1. Position
When exchanging sensitive patient information, individuals and organisations need to do this is a way that is safe, secure and efficient. The RACGP advocates for the use of secure messaging systems because they are the safest, most secure and most efficient communication method. However, despite the considerable efforts of professional bodies, government agencies and industry, the lack of interoperability between secure messaging systems remains a significant barrier to wide scale adoption. As such, the use of email in a way that aligns with advice provided in the RACGP’s Using email in general practice guide, is preferable to the other less secure methods for exchanging patient information.
2. Background
The provision of contemporary healthcare involves patients interacting with multiple healthcare professionals or organisations in different physical locations. The delivery of high quality, effective and safe healthcare depends on efficient communication between all these parties.
General practice has been an early adopter of electronic clinical, administrative and communication systems. This has enabled general practice to increase the quality, safety and efficiency of care provided.1 General practices should be able to receive, review and incorporate health information from other sources into their existing local health records efficiently and in a manner that supports patient confidentiality, quality clinical handover and effective continuity of care. Secure message delivery systems have been developed to support the safe and effective tranfer of sensitive health information and mitigate the risks that come with use of mail, fax and email communication. Slow communication between hospitals and general practice via ordinary mail has been identified as one of the contributory factors resulting in a patient’s death.2
The RACGP Standards for General Practices 5th edition (Criterion C6.3) requires practices to transfer relevant patient health information in a timely, authorised, and secure manner. There are no mandatory requirements about how this information should be transferred but the RACGP has long advocated for interoperability between different clinical information systems (CIS) to enable secure message delivery.
The 2018 RACGP Technology Survey reported 87% of GPs are operating entirely digitally, with no supplementary paper records held. The survey also found that GPs would like to see greater use of secure message delivery by hospitals, other medical specialists and allied health professionals, and interoperability between secure message delivery providers.
More than 90% of general practices have one or more secure messaging systems installed and most other specialists and healthcare organisation have secure messaging capability. However, these systems are widely underutilised, especially for outbound communications, due to a lack of awareness and encouragement.
While some jurisdictions have implemented secure message services to enable the sending of discharge summaries from hospitals to general practices, a significant proportion of health service and government agencies communicating with general practice do not use electronic communication systems which are compatible with those existing in general practice. Many health professionals and organisations continue to use mail and fax.
3. The issues
Most organisations fail to consider the implications and costs for general practices to manage information transfers safely, reliably and efficiently. The inefficiencies of current processes create a heavy burden on GPs, diverting their time away from providing essential medical care for patients. This impacts on patient care due to inefficiencies and the risk of information not being appropriately incorporated into the patient record.
3.1 Sending information
General practices are often required to manually transfer information from their clinical or administrative systems into paper based or online forms which often require handwritten signatures. This information is then sent to the relevant agency via an online upload, post, fax, or via standard and unsecured email. Information leaving general practice through these methods requires significant manual processing.
3.2 Receiving information
Hardcopy or image formats of letters, reports and requests received by general practice from other health services must be manually scanned and added to the patient’s clinical record. Some is received electronically. This information, even when received electronically, is not routinely coded in a structured form that can be incorporated into CISs.
Documents received by general practice provide the most clinical value when they contain atomised data that can be incorporated in a coded fashion into the CIS and then can be searched and interrogated by general practice clinical software. Fax and paper based reports which are scanned into clinical records and saved as an image are not easily searchable, and can’t be used for clinical audits or by general practice CISs to automatically generate reminders or recalls that are appropriate for the patient.
4. Secure messaging and email
Because of the clear advantages secure messaging brings to the whole health sector, the RACGP has long advocated for interoperability between clinical information systems (CIS) and messaging systems to enable widespread adoption of secure message delivery. Despite considerable efforts in recent years on the part of the Australian Digital Health Agency, industry and peak bodies, interoperability has not been achieved. Consequently, the RACGP believes it will not be achieved without regulation to help drive the necessary changes and recommends this is put in place.
Furthermore, The COVID-19 pandemic has presented many challenges regarding the systems and processes for sending and receiving clinical paperwork following telephone and video consultations. The evolving nature of communications during the pandemic has seen a shift in the way we communicate. It is clear there are many instances where email is an appropriate method of communication, provided both the sender and the patient are aware of the risks and limitations and consent is provided by the patient.
In view of the above, email can be regarded an appropriate means of clinical communication and should be integrated into existing clinical systems, provided it adheres to RACGP guidance on using email in general practice. Every effort should be made to secure it as much as possible, through the use of password protection, encryption software, or via a secure website with passwords requiring multi-factor authentication. Up to date antivirus protection and hardware/software firewalls should also be maintained, along with a quality email delivery service and internet service provider.
5. The principles of electronic transfer of information
The following principles should guide the electronic transfer of information to and from general practice:
- Any technology used for exchange of information should enable rapid, safe and secure communications and support the transfer of rich information, ideally including appropriate clinical coding
- The exchange of information should be secured to reduce the risk of information being used by unintended recipients
- The sender and receiver should understand and acccept the risks involved
- The technology should be user friendly and easy to integrate with existing general practice clinical information systems
- Tools such as templates to support electronic transfer of information should, wherever possible, support integration of existing data from clinical information systems to pre populate documents and forms
- Clinical information systems should integrate with existing messaging systems to allow the appropriate transfer of data
- All electronic communications to external healthcare providers and agencies should align with best practice data privacy handling principles, as outlined in the Office of the Australian Information Commissioner (OAIC) Guide to health privacy, to protect patient privacy and confidentiality.
6. Conclusion
GPs are often the “information managers” for patients and rely on other healthcare organisations to reliably provide additional details regarding diagnosis, treatments, management plans and outcomes.3 The adoption of electronic transfer of information should be a priority for the entire healthcare sector to ensure improved efficiencies and provision of safe quality care.