This appeared last week.
First we have this:
'Faxed and refaxed': AMA claims poor interaction between GPs and hospitals in Victoria jeopardises patient care
The doctor's group says it is "scarcely believable" that many public hospitals rely on faxes and has urged the state government to act on upgrading communication systems.
By Lynne Minion
April 28, 2022 02:55 AM
The Australian Medical Association has claimed that “chronically poor” communication between general practitioners and hospitals is putting patient safety at risk, and called for the Victorian Government to fix the problem in the state's health system.
In its submission before the state budget to be delivered on Tuesday, the AMA said it is "scarcely believable" that many of Victoria's public hospitals continue to use fax machines, contributing to concerns over quality of care.
"This chronically poor interaction results in significant problems in many areas including safety, equity and access, gaps and duplication. With respect to referrals, it is scarcely believable that many public hospitals continue to rely on facsimile (fax) as a mode of communication. This results in both clinical governance problems (lost referrals, lack of accountability and audit trails) and efficiency issues (hundreds of pages printed, faxed and refaxed)."
The doctors' group recommends the government mandate that "all public hospitals develop a single point of contact to receive electronic referrals sent by GPs" and ensure that "electronic referrals are able to be received directly from GP software".
WHY IT MATTERS
The submission said general practice "shoulders over 90 per cent of the healthcare burden in Victoria" but is "regularly and profoundly neglected by [the] state government, to every Victorian’s detriment".
The AMA urges the government to invest in improving "the interface between general practice and our hospitals, both public and private".
More here:
Communication rift between GPs and hospitals puts patients ‘at risk’
By Aisha Dow and Melissa Cunningham
General practitioners say people are getting rejected for surgical procedures for “arbitrary” reasons, medications are being changed without their knowledge, and in some cases, hospitals are failing to notify GPs when their patients have died, and that the poor or delayed communication is putting patients at risk.
In a submission to the Victorian budget, which is due to be handed down early next month, the doctors’ group is calling for a “division of general practice” to be established.
General practice is typically seen as the purview of the federal government, which partially funds the private sector via Medicare rebates. But doctors have argued the COVID-19 pandemic, an ongoing crisis of delayed care, and increasing numbers of sick patients have highlighted the need for better collaboration between the state and federally funded parts of the health system, including GPs and hospitals run by state governments.
The Victorian government funded GPs to help vaccinate those in vulnerable communities during the pandemic and a state government spokesperson said “work is already underway to strengthen these relationships further as we shift to living with COVID”.
That work includes a new GP advisory group being established by the department.
Australian Medical Association Victoria president Dr Roderick McRae welcomed the advisory group as a “first step” but said he stood by the need for a new unit within the department focused on how to better integrate primary care with the broader health system.
Some public hospitals continued to rely on fax machines to communicate, the association said, resulting in lost referrals and hundreds of pieces of paper “printed, faxed and refaxed”.
More here:
As you will notice the enemy would seem to be the fax.
With this, others have a different view:
Reader Comments
From Down Underware: “Re: Australian Medical Association. Wants hospitals to eliminate fax machines to improve communication and patient safety.” Banning fax machines would most likely cause communication and patient safety to tank in the absence of solid interoperability. The market will gratefully accept a substitute that checks these boxes and is documented to improve cost and outcomes:
- Faxes are universal. You only need someone’s fax number, not their permission or prearranged terms, to send them something and then walk away.
- They are cheap, easily maintained, and never go down.
- They can be used anywhere there’s a copper telephone wire even in the absence of broadband or cell coverage.
- Issues of sending and reading protocols don’t exist – the piece of paper on one end pops out as piece of paper on the other end that doesn’t need to be printed as an extra step. What is sent is exactly what is received, with no chance of misinterpretation or sender technology changes that render the information unreadable.
- Delivery is immediate and verifiable.
- The recipient is more likely to notice a new paper popping out of the fax machine than an on-screen alert.
- Fax machines don’t host viruses, there’s not much hacking risk, a malicious fax can’t take your network down, and incoming faxes are as secure as the physical location they are sitting in.
Here is the link:
https://histalk2.com/2022/04/28/news-4-29-22/
To me there are 2 points here:
1. The fax will only die when the replacement(s) really work.
2. Right now we are only part way rhere!
What do others think?
David.
17 comments:
But what's the problem? Technology?
A fax machine is technology. Replacing a fax machine is pretty easy. Just take an image of the fax and send it by email.
It could be compared with replacing land line phones with mobiles, which has happened quite seamlessly, although mobiles can have problems during emergencies.
Of course, the problem isn't really technology, it's communication at the clinical level. And that's much, much harder. The solution is usually presented as "interoperability" but is it really?
Is interoperability the same as being able to talk in English to someone who only speaks (say) French?
If not, what is it? Is it just a standard way of sending messages between two people who already speak the same language? If so, is the value (whatever that might be) worth the cost?
I suspect that it's been a long standing problem because it is ill defined and conflated with a change in technology. Everybody seems to agree its a problem, they just don't actually agree what that problem is.
The fax is like Churchill is supposed to have said (but didn't) of democracy.
Democracy is the worst form of government, except for all the others.
> Just take an image of the fax and send it by email
Indeed that would be much easier but there is a uniform prohibition observed across the healthcare system that no real healthcare information is ever sent by email since it's *not secure*.
In the past, that made sense, actually - when first introduced email was insecure, less secure than faxing. But after decades of experience with what can go wrong with faxing, and decades of improvements to email security, email is now much more secure than faxing, and we could pass a rule that it's fine to email healthcare information as long as the email is sent directly to the recipients server, and the server applies some basic security (all this is stuff worked out to reduce the spam problem)
but there's never been any energy to enable a general simple approach like this when we can chase more ambitious solutions that involve more change and more benefit. Seems to me that we should acknowledge that email is a low hanging fruit worth chasing, but I haven't found any decision maker willing to take that challenge on.
"Seems to me that we should acknowledge that email is a low hanging fruit worth chasing, but I haven't found any decision maker willing to take that challenge on."
Sounds to me like the sales-folk have got to the decision makers - think Aspen Medical.
There's not much money to be made from low hanging fruit.
I think it's not quite so simple as that, but it's certainly an element of the stake-holder consideration
How time flies, seems only yesterday fax bashing was the in thing, and yet here we are again, lost for answers? Let’s roll out the proven ‘blame the fax’. Interesting no mention of the people and funding factors. Regardless of the means of sending information a person still need to press send and a person still needs to bother to read the information. I am sure for less than a cost of an EMR money could incentivise the recording - sending and acknowledging receipt.
Still easier to shout at a machine these days. Bit like how companies blame you for climate change.
Its a little hard to believe we are having this conversation yet again! We have gone from semantic interoperability to emailed images of documents being the way to go. The AMA is clueless on almost everything these days and is not a useful organization, which is reflected in its low membership.
The issue with emails, which we have had implemented for decades ( eg "Argus Interoperability" which never really worked in a scalable manner and is now gone) is that there is no automatic import into PMS systems so its almost easier to scan the paper into a PMS system than save an attachment and do a clumsy import and select the patient it is for.
What we do have in a scalable manner is pathology in HL7 v2 which can, and does include atomic data at a basic level, and can have semantic data at a high level if the sender and receiver comply with standards. However you can rapidly move clinical data with automated import in HL7V2 messages now, warts and all and denial of the fact that can and is happening now is beyond belief. I suspect the Victorian public system, like most public health systems just doesn't have a clue and has spent millions on consultants that also don't have a clue about anything other than how an expensively suited consultant impresses clueless administrators and allows them to extract lots of $$ without delivering anything that works. The pathology departments of most State Health systems are probably (well certainly) doing it at a very average level of quality, but the clinical side of those health systems would rather spent hundreds of millions on non compliant systems that don't work and will probably never work.
Trying to talk to anyone sensible or with any depth of understanding in these state health departments is like getting support for a bad phone line from Telstra, although sometimes you can get problems fixed with Telstra, it just takes hours and hours to eventually get transferred to someone who knows anything. I have serious doubts that person exists in state health departments. The pathology side just tries to keep a low profile just in case the higher up IT gurus try and come and help them out, which is their greatest fear.
In some ways there is 2 much funding, which just attracts predatory vendors, rather than someone saying "How do pathology and radiology get their (often more complex) reports out, maybe we can do what they are doing?"
The solution of course will be to move to a new technology, that is not implemented to any significant degree at end points, but will "solve" the problem. We have solutions that are actually working, despite a complete lack of compliance testing and focus on quality, but so much domain knowledge and expertise has been lost by the endless wheel spinning by Healthconnect, Nehta 1 and 2 and ADHA that many with expertise have retired or walked away in disgust. The problem appears to be, as Ronald Reagan said were the scariest words in the English language: "I am from the government and I am here to help"
I'm sorry to derail the discussion but the PulseIT Saturday blog is so often a bully fest. I had hoped that Clan William buying the publication would change the tone and introduce a new era of objectivity, but the nastiness continues. So many terrific companies work in the digital health sector and do the best they can for people in the healthcare system yet there is this takedown/power thing that's been going at PulseIT for years. I've seen emails from there sent to people in the industry that are concerning. Why do we subscribe to and advertise on a platform that is so often mocking and hostile to what we do? It's so disappointing and shows the problems with monopoly
Might be Andrew that this conversation needs to be had again and again to slow some down from committing Australia to secure PDF messaging which will prove difficult so plan B is adopt GIF.
Why Grahame is suggesting email? He is correct that family of standards is petty good and might be the best to evolve from. I am not convinced the ADHA continued efforts to deliver secure messaging (no matter how often they rebrand it) will work. It the wrong approach lead by the wrong people IMHO.
G. Carter I'm torn about it. It feels stupid to suggest email, because if we're going to do something, sure we should do something that moves the needle further than just going from faxing to email. That's the prevailing wisdom, and I kept thinking that was right.
But we're still using faxing. The transmission is secure, sure (we trust the carrier) but Telstra recycles fax numbers and so faxing is *not secure* period. And it's not efficient either. So anything is better than faxing. And going to email is a small step. So the last couple of years I've been thinking that we just should, to get relief from the faxing problems for the users, since we don't seem to be getting anywhere from their point of view. Of course, it gets us less.
Except, in a way, it gets us more. If we could just email each other securely, we have a delivery protocol that's widely supported, and that allows us to gracefully add structured content. I think that's a kind of easy path. Maybe I should've pushed this harder earlier? Or maybe it's good that I didn't? I just don't know.
@11:45AM What I find quite troubling, indeed extremely disconcerting, is that on reading your comments it would seem that you ( as an 'expert') are now having grave doubts about your earlier views . I have to conclude that you are not alone. Having said that I wonder if you and all those other techy-focussed 'experts' were driven by and too enamoured with the 'technology' instead of being more focussed on the problem. The engineering types have been trying to point out to all the enthusiastic techies to first focus on, analyze and understand the problem rather than push technology for technology's sake.
I don't know that I'd call them 'grave' doubts, but sure, I'm wondering whether it was the right strategy. Though I haven't found anyone else asking the same question on this one. The consensus that we needed secure messaging was deep and broad and was driven by business and political considerations, not technology.
This bit is weird: 'engineering types have been trying to point out to all the enthusiastic techies' - the engineering types are the enthsusiast techies in my experience. But... I don't know anyone who thinks that technology is the thing for it's own sake. What I have seen repeatedly is that (a) a technology change is something that is generally non-controversial and also concrete, so it often becomes the stalking horse by which culture and process changes are introduced by stealth, and (b) forging consensus us *very expensive* (much more expensive than anyone, including the participants, can estimate), and changing a forged consensus has additional costs, so once you have a working consensus, it will ensure longer than it should in the face of objective reality (see the conduct of our elections for evidence)
> I have to conclude that you are not alone
I'm not aware of anyone else inside the process (Inasmuch as I am inside it) that thinks that we should try and use email to replace faxing, or even wonders whether that would be a good idea, which is where I am on it.
What else is on offer Grahame?
If the data within the information sent is simply read by a human then fax and email type protocol are fine, but what if the target was injection into workflows or into a rich information system.
Things like secure messaging and the stigma of emails are based on thinking from a simpler time. That is the problem with ADHA, they are stuck basing their thinking of specifications developed pre iPhone.
> What else is on offer Grahame?
well, if you want to support workflows, then you need something more than emailing text + PDF attachments. Which leads us to secure messaging, or even better, an actual API that can be documented and orchestrated. That way, a clinical use case, a clinical flow, can be turned into a set of technical exchanges that achieves something other at the computed level, not just humans causing each other work
The problem is security; health has a rightful minimal expectation of privacy that email didn't seem to support, so it never really took off - no PHI over email, that's the blanket rule. But email changed a lot over time. And the other approaches turned out to be expensive to implement (direct in USA, secure messaging here) and we still haven't got to ubiquity even in a narrow context, let alone scaling it up to all of healthcare.
In principle the choices are
* sending bits of paper around (still happens, waiting a week for a prescription from a speicalist)
* faxing images of paper around
* emailing images of paper around
* sending structured data via email
* sending structured data via some secured push exchange (SMD or direct (secured email) in USA)
* putting up an API (my personal preference, just suck it up and put the infrastructure in place so that every player has an API, which is the US choice)
I doubt there would be more than a handful of GP practices that do not receive HL7V2 pathology or radiology reports via secure messaging in Australia. The complexity/atomicity of that data, while not as good as it should be if much more complex than the needs of most clinical data. The quality of the HL7V2 is not checked by anyone other than messaging companies, who have limited ability to demand higher quality, but despite that its scaling to the whole country. In reality it is an API, create a message, address it and push it to the recipient. HL7V2 is often considered a document format, but it does support complex workflows, its just not taken advantage of in many cases.
It does support encapsulating pdf documents and having them automatically imported into PMS systems, directly into the patient file, which is basically the equivalent of faxing or emailing, but the workflow is integrated. The semantic side is lacking, but that is available without changing that API as the format supports semantic communication. To go back to automated emailing destroys the automated handling of documents at the endpoints and is nonsensical.
Getting anything working at scale requires infrastructure like PKI infrastructure, provider directory and routing directories and those exist (At least privately). What is lacking is quality content, hence the HL7v2 wrapped pdf documents, which at least import without manual handling.
Considering the complete lack of useful help from government who have not managed to solve any of the infrastructure issues despite about $3billion spend, its managed to deliver electronic distribution of pathology and radiology. Much of the clinical documents are also being sent this way, that is our core business, but its seems some like to deny its happening, we need to just get the ADHA out of the way. Content quality is an issue that will not be solved by saying "use FHIR" as good quality FHIR is as hard to get as good quality HL7V2 and we already have poor quality HL7V2. It is a much shorter path to get clinical HL7v2 up to the (somewhat average) quality of pathology and radiology HL7v2 which is working currently.
The focus on interoperable messaging is silly, first we have to focus on interoperable messages that work without a lot of massaging by messaging systems. The quality of the content is critical, not the format. Non compliant FHIR will cause as many problems as non compliant HL7V2. We have already seen that, and FHIR has a problem with lack of backward compatibility, that is less pronounced with V2.
Perhaps we should go back to discussions from 15 years ago about email messaging vs direct messaging rather than restarting them. The elephant in the room is quality of content. The elephant is getting quite old and is in danger or dying from old age. The government have failed to provide the infrastructure or compliance testing that enables interoperable messaging, but they are no closer to solving (or even understanding) that than in the year 2000, which is a sad observation of their abilities and the elephant cannot attract their attention, lets hope he decides to sit on them.
I said "we still haven't got to ubiquity even in a narrow context, let alone scaling it up to all of healthcare". Andrew talked of lab delivery, and that's the narrow circumstance where we have got close to ubiquity. But even then, there's no general 'any lab can deliver to any GP'.
All that Andrew said id true, including about quality. Fixing quality is *hard* and it's a long term journey that we have to go on. We id some work 12-13 years ago that lead to a profile I wrote up for MSIA but it never went anywhere, so we're still stuck relying on the messaging vendors (which is the other way in which we haven't got ubiquity)
"Non compliant FHIR will cause as many problems as non compliant HL7V2. We have already seen that, and FHIR has a problem with lack of backward compatibility, that is less pronounced with V2."
On the one hand FHIR is being heavily promoted by some of the major vendors. This could be a good thing as it will serve to entrench FHIR far and wide. However, although FHIR is still in its infancy, if non-compliance becomes the modus operandi of the vendors combined with a lack of backward compatibility, we could find that the issues which exist with HL7V2 are relatively minor compared with FHIR when FHIR becomes even more widespread.
It's certainly true that non-compliance will be a problem. But it'll be a different problem in nature than with v2. Many of the problems with v2 arise because of syntactical issues with the v2 encoding that simply won't arise with json or xml. Other problems arise from the lack of open infrastructure back when the vendors first laid down their v2 infrastructure. In particular, the lack of formal validation. We've invested deeply in that in the FHIR project, though of course, vendors have to use it - security and quality remain economic challenges for the market. Other problems are caused by squeezing ever more complex information into the tired old v2 syntax (which is a key driver for FHIR, e.g. the FHIR SDC and IPS specs)
But the problems around inconsistent business practices and poor data in the databases, because that's what users want to enter: they're not going anywhere, and they're the ones we will have to invest in if we really want something better than paper to be fairly widely adopted.
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