most is Government.

‘Waiting for Godot.’

The AAPP has been an active participant in standards development for many years. Hence, it is good news that the AAPP’s members have endorsed the standard (1) and that they may support using the standard ‘in principle’, but there is no getting away from the fact that they have not adopted it widely. This issue is further compounded, in that while they all support PIT, the AAPP’s members offer various versions of HL7 V2. It should be clear that first and foremost the various implementations of HL7 V2, which have been adopted by pathology services, must be unified without delay.

Absurd though it may be - ‘Waiting for Godot’ is not an option. It is easy for the AAPP and its members to ‘do nothing’ in the current environment. It is easy to pass off responsibility to the Clinical Desktop Vendors which are the least well resourced to address this problem. It is easy for Government to say ‘let the market decide’. It is easy for everyone to say ‘let’s wait for NEHTA to show us the way’.

Pathology tests are involved in over 70% of all diagnoses and, as Ann Webb points out, “Members of the AAPP provide more than 90% of community pathology services in Australia”! These two facts alone mean that the pathology sector should be pulling out all stops to create an environment highly conducive to advancing the adoption of e-health throughout the Primary Care sector. A major contribution to that end will be made when the same version of HL7 V2 is deployed by all pathology services. This will remove a significant impediment to progress at the Clinical Desktop level and bring to the fore new market forces which will accelerate the uptake of e-health in Australia.

However, responsibility for bringing this change about should not be left to the pathology sector alone. As Government has the most to gain from making this happen it should be prepared to bear a substantial part of the cost without contention.

Conclusion.

Given the very large sums spent over the last 5 years or so on some high profile less than successful Government e-health initiatives, such as healthConnect and mediConnect, it is particularly difficult to comprehend why this fundamental problem has not been given the highest priority by Government, the AAPP and NEHTA.

Dr Ian Colclough
0412 059 392
ihsipl@smartchat.net.au
15 February 2007

Anonymous said...

It sure makes a lot of sense. Remove the roadblocks and get on with the job. It’s obvious government will be a big winner as a major beneficiary of spin-offs and benefits coming from every which way, although not the only one. Atomised data being sent by a number of different pathology software systems which are all standardised to the same HL7 version and received by the clinical system on the doctors desktop is what we have all been waiting for. This will allow for better recall, monitoring and management of patients, facilitate population studies, and overall improve the quality of the medical record and the quality of patient care. Government might have less need to bootstrap IT into the market when it opens up becoming more competitive and the cost savings it will enjoy will come from a multitude of directions. So some of our SWPE’s and other incentives might go by the board but hey, at least one major barrier to development of interoperability in the primary care sector will have been demolished. Let’s get on with it.

Teki said...

The Australian Financial Review is tracking the discussions between Symbion and Primary Health. Since Healthscope has been mentioned in the articles (by Eli Greenblat), and all three corporations are major pathology providers, it's worth asking how their IT is valued.

Anonymous said...

Dr. Ian Colclough wrote:

> Given the very large sums spent over the last 5 years or so on some high
> profile less than successful Government e-health initiatives, such as
> healthConnect and mediConnect, it is particularly difficult to comprehend
> why this fundamental problem has not been given the highest priority by
> Government, the AAPP and NEHTA.

MediConnect and HealthConnect and many of the state programs have shown government isn't capable of succeeding. In addition, I suspect it's not something their pollsters say can be turned into a vote winner.

NEHTA, of course, was not set up to actually achieve anything. It was set up to distance the minister and his dept from failures of MediConnect and HealthConnect. It has succeeded well in both aims (not achieving anything, and distancing the dept), although I suspect it has spent a lot more money than originally intended and been higher profile than hoped.

In fact, having typed the above, I realise that there's only one conclusion that can be drawn from our present state of 'Waiting for Godot' ... so I'll go further and say :

For so long as medicos and their organisations, and hospitals (and insurers) keep talking about this, and waiting for govt standards or govt money or govt leadership, then they'll just keep talking, and going to NEHTA and other
meetings. If, on the other hand, they demand the functionality from their technology providers - and agree to pay for it - the medical industry and professionals could move forward quite significantly in quality of care and also in efficiency. Really, that's how most modern businesses work - the best ones improve their processes so they do better work, and are more efficient.


From the other side of the fence, if patients caring about quality of
health care - started quizzing their health care providers about the quality of their systems and procedures - starting for instance with some simple things like recording of history in a standard form shareable amongst other providers, recording of allergies/drug interactions/current issues, etc. There is an inkling of this happening - patients are using the Internet to come to their health care providers armed with a much greater level of knowledge than 10 years ago. Another inkling - a few patients are realistically concerned about the impact on privacy of the IT systems in use by their health care providers.

So patients might start preferring GP's, pharmacies, pathology services, hospitals and health insurers with accurate, efficient, safe, networked systems, over those still stuck in the 1950's or those with a near enough is good enough attitude to IT.

If this awareness came to pass amongst patients, there would be market forces pressuring the health care providers to lift their game. And the issue would register with the pollsters, and our government ministers might demand some actual results from their departments.

John Johnston said...

Reading between the lines of Ann Webb’s response to the Colclough dissertation on the position of the AAPP I am not sure whether we have another organisation “waiting for Godot” or not.

There are major consequences of the PITfalls of the status quo. Key clinical data for chronic disease prevention and management continues to live out of reach of the increasingly sophisticated recall and reminder systems that primary health system vendors have devised and the victims are the consumers and the government. Unless the clinician has the time to do the manual research through past pathology reports the poor old (and now young) diabetic is always overdue for an HBA1c test (for example) and the life-style impacts of “over-intervention” become onerous. The government foots the bill for the additional consultations and the diagnostic procedure to boot. Recently reviewing a clinical database of diabetics I discovered that 31% had no database record of the HBA1c test having been recorded at all.

We all know that our GP’s are better than that. The other 69% of patients with recorded HBA1c results were the beneficiaries of a diligent GP or practice nurse that had taken the time to read the PITed pathology reports and manually re-key the data into the clinical record. No GP really wants to do that.

So what we know is that the Government wants to fix it, the GP wants to fix it, and the patient would like to fix it now that they know why they are having so many tests.

Just wearing my MSIA board member hat for a moment, could I ever so cautiously suggest that some highly targeted funding assistance to some clinical desktop system vendors would solve this problem? Perhaps the funding pool might have contributions from DoHA, and to test the altruism out there, from AAPP and the clinical desktop vendors themselves.

While the most elegant technical implementation of AS4700.2 would be one that was informed by some of the projected deliverables in the NEHTA work plan there is no guarantee that the right dynamics and synchronisation of these outputs will produce the market result that we badly need. The software developers that support Australia’s primary healthcare clinical desktop systems are quite capable of building systems that will allow the “plug-in” of new terminologies and new identifiers when and if they should come along.

Lets not GO DOT all of the “i” s or cross all of the “t”s. Lets GO DOIT.