1 PCEHR CONNECTIVITY FOR HOSPITALS AND HEALTH SERVICES CONSIDERING CONNECTING TO THE PERSONALLY CONTROLLED Orion Health Information Brochure Andrew Howard, Global ehealth Director Former head of the PCEHR - NeHTA
2 Table of Contents 1 KEY MESSAGES 3 2 EXECUTIVE SUMMARY 3 3 STEPS TO CONNECTING Register, connect and start using the national identification service (HPI-I, HPI-O, and IHIs) and national authentication service for health (NASH) Implement a local copy of the national human services directory Implement the capability to generate nationally compliant discharge summaries and receive nationally compliant inbound e-referrals Implement secure messaging between the hospital and the primary care sector using a compliant secure messaging provider Connect your systems to the PCEHR to support assisted registrations, lookups on admission, and posting of discharge summaries Implement a provider portal that links your internal clinical information and the PCEHR into a single clinical view Improve the management of medications through the inbound and outbound patient flows Improve clinical orders by centralising orders into the clinical portal Implement template based clinical workflows for inbound referrals and care planning 9 4 SOLUTION OVERVIEW Interaction Actors Develop and execute Change Management Plan Rollout Support and Communication 11 5 SCREENSHOTS OF THE SOLUTION Clinical Portal 11 6 ABOUT ORION HEALTH 15
3 PCEHR CONNECTIVITY 1 KEY MESSAGES Collaboration is fundamental to improving health outcomes. Connecting your health service to the PCEHR allows your clinicians and consumers to collaborate on a shared record of health information. Success of the PCEHR will occur over time. The more services that connect, the more consumers benefit. Connecting to the PCEHR requires leadership and passion for health outcomes. The steps are easy to understand, but require investment in information technology and changes to clinical practice. There is plenty of help available. The Department of Health and Aging, Medicare Locals, NeHTA, Medicare Australia and compliant software vendors have worked through the issues. We can help you plan, budget, upgrade the OT and drive change in your practice. 2 EXECUTIVE SUMMARY Hospitals and primary care are collaborating to improve population health outcomes. Over the last five years, governments have made significant investments in national programs to standardise the means of connecting and incentivising patient centric care. The introduction of the Personally Controlled Electronic Health Record (PCEHR) on July 1, 2012 catalysed healthcare organisations to join into the wave of change enabled by these new technologies. If you are wondering how to get on board, or what you should be planning for in the future, this white paper will walk you through what you need to consider. This paper is for hospital CEOs, lead clinicians, CIOs and the lead hospital enterprise architect. It will help you understand why you should participate in ehealth, and the series of steps to connect seamlessly into the management and coordination of care across the acute and primary sectors. Connecting is now the easy part. Improving the quality of information used in care collaboration is more challenging, but it s how we will achieve major breakthroughs in health outcomes. The steps to get connected require leadership, investment, passion to drive the quality and use of shared information and commitment. The following outlines the major actions to connect: 1. Register, connect and start using the national identification service (HPI-I, HPI-O, and IHIs) and national authentication service for health (NASH) 2. Implement a local copy of the national human services directory 3. Implement the capability to generate nationally compliant discharge summaries and receive nationally compliant inbound e-referrals 4. Implement secure messaging between the hospital and the primary care sector using a compliant secure messaging provider
4 5. Connect your systems to the PCEHR to support assisted registrations, lookups on admission, and posting of discharge summaries 6. Implement a provider portal that links your internal clinical information and the PCEHR into a single clinical view Building on the base connectivity, the hospital can then: 7. Improve the management of medications through the inbound and outbound patient flows 8. Improve clinical orders by centralising orders into the clinical portal 9. Implement template based clinical workflows for inbound referrals and care planning The benefits of the national infrastructure are significant and include 1 : Assisting the self-management of stable chronic diseases (for example, high blood pressure, diabetes and asthma) Increasing communication between clinicians and individuals by using e-consultations and online services to support self-care management using broadband services and online records to share relevant health information Support the reduction of hospital re-admissions by making accessible timely and accurate health information essential to the better coordination of post-hospital care Improving use of scarce resources through better quality health information, faster clinical assessments, more accurate diagnoses and referrals, and more effective treatment and prescribing of medication Facilitate better decision making by healthcare providers and individuals through the availability of more complete, more accurate and more up-to-date health information Enhance policy development as a result of the high quality data potentially available for use in research and planning While the individual patient and the Australian population benefit from the programs, the direct benefit to hospitals and clinicians is not so obvious. From a hospital s perspective, the benefits arise from receiving better quality of information for patients at the point of admission or in the emergency department. The quality of this information is dependent on the primary care providers contribution to the PCEHR. While the overhead of sending and storing quality discharge summaries appears only to benefit the practitioner receiving the transferred patient; if the ehealth solutions have been implemented for the inbound processes, then the quality of an outbound discharge can have a direct impact on improved outcomes, especially as medications are being adjusted back to preadmission dosages, or being adjusted based on new diagnosis. The importance of communication in this transfer of care for chronic patients is well understood and should not be underestimated. 1 Benefits outlined in the NeHTA PCEHR business case sourced from:
5 So if your hospital is part of a health care community that wants to drive population health care improvements, reduce readmission rates, and run preventative programs of care, then read on. If you are reading this to find out how the ehealth initiatives will save your hospital money then look to automation and patient flow solutions to reduce costs. 3 STEPS TO CONNECTING 3.1 Register, connect and start using the national identification service (HPI-I, HPI-O, and IHIs) and national authentication service for health (NASH) Registering for the national identification service provides accurate and reliable identification of providers and organisations delivering an individual s healthcare. Each number provides a unique identifier. This means that when this number is used, there is no possibility of having duplicate identifiers in the system 2. In the current hospital systems, there are upwards of 30% duplicate records for patients. When viewing across the sector, the proliferation of provider identifiers further complicates the identification of providers. The national services (operated by Medicare Australia on behalf of NeHTA) issue a single number for an individual provider (HPI-I), for the organisations and their organisational structures (HPI-O) and for the individual patients as the individual health identifier (IHI). Changes to the privacy act mean that these numbers can be used as the primary key for identification of a patient for the purpose of healthcare service delivery. Using this number means you will have accurate and positive identification of the patient whenever you exchange information with other healthcare providers. The HPI-I and HPI-O mean that there is a consistent and accurate means of sending the information to the right provider organisation and the right provider so that information goes to the intended point in the patient s care. The benefit of unique and accurate identification of patients and providers means that the right provider has the right information about the right patient. This reduces the probability of clinical errors from incomplete information and improves the efficiency in reviewing an individual s patient records. Further, it improves the individual s management of their own care, as consolidation of an individual s records becomes possible through the PCEHR. Implementing ehealth identifiers requires the following key fundamental steps: 1. Setup your organisation in the national identification service. To do this, you must register your healthcare provider organisation and the organisation s structure as a series of related HPI-Os. During this process, decide which levels in the organisation will send messages. In most cases, a single HPI-O will be used as the identifying organisation for sending and receiving messages. The subsidiary HPI-O s will be used as information within the messages to support any follow-up queries being directed to the right part of the hospital and the right clinician. For these organisations, register for a NASH organisational certificate. The NASH certificate will be used to sign and encrypt messages being sent between organisations electronically. Registration is completed using this form: 2 Since the introduction of the HI service there was a single reported instance of a duplicate entry. The investigation revealed that a practice had tried to create a duplicate record for a patient and that the compliant software prevented the creation of the duplicate record. Reports by the Medical Industry Association of security and data quality issues with the service were shown to be unfounded concerns. As such, the service is duplicate free.
6 2. Identify which individual healthcare providers work in your organisation. Currently, this is all that is required to connect to the PCEHR and to post discharge summaries. In the next few years, the Department of Health and Aging may require all communication with the PCEHR and in point to point messaging to include an individual provider s HPI-I. Providers can register with Medicare Australia using During the application process, the clinician will likely apply for their individual NASH certificate and smart card. This token and certificate allows the provider to use the PCEHR provider portal remotely, and will be used in the future to electronically sign clinical documents such as prescriptions. 3. Decide if your hospital will use smartcards- e.g. for single sign-on, security access etc. The NASH smartcards use an international standard that can store multiple certificates on a single card. NASH was designed to allow hospitals to use a single smart card for multiple security control purposes that require a locked store of digital certificates. 4. Change your admission processes to capture an individual s healthcare identifier (the IHI) at the point of admission. Match rates of over 99% can be achieved if the admission process completes the matching of the IHI with the patient. The match rates drop to below 80% if matching is done after the patient is admitted. Note: If the IHI is matched against two hospital identifiers then there is a problem with the hospital s data. Most likely, there are duplicate identities in the hospital s systems that will need to be merged. At this point, the hospital has the information required to accurately identify an individual and to send and receive information about this individual between the organisation and the primary care sector. 3.2 Implement a local copy of the national human services directory Health Direct Australia manages and operates the national health services provider directory. It is the equivalent of a national yellow pages directory for providers, but also stores key information to support the national messaging services. This directory lists all health and human service providers. An agreement reached between jurisdictions led to the funding and creation of this service based on the Victorian directory. The Department of Health and Aging funds the directory on an ongoing basis. A set of web service APIs are used to access the directory. This means the local systems can seamlessly integrate the directory content into the local user interface. The directory provides a single source of truth for all healthcare service providers nationwide. For the hospital, this means that you don t have to spend time and money maintaining an internal directory of healthcare providers. The national service also provides additional search capabilities, such as searching for a clinician within a 5km radius of a location. Using the national service has the added benefit of broader information when the hospital staff are helping patients that are not from the local area. However, sending messages or making calls to the national service for standard lookups introduces a communications overhead and latency. Creating a local copy of the HSD will improve system performance for standard lookups. The local copy can be replicated as needed (nightly) through the APIs.
7 The systems should use this directory to lookup the details of clinicians that will receive documents. The directory also contains the information for the provider s HPI-O and HPI-I s and details of the end point location service (ELS) used by secure messaging. The systems should use this directory to lookup the details of clinicians that will receive documents. The directory also contains the information for the provider s HPI-O and HPI-I s and details of the end point location service (ELS) used by secure messaging. 3.3 Implement the capability to generate nationally compliant discharge summaries and receive nationally compliant inbound e-referrals Significant improvements to health outcomes occur when sharing information during care transfers. Implementing compliant referrals and discharge summaries means that clinicians using compliant software can seamlessly view the shared clinical documents as part of their work processes. 90% of GPs are planning to implement compliant software in the next two years. Already over 6,000 primary care practices have registered for HPI-Os and indicated their intent to implement software that enables compliant discharge summaries. In order to send and receive information, the information must be understandable. In conjunction with the sector, NeHTA has and continues to develop Health Language 7 Clinical Document Architecture (HL7 CDA) specifications for key clinical documents. This sounds complicated but really it is just the standards for the data in the document, how to display the document. The PCEHR only supports documents that comply with the NEHTA specifications. At a basic level, a hospital could accept inbound referrals and display them using a CDA viewer. CDA contains the necessary information to render the referral in the viewer so that a person can read the information. However, building the processes around the viewer to manage the referral in the context of the ED, inpatient or outpatient referrals is more challenging. A better approach is to consider the use of a clinical portal supported by a workflow engine. The portal becomes the central place where clinicians can see a consolidation of internal and external clinical documents. The workflow tools underpinning a portal, can then be used to scheduled work items into a clinician s work list. So a queue for inbound referrals can be setup that triggers an event for triage processing in each of the admission processes. The clinical document is simultaneously available to all clinicians in the hospital. So, in the ED, for example, the clinician will be able to see any referrals as they are received by the hospital. In many Australian hospitals, discharge summaries are prepared manually. The documents are often sent to the patients GP via fax and in the case of aged care patients, sometimes a copy may be sent to the aged care home via fax. More recently, jurisdictions like NT, SA, Queensland and ACT have implemented an electronic discharge summary system. These solutions provide the clinician preparing the discharge summary to view clinical information from multiple source systems. In ACT s case, the solution runs on the Orion Health Clinical Portal. ACT was the first jurisdiction hospital to submit a compliant discharge summary to the PCEHR. Closing the loop between the primary care sector and the hospital creates a closer connection. In the Northern Territory, the early implementations of e-referrals and discharge summaries led to a greater collaboration between the primary care clinicians and hospitals as the clinical groups worked through the quality issues in the information being exchanged.
8 3.4 Implement secure messaging between the hospital and the primary care sector using a compliant secure messaging provider Currently, many organisations have implemented multiple messaging services, because each service uses a proprietary messaging system (e.g. Medical objects in Queensland). Because there are multiple adapters, it is frequent that messages are incomplete or lost in the multiple messaging queues. This creates clinical risks associated with misplaced documentation. Providers implementing solutions that comply with the secure messaging Australian technical standard can communicate securely using a single reliable messaging service. The epip program is incentivising primary care clinicians to install software that can send and receive messages using the Australian technical standard for secure messaging. It is expected that within the next 12 months, secure messaging will be ubiquitous in primary care. A hospital, communicating with the primary care sector need only select and implement a single compliant secure messaging service. A list of compliant messaging vendors and products is available on the NeHTA website: Orion Health prefers to work with Healthlink. 3.5 Connect your systems to the PCEHR to support assisted registrations, lookups on admission, and posting of discharge summaries The more information available about the patient that is available during the admission process, the better the assessment and management of the patients care. The PCEHR provides information that has not been available to clinicians previously. Imagine a patient that arrives at the emergency department, they are elderly and have a plastic bag with their medications. They tell you which pills they take, but cannot tell you the name of the medications. At this point, the triage nurse uses the Identifier service to determine the patient s IHI. She sees that the patient does not have a PCEHR. She tells the patient about the PCEHR system, and the patient decides they would like to consent into the PCEHR. The nurse verifies the patient s identity and records the consent through the assisted registration process. The consent includes access to Medicare data. Immediately, the patient s Pharmaceutical Benefits medications can be seen. As well, information on the national prescribe and dispense repository can be viewed. The triage nurse is now in a much better position to query the patient on their medications. Further, the nurse can see the practices where claims have been made in the last two years. If there are further concerns or details required, the triage nurse can ask for additional information about these visits and/or contact these providers for more information. The outcome is a significant improvement in the quality of care for these types of patients. Connecting to the PCEHR involves a different set of technologies to the point-topoint messaging world. The PCEHR is a central indexing service that provides access to clinical documents linked to a consumer s personal health record. The consumer controls who has access to what information in their PCEHR. The PCEHR uses a series of web services to manage the interactions with the PCEHR for sending and receiving the clinical documents. In the simplest implementations, a clinician can see on their screen that an individual patient (identified by their IHI) has a PCEHR. The clinician may then access that patient s clinical documents through the PCEHR enabled clinical portal (provided by Orion Health in the national infrastructure).
9 3.6 Implement a provider portal that links your internal clinical information and the PCEHR into a single clinical view Delivering PCEHR connectivity delivers only part of the value. Ideally, the clinician wants a seamless view of the information in the hospital s systems and from the PCEHR. To do this, a clinical portal is required that can merge the PCEHR views and the Hospital s local views. Orion Health was the first vendor to implement this integrated view in their clinical portal at ACT health. This integrated view improves clinical decision making by providing a single interface for clinicians to use as they review a patient s history and available documentation. The advantage of this approach is that the clinician does not have to log onto separate systems to view a patients records. The integrated portal approach results in improvements to productivity and in the quality of diagnosis enabled through the ease of access to the additional clinical information. 3.7 Improve the management of medications through the inbound and outbound patient flows The latest National Prescribing Service review of medication literature summarised that: Around 6% of hospital admissions in Australia are associated with adverse drug events, with almost one third of admissions for the elderly associated with adverse events Consistently high error rates occurred during transfer of care between hospital and community settings Ten percent of general practice patients in Australia report experiencing an adverse drug event, while 25% of high-risk patients reported adverse events associated with medicines Medication errors in the community remain a problem and their prevalence varies according to the stage of the medication process Documentation errors that occurred during transfer of care had consistently high error rates, with 52 to 88% of transfer documents containing an error A significant portion of medication errors relate to clinicians not being aware of the medications a person is on when they are admitted, and in the adjustments to medications made during the patient s stay in the hospital leading to medication errors being made in primary care after discharge. Figure 1. Medication Reconciliation workflow:
10 Figure 1. Medication Reconciliation workflow: emedication RECONCILIATION PROCESS HOSPITAL Communicate medication changes to GP, patient & other care providers Discharge Reconciliation emedication RECONCILIATION PROCESS HOSPITAL Discharge Patient eds Med Card COMMUNITY COMMUNITY Discharge Summary - Change to Meds - Reasons for changes Patient Medication Card Prescriptions with changes GP Communicate medication changes to GP, patient & other care providers Reconciliation Discharge Summary - Change to Meds - Reasons for changes Patient Medication Card Prescriptions with changes Hospital Stay eds emrf Patient Med Card GP Update medical record with medication changes Manage ongoing care Hospital Stay Reconciliation emrf Update medical record with medication changes Manage ongoing care Compare with medication chart & reconcile differences Medicine Surgery Rehabilitation of Older Persons Older Persons Plastics & Burns Reconciliation Compare with medication chart & reconcile differences Medicine Surgery Rehabilitation of Legend Plastics & Burns Collect Best Possible Medication History emhf Admission Best Possible Medication History Collect Best Possible Medication History emhf Dispensing Admission Pre-admission clinic Emergency Care COMMUNITY PHARMACY Medicines Use Review Manage Long-Term Conditions (LTC) Best Possible Medication History Pre-admission clinic Emergency Care COMMUNITY PHARMACY Dispensing Medicines Use Review Manage Long-Term Conditions (LTC) emhf emrf eds Electronic Medication History Form Electronic Medication Reconcilation Form Electronic Discharge Summary Legend A key to effective medications management is the use of medications reconciliation emhf Electronic Medication History Form on emrf admission Electronic and Medication discharge. Reconcilation Orion Form Health has built a solution that provides a complete eds Electronic Discharge Summary picture of patient medication from admission through to discharge. This gives clinicians the information they need to make informed treatment decisions and deliver safe and effective care. The solution incorporates the capability of linking internal and external medications information sources. A logical extension of the current capability would be to link the national prescribing and dispensing repository information from the PCEHR when these interfaces are made available by the Department of Health and Aging s national infrastructure operator in late 2013.
11 3.8 Improve clinical orders by centralising orders into the clinical portal In many healthcare organisations the patient s medical record is held across multiple disparate systems. Connectivity to the PCEHR represents just another disparate system to a clinician. A clinical portal provides the means to bring together the clinical information from these disparate sources into a single view of searchable information. Once in a single place, the clinician wants to interact with the clinical information by placing orders and reviewing results. The key to these processes is to close the loop between the orders placed and the reviewing of the results by the ordering or attending clinician. The Orion Health Clinical Portal enhances these clinical workflows by providing these views on both traditional desktops and on mobile devices. Alerting clinicians of critical results further improves the allocation of resources to critical patients requiring emergency or high priority care. 3.9 Implement template based clinical workflows for inbound referrals and care planning Recent studies of referrals to speciality services has shown that as many as 5-15% of referrals are incorrect and a further 20-35% of referrals have incomplete information. Hospitals can have hundreds of specialty referral pathways, so the inaccuracies on referrals result in increased timelines to effective diagnosis and treatment pathways. Delays can lead to disease progression that further drives up the costs of care and reduces overall life expectancy and quality of life. Being able to send, receive and view referrals from the PCEHR is the first step in establishing effective referral management. Establishing a referral capability that can verify the completeness of a referral and route the referral effectively through a series of workflow steps improves the quality of referral information and hence reduces the time to diagnose and start treatment. Orion Health has developed Clinical Referral tools with configurable forms and flexible workflow. When combined, this toolset supports the dynamic implementation of new referral forms and pathways that can be tailored to any service. 4 SOLUTION OVERVIEW The following diagram is a high level solution overview of the Orion Health PCEHR Connectivity solution. Figure 2. High level solution overview
12 4.1 Interaction The following table provides a high level overview of the flow of information presented in Figure 2. More detailed information will be provided in the subsequent sections of the document. ID INTERACTION 1. The health service clinician selects a patient in Clinical Portal 2. The patient consent flag is added to the patient context from the patient administration system 3. Clinical Portal queries the local Human service directory for the provider HPI-I details 4. Clinical Portal queries the patient master index for the patient IHI details 5. Clinical Portal calls the PCEHR web service to check if PCEHR exists 6. The web service response is displayed in the Clinical Portal PCEHR landing page. Clinician provides additional information if required i.e. patient access code, emergency access code, reason, etc 7. Once authorised, Clinical Portal calls the PCEHR web service to retrieve the patient s PCEHR document list. The shared health summary is displayed as the default summary page 8. The clinician selects a PCEHR document from the Clinical Document Viewer (CDV) tree. Clinical Portal calls the PCEHR web service to retrieve the selected document and displays it as ready only 9. a) The clinician opens a Health Service discharge summary and finalises the document. The Orion Health Rhapsody converts the discharge summary to the appropriate CDA format; or b) The clinician opens a Health Service discharge summary and amends the document. Rhapsody converts the amended discharge summary to the appropriate CDA format 10. a) Rhapsody calls the PCEHR web service to submit the discharge summary; or b) Rhapsody calls the PCEHR web service to amend the discharge summary; or c) Rhapsody calls the PCEHR web service to remove the discharge summary 4.2 Actors The following lists the users/actors that will interact with the PCEHR Connectivity solution:. USER CLASS Healthcare Professional System Administrators DESCRIPTION Health Directorate healthcare professionals including clinicians, members of a treating team, specialists, etc. Clinical Portal system administrators
13 4.3 Develop and execute Change Management Plan Any implementation of a clinical information system will require process changes in work practices. As the changes involve clinical process change, the change program must be led by the clinicians. Ensuring that the clinicians are involved at every stage will simplify adoption challenges. If the hospital s clinical leadership supports the benefits and outcomes, and have been involved in the conceptualisation of the solution, and in the testing of the new work processes, then there will be less barriers to adoption. Orion Health has shown that usability plays a key driver in adoption rates and benefits achieved. The Orion Health solutions have been used in thousands of hospitals to manage millions of patient encounters. The user interfaces have been refined to best suit the way clinicians interact with their patient records. In most cases, clinicians require only an hour of training to understand the capabilities and outcomes they can obtain from the new portal solutions. The change plan should be coordinated with the Medicare locals referring into the hospital. The Medicare locals are running their own change programs to drive ehealth adoption. If these programs can be aligned with the timing of the hospital implementations, then the likelihood of improved adoption and outcomes will increase. 4.4 Rollout Support and Communication Post go-live, the communication processes defined in the Communication Plan need to be executed and supported. For example, working directly with representative of end-user groups, distribution of pamphlets to affected areas, and other channels for communication should be supported and monitored. 5 SCREENSHOTS OF THE SOLUTION 5.1 Clinical Portal The following screen shots are from the clinical portal. The key point from these screen shots is that the PCEHR logic is not visible. Connectivity is seamless to the clinician. Viewing of documents, and the workflow actions all occur within the portal. This is the key to real use of the PCEHR. All patient information shown in any imagery is for representation and demonstration purposes only and is not related to any patient. Figure 3. Patient Demographic Search
14 Figure 3. Patient Demographic Search Figure 4. Worklists
15 Figure 5. Patient Summary Figure 6. Discharge Summary
16 Figure 7. Demographics and Allergies 6 ABOUT ORION HEALTH Orion Health is a leading global provider of Health Information Exchange and healthcare integration solutions. Founded in 1993, we have offices throughout the world. Our products and solutions are implemented in more than 30 countries, used by hundreds of thousands of clinicians and help to facilitate the care for tens of millions of patients. To find out more about Orion Health: Visit