Hi Grahame,
I am going to say something cheeky here…it has little to do with luck it is just been down to a few clinicians refusing to say no for decades (since the early 90"s). Call us dogged and one eyed if you like but we have the framework for a common health record that gets 200,000 + accesses a month so we must surely have got something right. The thing HCP’s outside the SI don’t necessarily know it is all based on a privacy framework that means all those accesses are put thru an algorithm to look for inappropriate access and letters asking for help in understanding why the access was made go out regularly. Yep its a needle in a haystack because most all HCP’s don’t do that sort of thing. We have netted one HCP who fessed up when sent a letter and he / she was referred to the NZMC for action. I say to my patients when they ask how secure is HealthOne 'I cannot guarantee a suitably credentialed HCP will not inappropriately access your record but I will catch him/her and there will be severe consequences including notification of the action to you and the NZMC" Is that good enough I ask? I have never had a no.
There is absolutely no reason why the HealthOne tool cant be in the North Island. HealthOne uses all the components that you have in the NI. GP PMS’s like MT32, MT evolution, Indici and my practice all have the FHIR API’s built and talk to HealthOne. You guys have Orion’s concerto (HCS in the SI) and for the life of me I cant see why there is no HealthOne in the NI. We have presented to Wanganui and Masterton and the clinicians were keen but I can only say that I believe IT fiefdoms declared “we have something better” and they weren’t allowed to have it. All I can say to that is “so show me the something better” and the SI will go for that but there don’t seem to be any starters for 10.
Can we not get the clinicians in the NI to start a movement and get NI HealthOne done for the other 3million NZers . The patients would be so much better off and life for the HCP’s would get easier.
We know HealthOne is not perfect but its getting better every day and it is on FHIR with FHIR API’s and a Firestore for the data.
come on NI give it a push
sorry to rattle on. you can tell I an a zealot!!
@martin.wilson
Hi Martin. I have been trying to get this raised in various fora on the NI very little traction. So I agree we need a grass roots led major drive to get a NI HealthOne.
Cheers Inga
I couldn’t agree more, Martin! I know high profile clinical informaticitans all over NZ who have been pushing for this (@nigelmillarnz, @lara, @Mat, @searnshaw, etc) - but with exactly the types of push back that you and @i.hunter elucidate.
When I have approached Orion staffers about this, they have told me that it is technically feasible from their perspective - and even not that difficult. The problem is that no-one with the $$$ has asked them to do it, and they are a business which needs revenue to survive.
As far as I know its not about money. Most hospitals in NZ have Orion concerto (HCS) and GP’s pay for their own PMS’s. So is it a huge HealthOne cost? The answer has been addressed in the past and the cost was in the 000’s not the 000,000’s. In fact David Meates (CEO CDHB) has suggested to me in person H1 just give it to an area as long as their Orion product was up to date and they could help locally with the roll out.
I will see what I can do about offering it for a token fee but we need a huge clinical response passing up through the various IT local structures to just get it done.
How do we use this forum to get clinicians clamoring for this tool?
I work in a hospital clinic and in general practice and I always have H1 running. It is incredibly helpful when the patient is new to you, there is no eDS in your record, the patient has had labs somewhere else, the outpatients letter is not available in your GP PMS, when you want to see the next outpatients appt date, when you want to see prescribed and dispensed meds across the system etc etc. It is accessible in GP with 2-3 clicks in patient context. Max time to load (in patient context) that I have seen is around 4 sec and usually faster.
Remember this product is able to be scaled and already spans 5 DHB’s and 1,000,000 + citizens.
as a caveat here I do not have any financial interest in H1 but i do have a huge interest in patient care, Help me here Nathan how do we get NI HCP’s demanding HealthOne at very least on our network.
Why are we not clamoring - because we’ve always had different DHBs who have done this in different ways - the usual pepper potting around the country. So I’m not clamoring here, but other regions may be.
Not sure how may years ago this region went with MMH for sharing shared care record to the 3 local DHBs (Hutt, Wairarapa and Capital Coast). 8 years perhaps? How many years have we had one touch button to concerto from our PMS? 3 or 4 years? Now have Conporto instead of MMH, which picks up dispensing and anywhere the patient has had an interaction based on NHI. Its not a database, just finds interactions from various sources and amalgamates the view. One lab to rule them all - so one button acccess to that via PMS to order or view results…
Not sure what other regions have done, but its not as if its been a vacuum outside of the south island. Sometimes you’d think Canterbury is the only place that has done anything in this space… Kudos for the privacy framework, our relies on random and focused audits. An advantage of when we used MMH was patient could look at any accesses to their record themselves and ask the same questions of who and why. Sadly lost that with Conporto.
I was pushing very hard for national primary care dataset, and we thought we’d go that over the line only to fail at the last hurdle… Now technology moves on.
It would be interesting to see if clinicians from other jurisdictions tell us what access they have to patient information. Clearly Inga not happy in mid central. Clearly the big player would be Auckland with so much of the population up there.
As far at my area goes, with about same population as South Island, I’m not sure what more I’d get? We did it all on the smell of an oily rag. Of course things change, and it may be time to look at platforms at some stage, but right now focus is elsewhere which is understandable. I think once the local region gets off the ancient version on concerto then will be time to look at what modern API’s can do.
Hi Richard
You are right pepper potting had been the order of the day in the NI. MMH gives the hospital a view of primary care data in concerto right?
I am ignorant of what you have in the wellington area so I will just ask questions and make statements for confirmation if that’s ok?
Is the pharmacy dispensing seen in MMH? or only in comporto and is comporto available to HCP’s in some way so that GP prescribing sits beside pharmacy dispensing like it does in HealthOne? Or is it a separate thing? Is comporto storing the data or does it go find it from the source realtime and as such how does it deal with source outages etc? HealthOne finds storage is most reliable. I am assuming you can see the whole North Island prescribing and dispensing like we can in HealthOne.
Your one touch button in your PMS lands you in concerto in patient context right? I imagine you can see hospital appointments there.
You don’t have a privacy framework that enables all accesses to be assessed yet. Is there any plan to move to this because I would guess random audit will have as much chance of detecting a privacy breech as winning lotto? I saw Peter Hicks present at HINZ some years back (he was a lovely and great man) and his audit could not explain thousands of accesses. Your social licence is at risk here I would say.
I am sure you have material for patients displayed in waiting rooms in GP labs radiology etc to explain about information sharing.
You will, I imagine, also have a simple opt off process for patients like we have with HealthOne
Your lab results are available for the whole North Island are in an éclair (or similar) instance which is in your HCS like in HealthOne right?
I am assuming you have care plans and advance care plans generated in primary and secondary care throughout the north island and available in Concerto like HealthOne has.
I am assuming you have all north Island hospital letters and investigations (ECG’s scoped etc) in Concerto’s CDV tree like the South Island documents in HealthOne
Your integration will all be on FHIR now I imagine
I imagine all the regions patients are in MMH so you can see important information for those who don’t or won’t have a portal?
Better get on with patients but very keen to hear about your NI system
We in Canterbury are keen to learn if you have a better integrated view of the patient data than HealthOne because we would like to be part of that.
Cheers Martin
Richard, you are in a better position than I am, as a consumer I don’t even have access to a patient portal. In a nutshell, some parts are excellent, some parts are missing, and some parts are improving. There is a will to get things done but an invisible barrier seems to stop primary secondary data sharing.
sorry I forgot to ask Richard
When we set up the CBACS in the south Island we were immediately able to share the CBAC daily record to HealthOne like we do in acute care settings like the 24HS and several others in the South Island. We have always figured sharing daily records especially in situations of increased acuity is a good thing. Hospital Drs have been asking for this for years. HealthOne is working on trying to do this for all GP silos.
Do all your NI patients benefit from shared daily records (using the MT term here = encounter records) through MMH?
cheers M
It is a tricky one - we do have the ability to share what is written in the shared care record, and I have promoted that we should share for selected high risk patients with specific consent. For the majority of patients I’m perfectly happy getting the lab result of Covid negative - clearly if we didn’t do it then they’ve been to the CBAC. Its not many, we probably do about 95% of our patients in our wee Covid Cottage we set up.
We had a system in MMH called ‘request access’ where the another provider could request access each different part of the record, including what we write as well as labs, meds etc (Pre NZePS + Conporto). It was a great piece of kit that I promoted to the local hospices. They were rubbish at picking it up! It incuded messaging between clinicians and patient if patient on the portal. Perhaps it was becaue it was not integrated at the hospice end so they needed to use a browser. Anyway, it was disappointing that it was not taken up more widely. It was offered to private surgical hospitals as well. You set a time limited on access. So the hospital might ask for the preceding 1 month of notes + labs, meds, measurements and have access close after a month. Clinician had ability to accept or decline each part of that request and set the time frame.
I think having clinicians being able to access my complex patients notes would be great - see why I changed the ACEI or stopped the betablocker. See my thoughts about giving madopar to the patient with a bit of postural drop. Sadly the opportunity went begging. I think this is something we need to raise again. In many ways I saw this as more powerful than the whole shard care plan with all the tasks and goals etc - seemed the patient got lost amongst all the ‘things to do’. That was never fully implemented before we swapped out of MMH.
Patients generally fine with sharing most ‘data points’ but not what we write. Clinicians feel the same way. I’d favour opening that up on a case by case basis.
Our information management space on the shared record has been on a hiatus thru Covid - PHO busy supporting practices in other ways. We’ve also had IT team rebuilding our entire PHO IT infrastructure - which has gone really well. Kudo to the Tu Oral Compass team and Aceso. We go live with all the new reporting on Monday - really looking forward to that. Lots of power BI integration to our datasets. Once that out of the way and the dust from Covid settles time to refocus on shared care information.
Hi Richard . A reference to Indici sneaked in to your discussion. Has Indici replaced the majority of MT32 as PMS across the region or just your own practice which gives you all this wonderful access than we do not even come close to in Northland. Recently all resthomes appear to have been given access to CWS ( Concerto) at NDHB but I am unaware any GP practice has been afforded the same price ledge. We have testsafe access (Eclair) but no access to Radiology image(PACS). We do from Private Intelliviewer though. Our hospital sees a simple summary report extracted out of PMS by Whanau Tahi. Nobody engages actively with Whanau Tahi as when rolled out was no and not sure even as yet a single sign on. GP services poisoned by poor initial rollout so now difficult to engage them even when probable benefit to be realised . Poisoned chalice?
I have heard four Northern DHB ‘ through HealthAlliance NZ are looking at some form of regional shared care instance . Unsure what platform. Did receive note via Medinz that NDHB have installed Indici as the means to facilitate NZePS for hospital. Majority PMS in Northland is MT32 or Evolution. Maybe two MyPractice so again Hospital seems to have chosen a Primary PMS with no ability to communicate with majority of their regional GP services. Perhaps we will all be anticipated to change PMS to Indici. Not aware of any stakeholder engagement in this respect.
Hi Grahame.
When Tu Ora Compass selected Indici as the network preferred (not mandatory) PMS the PHO also switched over to using it as the base of the shared primary care record. It pulls primary care data from multiple PMS, including medtech. Our practice is on MT32 and all that functionality is there whichever PMS you have. Conporto is a Web scraper that collects info from multiple sources, including the Indici SEHR, abs displays in real-time. This includes hospital concerto. Currently 2cways of viewing hospital record. Personally I prefer the old way that skies concerto in an iframe within PMS with pass through of patient and provider credentials. Conporto does the same pass thru but reformats the concerto info. They are working to get it better, but filtering and presentation not ideal.
Tu Ora Compass has a real mix of PMS that we cope with just fine. Martin is right about FHIR and standards, I agree they are important to enable a multiPMS world. Practice owners should get to choose the most important bit of equipment they use! At the same time there should be a commitment from IT solutions to use standards to enable appropriate flow of information.
So if I understand you the comporting and Indici run the shared record view irrespective of the PMS chosen by the individual practice. Indici shared care record independent of its own PMs and Conporto the equivalent of the First Health concept of Babelfish some years ago. Essentially and translated that accepts and consolidates multiple API feeds into a single instance Which the is provider facing through the Indici Shared Care instance ?
Interesting. Thanks for the extensive reply below and I will look at it in due course. From a browse it seems your solution is at a district level not a whole of Island regional solution and it looks like it serves your local colleagues well.
As to sharing notes H1 ran a small survey and 2ndary care HCP’s wanting GP’s notes went to 30% of responders. This was much more than other requests for more data. There were no prompts just what else do you want in H1.
As you say I think what they were after was the GP’s wisdom in whatever was being discussed. H1 also want other HCP’s who do not have systems to come on board directly and share the encounter records. H1 vision was a full read write medical record and we are doing OK on this trajectory. The pandemic has really given this a shove forward and we have GP’s (as well ass urgent care facilities) now beginning to share notes.
more anon
• Is the pharmacy dispensing seen in MMH? or only in comporto and is comporto available to HCP’s in some way so that GP prescribing sits beside pharmacy dispensing like it does in HealthOne? Or is it a separate thing? Is comporto storing the data or does it go find it from the source realtime and as such how does it deal with source outages etc? HealthOne finds storage is most reliable. I am assuming you can see the whole North Island prescribing and dispensing like we can in HealthOne. In Conporto, not in MMH (MMH not the shared care record any more) GP prescribing sits separate to NZePS/pharamcy/dispensing data. Finds it in real time - not a database. Works really really fast. I can be typing my notes and the prescription appears in realtime in Conporto - freaky fast. You’d have to ask Conporto what the coverage is re pharmacies and practices, but it is used very widely. Its a Dr Info/Patients first collaboration. If its been dispensed we can see it - nationwide via NZePS. (Pharamcies upload to NZePS whther or not the gp sent it via NZePS)
*To be honest I would have to see it to understand it so I am better to describe what I see in HealthOne (H1). It’s very simple and is not dependant on other systems being “awake” at the time of the data request and it is standards based to be sure of interoperability. * Every point of collection is displaying posters and providing pamphlets on H1 and information sharing as required by the privacy commissioner’s office. This along with a website and the ability to opt off any or every piece of data is part of the H1 privacy framework. Opting off is a very rare event in my experience and would only be done after discussion with the patient (as we all know opting off on say a sildenafil script is a potentially dangerous thing to do but it is at the end of the day a patients right to do so). Every prescribing in GP in the south island is collected at the time of prescribing and likewise every dispensing is likewise collected at the time of dispensing and both are stored in the H1 CDR6 database soon to be in a FHIR store. All new generation PMS’s use a FHIR API to do the legwork and any new PMS vendor has a FHIR standard to build to. This puts an end to bespoke extractors which differ from one system to another. This data is displayed side by side in the medications tab. Metadata is collected so the dispensing pharmacy and the GP can be visualised on hovering. Data now goes back for many years now. Changing the data to confidential at source will remove the data (never seems to happen). Prescribing is mostly done from the MIMS database though there is a move to NZULM) the MIMS coding is captured so the data is not just TXT. Prescribed drugs are marked by colour coding by regular medicines if the GP uses that methodology.
• Your one touch button in your PMS lands you in concerto in patient context right? I imagine you can see hospital appointments there. Yes to both
*Excellent same as H1. * I don’t understand the two systems. Are you using concerto for the local hospital data such as appointments and Comporto for other data? Help me understand here. Two systems sounds unwieldly as opposed to H1 as a single system. Have you seen the screen shots I posted?
•
• You don’t have a privacy framework that enables all accesses to be assessed yet. Is there any plan to move to this because I would guess random audit will have as much chance of detecting a privacy breech as winning lotto? I saw Peter Hicks present at HINZ some years back (he was a lovely and great man) and his audit could not explain thousands of accesses. Your social licence is at risk here I would say. You may be right, I do miss the pateint as auditor aspect that we had with MMH (if thy were on the portal). It does log all accesses, so what you right is not quite accurate, it doesn’t have the sophistication of your proximity alerts. Framework in place regarding access. Gernally open with access but all that do access aware of consequnces of incorrect access if they are caught. I think its better chnae than wilnning Lotto. Good question to bring back to Conpoorto re how this proximity alerts is going - what can they add. H1 believes the privacy framework is like the foundation of a house and we in Christchurch have found the serious consequences of not building our houses on strong foundations. As above the patient has the power to see the sharing is happening and to speak to a GP or the full time H1 Privacy officer to understand what is shared and to block part or all of it even after the fact. H1 believes it exists because the public allow it and we call this our social licence. Nothing that could destroy the social licence gets through. I believe we would be totally exposed if we didn’t have this sort of framework. We would only need a breech by some idiot HCP (as you say almost all HCP understand privacy) to be exposed and for the privacy office to come down on us like a ton of bricks.
• I am sure you have material for patients displayed in waiting rooms in GP labs radiology etc to explain about information sharing. Clearly you just being provocative there, yes we have posters and broches and an enrolment form. Which they never read. And in fact the idea that any poster/brochure could actually say where your information goes is pretty naive - they all play lip service. The information goes far and wide every consultation we do. Planning to write it up some day and perhaps present at HINZ or similar - its mind boggling how much data goes. (hospital, regional public health, labs, ACC, MSD, PMS in cloud, Pharmac, pharmacy, simple, toniq, Healthstat, PHO, medsafe, private specialists, email, shared record Not at all provocative on this one…see above. We have the privacy office’s opinion on what is required and we deliver that. The HCP signs a contract which amongst other things required them to display the posters and info pads. H1 is very canny in where our patient information goes. Happy for it to be displayed in another system if the HCP using it has fulfilled certain criteria that indicate he / she is caring for the patient but it does not transfer to that system
•
• …
• You will, I imagine, also have a simple opt off process for patients like we have with HealthOne yes - phone or email or ask practice. Can’t remeber how many opted off, very few ( way less than 1%)
• It’s good you have opt off. Does this go down to the data level like it does in H1? Say a single classification if the patient demands that even after being advised?
•
• Your lab results are available for the whole North Island are in an éclair (or similar) instance which is in your HCS like in HealthOne right? Not for all north Island - we use SCL - not sure how far they go. In ral case use how often do you need wider than your region? May be differnt in hospital land, but with GP2GPO and access to a regional record I have NEVER needed to go wider. Interesting how experience varies. H1 has all the South Island in éclair including both radiology and labs. I find it fascinating how often I use data from other parts of the Island in caring for the patient. It is all about the patient journey and not wasting their time or causing them pain, along with not wasting precious national resources. In the USA studies about repeat MRI’s demonstrate huge wastage in unconnected silos. I am not suggesting we are like that with the big tests but many repeat tests are about not having access to the most recent one. If you have all the SI results available in H1 as a HCP you tend to look at éclair rather than your subset in your silo. I suggest if any HCP had the national lab dataset they would use it but if it’s not available they have learned to work around it. Let’s get together to achieve this end point.
• I am assuming you have care plans and advance care plans generated in primary and secondary care throughout the north island and available in Concerto like HealthOne has. Sadly not, we swtiched shard care provider from MMH just as we were about to go live. Isd being worked on currently. H1 has these in HCS (concerto) and HCP are funded to produce them. We believe the fact that an Advance. Cp says the patient wants comfort care after their MI aged 90 then uprooting them from a safe caring home and rushing them to a hospital can be avoided and it is the patients will that this be so. In the cliché it’s a win win
• I am assuming you have all north Island hospital letters and investigations (ECG’s scoped etc) in Concerto’s CDV tree like the South Island documents in HealthOne Nope - again would be nice but in ral day to day use not mission critical for 99% of the work we do. When you need it you need it. After all with your own patients you have a fair bit of the data in your silo but I used to find it frustrating when what I wanted was not there and information about an event outside your DHB such as at the other end of the island can often be of use. Could be you learn to practice without it. For example I now look at my practice pre H1 and wonder how the patients put up with it. On the exceedingly rare occasion when the Orion platform goes down it is minutes before the H1 service desk phones start to ring
• Your integration will all be on FHIR now I imagine Ask the architects, don’t rally care as long as it works. They can use what is there - clearly FHIR as a standard would be great, but really Martin - most practitioners will have no idea what you are talking about and won’t give a brass razoo. They will when they can’t get their new XXX (say specialist system) PMS to integrate because it is too expensive. FHIR standards are the underpinning of any modern system. It’s like the English language is predicated on the Latin alphabet. You could probably do it another bespoke way but that would be hugely complex and expensive. When a new XXX wants to integrate with H1 they get sent the “alphabet or perhaps plug wiring” and they do the work.
• I imagine all the regions patients are in MMH so you can see important information for those who don’t or won’t have a portal?
*You don’t have to be registered on portal for the info to go up. The info goes up to Indici shared care record and conporto picks it up from there. That’s the same as it was for MMH. Portals are great, you guys should catch up, but patient doesn’t need to be on portal. Not sure of latest data on regional portal enrolment, but it many regions have been painfully slow at promoting such a useful patient centred tool. So around portals the SI is behind because H1 have the view that a good patient portal has both secondary and primary data and H1 is now beginning to look at populating secondary data into the primary portals using FHIR. I would be very concerned if we were doing what you are doing without a privacy framework and allowing opt off. I am assuming what you are doing is predicated on Medtech and Indici having an agreement but without a privacy framework I would be concerned. I guess I would have to say that having a future that was predicated on a PMS vendor would concern me as by definition vendors are beholding to their shareholders and are profit driven
• Better get on with patients but very keen to hear about your NI system Happy to share. Hope its not patients anymore 630 time to knock off! yep evening surgery We in Canterbury are keen to learn if you have a better integrated view of the patient data than HealthOne because we would like to be part of that. Not sure its better integrated, but it works. Was low cost, has been running for years in various guises. Yours works for you, ours works (largely) for us. Is it perfect - no. Will it always be the solution - I doubt it as technology changes. If we did change would it to be a central database - not sure - ask the architects but it doesn’t seem to be the direction of travel HealthOne was also done on the smell of an oily rag and now has around 200,000 accesses a month. This figure just goes up and up and has done so for years. We must be doing something right. The last workshop we had around the future vision for H1 was a single read write record for the south island (or anyone else who wants to come along) and as each day goes by we creep towards that goal.
