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Sunday, June 24, 2018

It Would Be Nice To Have The Facts On Secure Messaging Without The Spin! Look More Closely And We Get Facts And There Is A Long Way To Go! Baby Steps!

This press release appeared last week from the ADHA.

Media release - Industry collaborates to end the era of the fax machine

June 18, 2018
Out of date and unsecure fax machines are being used to share patient information between healthcare providers, despite other sectors discarding them over a decade ago. Not only do fax machines cause frustration for healthcare providers trying to communicate with each other, they can also cause patient harm.
In May 2018, a coroner’s report revealed that Hodgkin’s lymphoma patient Mettaloka Halwala died alone following chemotherapy complications. His medical test results were faxed to the wrong number, which meant his treating haematologist did not receive information that could have saved his life.
Coroner Rosemary Carlin called for the hospital involved to phase out fax transmission of imaging results as a matter of urgency. She said it was difficult to understand why such an antiquated and unreliable means of communication exists at all in the medical profession.
To support the uptake of digital health services, the Council of Australian Governments (COAG) Health Council approved Australia’s National Digital Health Strategy – Safe, Seamless, and Secure. A key priority in the strategy is to end dependence on the fax machine and paper-based correspondence by empowering healthcare providers to communicate with other professionals and their patients via secure digital channels.
On 6 June 2018, key industry participants at a secure messaging industry collaboration workshop agreed to adopt the tools, processes, and standards that have been demonstrated to solve the interoperability problems across secure messaging and clinical information systems.
Through this collaboration, Australia is on track to end the use of fax machines in healthcare, with key industry players agreeing to the next steps to improve secure messaging of patient records between healthcare providers using clinical software.
The meeting was co-chaired by Medical Software Industry Association (MSIA) President Emma Hossack, Agency Chief Operating Officer (COO) Bettina McMahon, and Dr Nathan Pinskier, Chair of the Royal Australian College of General Practitioners (RACGP) Expert Committee – eHealth and Practice Systems, and Chair of the Agency’s Secure Messaging Program Steering Group. Over 50 participants from the technology and healthcare industry also attended.
MSIA President Emma Hossack said that industry is committed to progressing interoperability in secure messaging, as well as more generally across the health sector.
“Health information is stored in diverse health software and frequently needs to be shared. Without interoperability, this information may need to be scanned and faxed or even posted. Not only can this be dangerous but also highly inefficient.
“To share and manage access to health information, we are working towards adoption of agreed compliant messaging standards, conformance at the receiving ends, and a federated approach to directories. This will make health communications more seamless and safe. It will also make it easier for industry to innovate in this area, as digital foundations will be in place,” Ms Hossack said.
Today the Agency and MSIA released a communique with a commitment to support message formats that give healthcare providers flexibility to construct messages and consume content within their clinical information systems. Authentication and the approach to sharing endpoint locations across directories was also addressed.
Proving interoperable messaging in real world projects
This commitment follows good progress with proof of concept projects led by Telstra Health and Healthlink.
Telstra Health is leading a consortium to test the delivery of discharge summaries from Royal Melbourne Hospital to a range of general practitioners. CorePlus, Genie Solutions, Global Health, HealthLink, and Zedmed are also participating in this project.
Telstra Health Head of Strategy and Policy Dr Phuong Pham said enabling providers to reliably connect and securely share information with each other is crucial to support the safety, quality, and efficiency of the health system.
“Telstra Health is proud to be collaborating with industry colleagues and the Australian Digital Health Agency to make interoperable messaging possible. With the proof of concept activity nearing completion, we keenly anticipate the next phase of digital enablement in healthcare,” Dr Pham said.
Healthlink is leading the other consortium and is testing the delivery of referrals from a range of general practitioners to specialists. MedicalDirector, Best Practice Software, Genie Solutions, Global Health, and Telstra Health are supporting this work.
HealthLink CEO Tom Bowden said that he is pleased with the progress to date on the federation of messaging directories.
“The ability to select any practice from a federated directory search will be a major step forward for eHealth across Australia,” Mr Bowden said.
Both consortia are finalising a federated search capability to allow the searching of provider directories and care provider electronic addresses. This means that a single search will identify Australian healthcare providers, providing convenience and transparency for clinicians looking up other clinicians. The sending of messages across these sites will commence this month.
The projects have also been extended to include allied health practitioners and electronic medical record (EMR) products used in that domain. The Telstra Health consortium will enable allied health practitioners to send reports to their referrers and the HealthLink consortium will extend the sending of referrals to and from allied health.
In addition to laying the foundations for national secure messaging, the lessons learnt in this project will inform other industry collaborations as Australian healthcare drives towards full interoperability across digital health systems.
Dr Nathan Pinskier reflected on the progress made with secure messaging in Australia.
“In late 2016, Agency CEO Tim Kelsey visited my practice to obtain a better understanding of the complexities frontline healthcare providers were facing when attempting to utilise secure electronic messaging.
“During the visit, Tim offered me the opportunity to become involved with a new and invigorated secure messaging program. Clinicians have been understandably frustrated with the ongoing delays and lack of progress towards achieving truly interoperable, easy to use and highly available secure messaging in the healthcare sector.
“Well the good news is that as a consequence of the significant work undertaken in the past 18 months we are closer than ever to achieving this vision. I’m looking forward to the outcomes from the proof of concepts and then moving on to national deployment. It has been a privilege to collaborate with industry and all key stakeholders to support this vital piece of national work,” Dr Pinskier said.
Agency COO Bettina McMahon said that the key to solving the interoperability issues has been partnering with industry and their customers.
“Secure messaging systems and standards have been in place for many years, but as a country, we’ve struggled to implement at a national scale. It has taken time to co-produce a workable solution with industry that meets the expectations of the clinical community – we started this project 18 months ago. But to adopt a true co-production process takes this long, and ultimately, has allowed us to reach consensus about how we will scale digital communication,” Ms McMahon said.
Here is the link:
Now with all this we need to see – with the communique just where things are – as of June 2018. Unspun it is clear there is a lot of work still to do!
Communique –

Industry Collaboration for Secure Messaging and Interoperability

The Australian Digital Health Agency and Medical Software Industry Association jointly ran a Secure Messaging Industry Collaboration Workshop in Sydney on 6 June 2018 to make decisions on key issues to the progression of secure messaging and interoperability across the health sector.
The meeting was co-chaired by Ms Bettina McMahon Chief Operating Officer, Australian Digital Health Agency, Ms Emma Hossack President, Medical Software Industry Association and Dr Nathan Pinskier Chair of the RACGP Expert Committee – eHealth and Practice Systems and Chair of the Secure Messaging Program Steering Group for the Australian Digital Health Agency.
The meeting was attended by 53 members from clinical and secure messaging software suppliers and stakeholders from industry.
The group discussed a number of items and reached the following agreements:

Message payload

Healthcare providers are requesting their software providers to give them flexibility in the methods to construct messages and consume the content of messages within their clinical information systems. Industry is responding to this call through innovations in the way systems communicate with each other, and how they support clinicians to process and interpret message content.
The Australian healthcare system currently uses messages in HL7v2 and CDA. CDA is used for interactions with the My Health Record, which are increasing in volume and spread across the healthcare system. HL7v2 is used by the pathology labs and clinical software which have high volumes of messages that span across many parts of the healthcare sector.
There is consensus that both standards are in widespread use today and we need to support both.
Challenges in supporting HL7v2.3.1 and HL7v2.4 will be resolved by the version of HL7v2.4 that has been refined by the Technical Working Group and is currently out for comment through HL7 Australia. The standard endorsed through this process will be the HL7v.2 message format to be supported in the medium term.
There is a need to develop tools to test compliance with these standards by sending and receiving systems, and a scheme to manage compliance.
There was broad acknowledgment that work is required to improve payloads to optimise their compatibility with clinical work flows. In particular, there is a need to increase receiver compliance and to engage with the pathology sector in relation to sending compliant messages once receiver compliance has been achieved.

Agree an approach for certificate and trust management

In order to safely share and manage access to information in the healthcare system, it is essential to be able to authenticate users, including organisations and people. This is currently achieved through the use of digital certificates that conform to the Australian Government endorsed Public Key Infrastructure (PKI) standard.
NASH remains the national solution for the authentication of users and certificate management for those wishing to send information to the My Health Record and it continues to support secure messaging across health care providers.
In addition to the continued role of NASH as the national authentication solution there was also majority support for a national trust framework to support those suppliers wanting to use private certificates. This framework will provide the agreements and model required for vendors to trust each other’s certificates. This will also support the issuing of certificates for those organisations not eligible for a NASH certificate.
Although participants provided in principle support for continuing with NASH, participants expressed concern regarding the current system’s responsiveness. NASH does not adequately meet the needs of messaging providers and their customers; both the process to obtain a certificate, the time delay in certificate issue, and the problem rectification process. The Agency is working with the Department of Human Services to improve service levels.
The Agency has agreed that privately issued certificates have a role in secure messaging, where those certificates meet appropriate standards.
It was agreed that the decision to trust non-NASH certificates for secure messaging is one for industry to make with clinical input. The Agency has confirmed that it will facilitate a discussion with industry on a trust framework to provide assurance over the quality of the certificate issuance processes.

Agree the direction for the next phase of provider directory and addressing services

There is a base layer of data about providers that is being collected and maintained in multiple places across the health sector. There is significant duplication to keep this data up to date, and while it is required as a starting point to provide other services, in itself it is a commodity rather than IP.
It was agreed that defining this base level of data and sharing it was the right approach. The organisations present agreed to share this information through the APIs developed through the Technical Working Group and validated through the proof of concepts. This will allow resources to be applied to developing services and products that build on top of this foundation – which presents the ‘value add’ and competitive offering for industry participants.
The model to aggregate and assist the user experience in bringing together a distributed data set was discussed. A proposal was discussed, with feedback that it could be leaner than what was presented, and privacy issues were raised that would need to be worked through.
The Agency agreed to continue to work with industry and healthcare providers on the services that could support the distributed directory model. This will occur in parallel to messaging providers sharing base level data in their provider directories through the APIs already available.

Compliance and governance

Implementing the agreements of the day will require additional activities including:
-          Compliance tools and a compliance regime
-          The right governance at a program and industry level
-          Resourcing and funding support to achieve the vision
Signed etc.
Here is the link:
So there you have it. The facts are.
1. We don’t yet have a messaging standard.
2. We are compromising on message payloads.
3. NASH after many years is still a flop and we need to work out how to use private certificates
4. Overall directory services still need work to be integrated.
5. Compliance and governance need more work.
6. There are still a host of message destinations that are not digital messaging enabled.
We can safely conclude the fax machines are here for a long time to come!
Nice to see the communique was reasonably spin free and clear – as opposed to what the ADHA itself put out – the trust deficit just widens! Also it is good to see industry is working cooperatively - a very good thing indeed which hopefully means, in time, good outcomes will follow!


Anonymous said...

Industry has ADHA well and truely strapped over a barrel. Government will now be forced into a funding cycle it will never escape from. They smelled desperation and like any good guild used it to cement their closed vendor system. Interoperability, what a joke the ADHA has become

Anonymous said...

'... fax machines... can also cause patient harm.'
"In May 2018, a coroner’s report revealed that Hodgkin’s lymphoma patient... died alone following chemotherapy complications. His medical test results were faxed to the wrong number, which meant his treating haematologist did not receive information that could have saved his life."

Well really? We are blaming an individual fax machine for this patient's death?
If the patient was undergoing chemotherapy for HL, then he would have been on a very defined care pathway, and his haematology care team would have been proactive in chasing up his results would they not? Surely they would be aware that they had placed a pathology or an imaging order, and expected a result to be available. If it did not arrive, then they would make a call. (Hopefully they would not phone the wrong number when chasing up the result, otherwise the phone might need to be arrested as an accomplice.)

Sounds like a cop out to me. And even if that particular fax machine was guilty, then is it right to generalise and conclude that all fax machines would behave this way? Some fax machines may truly be trying to do the right thing.
For example, many fax machines, as we speak, are working hard - transmitting much needed current medicines lists to GP surgeries, hospitals and aged care facilities. These fax machines are saving lives!

Anonymous said...

This at least seems a step forward. It does seem a lot still to be done. The governance, operating models and roles and responsibilities will be interesting to watch unfold. A simple question to answer will be - who do you call if "A" goes wrong, if "B" fails, and so on

Peter said...

About five years ago, AusPost set up the "Digital Mailbox" system which provides secure reliable messaging for anyone who signs up. It can be tied to an email-like client or read/written by a computer system (e.g. patient records, clinic support etc.).
I suspect that setting up a restricted list of senders/recipients would be straightforward - say through some sort of Health Identifier Scheme...

The point being, secure messaging already exists, is already owned by a government department and can easily be adapted to purpose. Is it really necessary to re-invent the wheel from scratch just because the Health industry is so different from everyone else?

Emma Hossack said...

A couple of points to add to the conversation:
1. The communique on the status of this program was jointly developed by all parties present. ADHA was facilitator and typed and distributed it for comment. Those that left before it was finalised were then given the chance to review it & their comments were included. It was a productive day - an excellent and transparent process.

2. Good news is rare in interoperability conversations, so I can understand why people don't quite know how to react. This is however a positive step so give credit where it is due. Whilst cynicism is fair given the history of the health software industry with the Agency's predecessor, there is nothing to date in this process to indicate anything but a commitment to getting this right as a genuine attempt at co-production. Give it a go.

3. I am unaware of having the government over a barrel, or the said ongoing funding stream. To the contrary, everything that has been said and done indicate that those involved in the program are already finding the move to greater interoperability positive. Nor is the work entirely government funded which demonstrates a genuine commitment by the parties - all of which have skin in the game.

4. There is a way to go but there is at last trust and commitment. Optimism isn't a dirty word!
Emma Hossack
President Medical Software Industry Association

Anonymous said...

"There is a way to go but there is at last trust and commitment."
Emma Hossack, President Medical Software Industry Association

This seems like a reasonably balanced counter to David's comments.

BTW - "Optimism isn't a dirty word!" ... true, but it doesn't negate naivety.

Anonymous said...

Do we really trust this government?

tygrus said...

So it took about 18 months to organise a meeting to agree on standards that started more than 7 years before that. At this rate it might take another decade. I'll believe it when I see it.

Anonymous said...

If it took 18 months to organise the meeting how long did it take to agree on standards. The reason I ask is because reaching agreement is many times (say 10 times) more complex than the simple task of organising a meeting. 18 x 10 = 180 ... !!!! that's 15 years !!!!

Anonymous said...

Emma, when transmitting and receiving patient information over the MSIA agreed secure messaging, will my information be used the same way as Health Engine apppears to be doing? They are a member of MSIA. Just seeing if this is a benchmark going forward.

Anonymous said...

And no mention of the commercial model. Sender's billed, receivers billed, what will the interchange agreements look like. Until that is worked through, there is little motivation to open up closed customer networks, regardless of the co-produced technical solution. That model does not need to be public, but it does need to be consistent for a competitive and vibrant market.

Anonymous said...

"And no mention of the commercial model"

you mean - think it all through?

Come on, get real. That's never stopped the government before. Why should they change the habits of a lifetime now?

Anonymous said...

Commercial model - sounds like the barrel the government is being strapped to an earlier commentate mentioned. The Government will need to make sure this works.

Alternatively we could move on and deploy something from this century and open the market up to technology providers outside of ‘digitalhealth’