This is actually a series of topics and each needs considering separately
Quick history.
Frustration of ADHB clinicians not able to view Canterbury data, especially metabolic
Midlands clinicians needing view of Starship data
What Do we want
Single medication list
Single opinion list
Vision
Patient record - viewable by all clinician involved and settings Single, long term longitudinal record
Standards based
Open API
Vs what can we solve - best thing to do with what I have
Start what you can do.
Single next step
Link four portals
view of DHB only
view of GP next
Then contribute
cognitive of the impact on other projects as it might corner us
Hey Nathan Definitely feeling sad not with you all today Looks like great conversation.
Was patient portals mentioned? For me, Iām increasingly thinking this is vital. As a āsingle next stepā, what would be the next step to add to patient portals? DHB view of DHB appointments on patient portal? Something?? What feature could be brought to patient portal, so clinicians were asking patients to look into their portal . ā¦ thus, forcing clinicians to engage with patient-controlled data, and empowering patients? I appreciate there is much to work through (not least of which is rural connectivity, etc . . . but near everyone knows what Facebook is now!!), but I feel the patient-facing side should be a starting point, not after-thought.
I am convinced the future of the single, long term longitudinal record (or at least comprehensive care plan), must be centered around a patient . . . and for me, this means patient portal.
I totally agree Emily. However in reality, the clinical risk for clinicians not being able to view cross regionally is a big and daily issue. And within some regions. For us in Nelson Marlborough it is mostly the Wellington hospitals in particular that are flying blind when they admit our sickest patients. So my take on the desperate call from the North Island is that;
Things are very unsatisfactory as above
At least we all have Orion core platforms
THis has been modelled already (across the SI and elsewhere to varying degrees)
Stella Ward from CDHB is already leading some work here
THe patient portal issue is confounded by:
Multiple GP PMS vendor portals (2 main)
Variable uptake across the country
No common platform
No integration to achieve the āhospital appointmentsā and other aspirations.
No intrinsic messaging (in patient context) within the hospital / DHB sector to leverage and no workflow to support this in those systems.
I think setting an objective where some progress is possible in 6/12 window is good for morale! I wholly agree that we need always to reference our decisions on their relevance to the patient-centred vision we have as our goal.
Agree Emily - but as bev mentioned kind of two arms to same end goal, - full longitudinal notes at available point of care.
I am certain the value for Primarycare in the future will be via a functional patient portal. Sadly I dont think everyone in primary care understand this yet.
The essence of good primary care is long term person centred relationship - ie not hospital based episodic or SODs (single organ doctors). Many times patients of mine have logged into their portal, and shown results/letter to a specialist from their ipad, what better way to have patient empowerment!
For myself having full open notes has been fantastic for this, and I came away thinking I need to promote what it is and isnt more as there where some incorrect assumptions around.
But then their many who just assume the doctor in waikato ED can see all your kids operation notes from starship last week. As for joining the four regional Orion portals - that has to be a good step to getting a full provider centric record - which can only helpā¦ but as you say we also need to concurrently develop the functions for a patient portal - eg having outpatient letters CCed into patient portal rather than mailed ( which I currently do by simply having open notes! )
No, we didnāt include patient portals in this topic - but I think that we should have as they need to be deeply connected to all the parts of our healthcare spectrum as part of the whole data flow / interoperability picture.
We discussed it and as Karl put it and we have it in the BIG vision
What we are aiming for is a person centred health record that is viewed and used in all clinical settings.
Ie we have decided to look at the sillyness of the word āpatient portalā and reframe it
And we want to start looking at the record for a different point of view - the person - rather than the clinician
But as Bev said thatās too far to get to this month, so we now start where we can and our first pragmatic step is to now increase the sharing from āwithinā our regions to ābetweenā our regions
Yep I agree with the what we want statement. Single list of meds allergies and opinions
However I am not sure with the MOH view that we are now going to continue to have a number of portals which are federated in nature and then the set of portals are to be themselves federated. Sounds like a complicated future and if it is to work at all it will need to be FIHR based.
Anyone know how I attach a document?
Cheers M
New to forum . Recent rural workforce summit question was asked . Why just health one south? What stops Healthone North and Health one National if most DHB on Orion and South Island already have shared primary secondary view plus acute and long term care planning already developed within Canterbury ? Northland now making Whanau Tahi patient portal open to patient and provider and provides hospital with LT Classification, LT medication , allergies and alerts plus view of care plan. Previously care plan only upload via GP now patient can directly contribute . Priblem for Northland Primary Care is already alienated from Whanau Tahi by poor comms and rollout and no single sign on from PMS . Currently single sign on being addressed at significant cost. Hospice have Palcare , resthome have E - Care now and 1 chart and the primary can view testsafe all requiring a step outside PMS and no co ordination.
I like the idea of Healthone National, as long as this is a single federation data-bank that multiple interfaces can integrate with (presumably FHIR APIs). As a reasonably happy user of MedTech (because of current usability), MedTech has huge innovation limitations because of itās (mostly) monopoly: though useable, itās usability is static. In the US, Epic has similar limitations . . . if you are only in the Epic-world, things are ok . . . but that means everything is dictated by Epic, and as it gets bigger, modifications are much slower to occur. A future would be to have a national data set that directs and promotes co-ordination of MULTIPLE innovative interfaces/platforms (like Whanau Tahi) that ensures diverse patient and provider (including resthomes, hospice) user interfaces. This is where āshared careā may actually occur and break down the current problem of a patientās data being spread across multiple EHRs.
A primary care example: If we want to run a collaborative service across multiple GP practices, all of which use MedTech, we currently will have to log in to each individual MedTech server to access and add to a patient record. A clinician running a service that includes patients from multiple practices, will be working across multiple MedTech records. Then, to understand what the collaborative service is actually doing, data will have be duplicated into a separate MedTech system that is for the collaborative service. Yes, there are work-abounds, but they arenāt great: one of the practiceās MedTechās could host the ācollaborativeā service . . but then, the ācollaborativeā work becomes hard to separate from that practice . . and it quickly defeats the purpose of collaboration.
Hereās a workflow that needs fixing, because itās taken 20 + minutes of my time, and wasted lots of other resources. It is an excellent vignette of the need for interoperability across platforms + secure Instant Messaging thatās integrated to a patient file (to ācircle of care collaboratorsā AND patient):
I, GP, simultaneously gets 1) unsecure email from patient; 2) letter addressed to me (GP) from external DHB providing specialist care for patient. Both sets of information request me to perform scheduling task.
Email from patient reports that the last time surveillance imaging appointment occurred, that I had request at the direction of external DHB, the patient was in the scanner, to be told that it would not be completed, because another specialist had just arranged a scan 6 weeks prior, so it was unnecessary!! (pt didnāt realise it was same request, just assumed needed another scan and dutifully attended appointment . ā¦ . he has high health literacy).
At bottom of this email, is email to patient, from a registrar, stating āI have requested next scanā.
ON SAME DAY, I received PDF document as RSD into patient record (MedTech), addressed to me (GP) asking me to request the next surveillance imaging (presumably because itās external DHB, so canāt request directly to our DHB?!?).
So, I have spent 20mins, unclear whether registrarās statement of āI have requestedā means theyāve done this OR they have requested by writing the PDF to me, asking me to do it. Because trying to establish communication with the registrar will not occur in the next 20mins as Iām trying to work through my inbox, I am requesting the imaging myself. To do this, electronically, I have had to manually download and save the PDF letter because our e-radiology request system cannot pull RSD PDF files from MedTech. Iām also needing to reply to patient to apologize for unfortunate experience of being in scanner, to be told it wonāt proceed, and ask patient to contact scheduler by phone during working hours, to avoid this. . . because I cannot offer to be ringing schedulers during working hours. I then manual copy and paste my email correspondence into the patient record.
I dream of a day, all of the above is securely automated and GPs no longer are asked to be the scheduling assistants between DHBs and patients!
Recent Clinical Governance agreement across 3 Auckland DHB around suggested guideline around appropriate handover between providers and where responsibility lies . No generic GP to follow up or organise. No hand over of responsibility from person requesting or ordering test or care plan without clear consent of patient and destination provider. Was also discussed at National PHO Clinical Leaders meeting. If we can enable these guidelines to become national standard then some of this workflow challenge should settle. Agree we are not,here in Primary Care , a default house officer for hospital colleagues managing their scheduling.
In CDHB we have been working on a similar agreement re principles of Transfer of Care, copying in to results and requesting GPs to follow up or set up investigations. As a GP, the principles are very appealing, clarifying the lines of responsibility and drawing a much needed line in the sand about work flow shift to primary care. My concern comes from my experience as a GP liaison and the realities of work flow and personnel flow in busy hospitals. An example of this would be a follow up chest xray 6 weeks after a respiratory related admission. In theory, it seems reasonable to say-you want one, you order it to secondary care. The problem is that doing this sets up unacceptable levels of patient and clinical risk.
6 weeks after discharge, 50% of the time the ordering RMO will have changed to another run/region/country. They have no ongoing relationship or practical responsibility for patients they saw on a previous run. There is no alert system which would tell them that the patient did not turn up for the xray. There is no facility for them to refer to community providers to have the xray done, which makes it all the more likely that the patient will not turn up. They have no ongoing clinical relationship with the patient so will be unaware of subsequent clinical, social or geographical changes for the patient and may not even be able to find the patient to follow up on the result. They have no wider understanding of the patientās health issues which would allow them to interpret the result in the context of the patientās comorbidities. They canāt even bring the patient back in to discuss the result. All this if we could persuade them to add this extended follow up to the existing task list and responsibilities. SMOs who will all tell you that changing RMO behaviour or mandating any specific work flow is really difficult. Any GP can tell you how often discharge summaries fail to arrive and this is a mandated core task for RMOs.
The principles are great āin principleā but they have some serious risks if applied to imperfect, human and technologically integrated systems.
Hi Emily
Not really an IT back office champion but agree there seems great opportuniyty with colleagues on forum to drive this. Somehow need some government direction to players like Medtech to overcome the monopoly bullying around pricing here
Grahame
Greetings Rose
Thanks for your thoughts. We are all busy in the health space. I have a significant patient load with all the inherent investigations associated . Unfortunately we do not get the dedicated non patient clinical contact time that the MECA ensures for hospital SMO and RMO. Surely there should be a requirement of the hospital for escalation of any action up the hierarchy if not attended or result not signed off. If I am away on leave I am required to ensure my results and action are appropriately delegated . The difference in behaviour ,the principles should support ,are as I see it , an appropriate delegation of the required care . If the SMO /RMO sends a notification electronic or hard copy- ādear Dr Jelley Please kindly arrange a follow up X-ray following this recent admission to ensure resolution of current pneumonic changeā. As opposed to āGP to follow upā then this would be in keeping with current behaviour between specialist services in hospital. Interspeciality referral occurs formally via usual dictation service. More and more we are receiving a genericā GP to follow āwhich based on a recent conversation around discharge summary review may be a tick box enabled quick key . Not helpful when biopsy from colonoscopy. Wouldnāt it be better if actually ā I would be grateful if you could review the histology from the recent colonoscopy .if hyperplastic polyp the followup x if adenomatous then follow up Y . Much safer and more in a shared intent framework.
Definitely feeling sad not with you all today 
icon - upload on hover over - that allows you to choose the file and well upload it