| Project Objectives / Summary:
Prior to the start of the project, two important local initiatives had been established in the area of general practice computerisation and hospital to general practice linkages.
1.The Illawarra Coordinated Care Trial (1997-1999) provided 98 local general practitioners (GPs) with networked computer facilities in their surgery as well as training in the use of clinical software and basic computer skills.
2.The DocMail Project (1999-2000) provided a system for the automatic notification of patient hospital admissions, admitting conditions, transfers and discharges from any of the Illawarra Area Health Service's (IAHS) nine hospitals to the patient's nominated GP. GPs were able to dial-in to the IAHS network and access intranet and e-mail facilities. A search engine was then applied to enhance the functionality of Docmail. Using this engine, GPs could explore previous hospital admissions relating to particular patients and could also identify all their patients admitted to any of the IAHS hospitals at any particular time.
Working with Admissions and Medical Records staff to gain patient consent and maintain patient privacy, gave the Illawarra Division of General Practice (IDGP) an ideal foundation to expand clinical information available into a system to be known as GP Gateway. GP Gateway, as are all IAHS/IDGP information management projects, is governed by a joint committee of both organisations.
The four deliverables of the GP Gateway project, as described in the initial project proposal were as follows:
- An interface based on web-technology that will enable GPs to access hospital information on patients in their care, with sufficient speed as to make its use feasible in short patient consultations.
- An agreed accreditation process that gives GPs authority to access data held by hospitals in the local Area Health Service (Illawarra Area Health Service ).
- A system of improved data security and transfer between computers of Area Health Services' hospitals and local GPs.
- Interim and final reports that describe the development of the interface and its evaluation.
Project Collaboration:
Illawarra Area Health Service Information Services Department
Project Outcomes:
The layout of the website was designed by a representative group of GPs. Specifications by those GPs were that the site be simple and that clinical reports be presented in the same format as paper based reports. Access to GP Gateway information is either via the web or by means of an HTML link contained within a Docmail message. Both GP Gateway and Docmail are designed to sit on an administration system which links patient demographics to an identifier. This identifier is the basis for identifying results at any of the otherwise unrelated systems where clinical information is stored. In this way GP Gateway is a framework acting as a single point of contact for information held in many other independent databases. The fact that the IAHS has a single patient identifier makes it possible to track the patient across the Illawarra public hospital system.
In its earliest forms information made available to GPs included Microbiology, Radiology and Nuclear Medicine results, Histopatholgy, surgical details (including endoscopy details), and cancer outpatient services. To this list was later added Haematology. However, when the IAHS amalgamated its haematology services with those of South East Sydney Area Health Service, access to haematology was lost. A salutary lesson about local control.
The list of results available reflects the large number of interactions that IDGP Gateway staff had at both the clinical and non-clinical levels. Negotiations that occurred involved surgeons and anaesthetists (Operating Theatre Information System or OTIS), Pathologists (HOSLAB) and Radiologists (HOSREP) as well as cancer and other specialists. Technical capacity was only possible by means of excellent working relationships between IDGP and the IAHS information Services Department and the executive of the IAHS whose interests centred around protecting patient privacy and maintaining internal security.
There are two outstanding areas of importance to GPs that have not been delivered to date: discharge medication lists and patient's intervention results / reports for outpatient services (currently only available for inpatient services). Although medication information is not difficult to capture, the information is incomplete at any single source. This is because a number of wards dispense their own medications without reference to a single register. The decision was made by the GPs involved that incomplete information was worse than no information. Thus electronic discharge medication lists are not a possibility in the near future.
The website was published on 8 May 2001. Access is available to 100 GP members who have IAHS internet accounts. The IDGP is sponsoring full-time access to the IAHS network for 40 GPs involved in the IDGP diabetes research project. The hypothesis being tested is that GPs who have immediate access to the network, rather than having to initiate dialup, will be more likely to use the resources of the GP Gateway website and e-mail in the course of a patient consultation. Immediate access should encourage real-time usage of the system at the time of consultation.
Lessons:
GPs' lives are busy. Access to information should be timely and we suspect that full time access is a critical element of the success of this type of clinical communications. However, the information that is accessed must also have several features. It must be of sufficient quantity that the use of the technology becomes a way of doing business. It must also be of sufficient relevance that GPs will take the effort to look at it. For example, pathology results performed as an outpatient should be able to be viewed as a single process, not at the end of several phone calls to different pathology departments.
But two other issues are also critically important. The first is a valid relationship between the GP and the Area Health Service or hospital that defines the responsibility of the GP to capture, view, record, distribute and archive clinical information. This is an area that the IDGP has been working on for two years both locally and at the state level with no satisfactory resolution.
The second is a functional means of a patient giving consent to a GP, transferring it to another doctor, or removing consent altogether. This mechanism was the subject of an additional three year grant nearing completion with the University of Wollongong and is referred to in the next section.
Lastly, and less importantly, it should be recognised that GP Gateway was conceived, designed and implemented over a twelve month timeframe. Few IT projects of this size can be adequately completed in such a short period. GP Gateway was one of the few, but relied on intensely dedicated staff and an Area Health Service willing to meet new challenges in patient care.
Events post implementation of GP Gateway
In 2001 it was possible for 100 Illawarra GPs to access their patient's clinical information electronically through a central portal, but it was not possible for any other clinicians to do so. Issues of equity were raised that recognised that GPs working up to 160 kms from an IAHS hospital had better access to clinical data than did the ward staff or treating clinicians. Therefore GP Gateway was expanded to give access to other users, the system name being changed to the Clinical Information System.
As mentioned in the previous section, a functional mechanism for consent to access records was required. Once a patient denies consent for a GP to access data, there was no mechanism for them to contact the hospital at a later date and inform them that they had had a changed their decision. Working with the University of Wollongong in the Smart-IDs trial, we have successfully used electronic keys held by both the GP and the patient to denote consent to access. Withdrawal of the key withdraws consent. The key is transportable and can carry virtually any identifier.
The success of this project has led the IDGP to negotiate with the IAHS Diabetes Service for access to clinical information. In this case the Diabetes Service will be able to access GP data, using rules already developed with the IAHS, over the internet. And it is to this technology that GP Gateway will soon turn. To this date, GPs have had to utilise the IAHS as an ISP. Hardware and software advances in security, now mean that GPs will soon be able to access the IDGP using any ISP. The IDGP will then act as the security portal to the IAHS system and on to GP Gateway aka, CIS.
Future uses
GP Gateway (we still use the name on the web site) will become the means for accessing PACS in November 2002. The Picture Archiving and Communication System is able to disseminate thumb nail and full images of x-rays and other radiological images. PACS will only functionally be available to GPs with broadband connections but represents the latest development of GP Gateway.
In the longer term GP Gateway is the logical tool for a primary care communication system. However, issues such as governance and custodianship need to be resolved before our health care service community can operate as an effective primary care health system.
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