Presentations from:
Dr Jeffrey Tobias , Cisco Systems
Dr Andrew Siegmund, Goldfields Project
Dr Philip Dubois, AMA Radiologist Craft Group
Discussion and debate

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Industry Perspective
Dr Jeffrey Tobias
Cisco Systems

When analogies to banking occur we can see disquiet, however we can learn some things from banking: prevention of errors, scalability. Banking is a process that is central, and in healthcare it is the clinician who has to make the system work for patients. Industry has to understand what is important for the clinician.

We have created a video presentation 'The Connected Clinician - Unlocking the Value' which tracks a day in the life of the Royal Prince Alfred hospital. Let's look at a technologically advanced hospital. Is everyone happy? Not yet!

What are next are some improved solutions to the types of problems we have seen. It is clear that hospital information and communication systems have a long way to go.

Medical Profession Perspective
Dr Andrew Siegmund, Goldfields Project

This presentation described the Eastern Goldfields Regional Reference Site - a demonstration site for the benefits of broadband to connect a wide range of healthcare providers in a vast rural area of Western Australia. This is an area under severe workforce stress in relation to numbers and difficulty of practice. Can broadband make a difference?

The presentation describes the establishment and functionality of a virtual private network. Components include secure medical grade broadband, access from the medical practice, home and other health sites, e-mail, videoconferencing, security, firewall, virus and spam filtering managed centrally, IP telephony, remote access to medical records.

GPs can now communicate between each other using email and with the Division of General Practice; hopefully improve recruitment and retention, access to specialists without travel and education and peer support for GPs.

In Phase 1, all GP practices, homes, local specialists, aboriginal health services are connected. Phase 2 links with the hospitals for remote GP record access and electronic discharge summaries and more remote aboriginal health services, rural clinical school, aged care facilities and pharmacies.

There is a range of broadband delivery based around a fibre backbone, linked to the national system with various delivery methods including wireless, satellite, ADSL - depending on what can be best delivered to each site.

This reference project will operate until 2006 and after a fixed price continuation period, practices will have the option to continue with the service or send back the equipment.

Our practice is seeing a decrease in the need for scanning with electronic results and referrals. Information is more rapid, secure, less work to scan by 50%, reduced consumables and remote access to notes. Reduced communication costs with reduction of $300 per month in phone bills. We hope this service will make the bush a more livable place and support our workforce retention. We have a desktop portal, which gives access to a range of information and links with the Royal Australian College of GPs. Practices have adopted HIC Online. We can videoconference and we are exploring new aspects of communication.

We have focused heavily on communication, consultation and individual needs. Change management is an issue with training and support. Barriers include low IT literacy skills, issues with relationships with governments and a few technical hitches.

We look forward to expanding the possibilities eg online real time claiming, expanding to include allied health to other parts of WA.. We would be ready for HealthConnect when it arrives. Finally our region is a model for the new round of DoHA Managed Health Network Grants.

Medical Profession Perspective
Dr Philip Dubois, AMA Radiologist Craft Group

In this paper I will discuss connectivity for specialists. We have heard a lot about the needs of GPs. As a radiologist we have a range of special needs, primarily for bandwidth needed for teleradiology and filmless departments using Picture Archiving and Communication Systems (PACS). If our needs can be met, it will be fine for most other specialist groups.

We need connectivity covering Specialist to GPs, Hospitals, other specialists and imaging and pathology. Telemedicine, telemetry and tele-radiology is well established. Radiologists want to be able to receive requests and send results, however these results have to have capacity to contain images varying from full diagnostic quality to thumbnails. These requirements are bandwidth hungry. Referral between radiologists is fine inside our department on the network but do it across town and speed is another issue. A practical application of the work practice improvement is load sharing. Our practice was one man down in one location and with surplus capacity in another city - it took a whole day to just send the images!

Other issues are the provision of image archive - private practices have not traditionally archived films and passed these to patients to keep. Public hospital practice tends to manage the films. Will archiving be funded by private practice as an additional service, but also at additional cost? There is talk of State wide archives, but connectivity may be a problem. Should we do something at a national level?

Radiology has changed the face of clinical medicine; how often is an exploratory laporotomy performed with the advent of pre-surgical diagnostic imaging. Demand is growing with 20% growth, under a 5% growth in the funding cap. Maintaining quality is a challenge in such situations.

There are significant interoperability problems between the multiple types of computer equipment - modalities and PACS such as Siemans, Agfa, Kodak, GE, Phillips to name a few. There are then various radiology information systems (RIS) eg Kestral, Agfa, Promedicus and of course the radiology department in a hospital is linked with various components of the Hospital Information System (HIS). The Integrated Healthcare Enterprise (IHE) is a process alive and growing in the US and Europe. Europe has sorted out many of these connectivity problems using existing standards rigorously implemented. In the US all modalities will be IHE compliant. There are communication problems in the patient journey between the public hospital, private hospital and community sector and differences between Australian States, which create unneeded complexity. There is privacy, medico-legal and of course not all images are taken in radiology services so how to link in with these will be an issue for the future.

The slides demonstrate examples of the new generation of images. Newly trained hospital doctors are used to online access to images which is difficult to provide in the community due to bandwidth. Three-dimensional or volumetic images can take 2D slices and create a 3D image - all very data intensive with huge file sizes. Some examinations use hundreds of images, the only way to cope is with digitial image storage and viewing - PACS. With an integrated RIS and PACS the request and other paperwork can come digitally to the radiologist.

Radiology is replacing invasive imaging such as peripheral vascular angiography, a dataset may go up to 150 megabites for one patient. Cardiac MRI may well replace echocardiography, again with significant image management issues. Such an examination may need to be sent outside the department to a cardiac specialist for reporting and this will require lots of high capacity broadband and compression techniques. PACS has raised expectations "once you look you are hooked" - instant digital strategies are needed. Australia is lagging in broadband.

What does the industry want? Apart from the usual access, affordability, quality, privacy. There is the issue of what the referrer wants, what does the radiologist want, what does the hospital want? The Government wants cost effectiveness and they should be "avoiding infrastructure". The industry will be looking for funding of the infrastructure, as this is necessary, beneficial and unavoidable. The IT industry want clarity about policy, guidelines, a level playing field and some predictability that Government will continue to support the strategy once commenced.

An outcome the radiology groups would ask the AMA IT Committee is to push for economical broadband at much higher speeds than is currently possible.

Discussion and debate

How do we turn good projects into national action? (Peter Thursby) The opportunity with the Goldfields Project is to push this from ground up.

DICOM is meant to be the answer to radiology connectivity. (Peter Schloeffel) DICOM helps with modalities, a similar degree of interoperability for links with RIS and hospital systems. High-speed connectivity 8 megabit doesn't exist in North Queensland. (Phil Dubois)

HL7 messaging standards are being used in the EGRR trial - will need to keep abreast of NEHTA approach when it happens. (Andrew Siegmund, Vince McCauley)

I treat patients for Goldfields how do I join the network? (Bill Heddle) Potential to join networks - looking at this now. (Andrew Siegmund)