Technology in general practice

MAHALA: Welcome to today's webinar – ‘Technology in general practice’ as part of our eHealth webinar series. My name is Mahala Boughton and I'm the Project and Events officer for the RACGP Practice Technology and Management team and I'll be your host for today.

I'm joined by Dr Rob Hosking, a GP based in Melbourne who will deliver the presentation for you today.

Rob has been interested in eHealth since commencing practice in Bacchus Marsh in Victoria in 1990. He gained his graduate certificate in health informatics from Monash University in the year 2000.

Rob was the chair of the Privacy and Security working group of the General Practice Computing group. He has also been a NEHTA clinical lead and has worked on a number of eHealth related committees at NPS Medicinewise and the College of Pathologists of Australasia. Rob has been a member of the RACGP National Standing Committee for eHealth since 2008 and has recently become a chair of that committee, which has been renamed the RACGP Expert Committee - Practice Technology and Management, formerly eHealth and practice systems.

Rob, Welcome to the webinar.

ROB: Thanks Mahala. And I hope we can keep everyone entertained today, we have a lot on the agenda today, it is a broad topic.

MAHALA: Yes, hopefully. So Dr Rob Hosking, myself and the RACGP would like to thank you all for joining us today. And you are joined online by a number of your peers as well as other eHealth experts who will be available at the end of the webinar to assist Rob in answering your questions. So before we begin I'd like to make an Acknowledgement to Country.

I'd like to acknowledge the traditional owners of the respective lands on which we are meeting here today and to pay my respects to Elders past and present. I'd also like to acknowledge any Aboriginal and Torres Strait Islander people present here today.

ROB: Thanks Mahala. So look ah, as is usual we have to go over what we are going to be covering and why. So at the end of the session we want everyone to be able to describe the role of technology to support safe and efficient clinical care, be able to articulate the role of the current status of secure electronic communications to share information with other healthcare providers, describe how technology can create practice management efficiencies and to describe the technical and clinical considerations when implementing new technologies. As well as, and very importantly, how to safely dispose of hardware to ensure that the data is protected. So if we move onto the next slide…

The agenda – to cover all of that, we will look at technology in general practice overall, and understanding secure electronic communication, technology for practice management efficiencies, technology within the consulting room and in consultations, how to safely dispose of e-waste, and we'll go over some of the resources that the RACGP Practice Technology and Management team have developed over the years.

So technology in general practice, it's a broad topic and there's a lot to cover. Some of the example are there, so you can see, that it includes all sorts of things from the IT systems and software. Also, it talks about information security, and whether it be a clinical information system or appointment system, email, telephones, printers, scanners, secure messaging, Telehealth, and video conferencing and practice websites, social media are also included.

 I think we're going to have a polling question here now?

MAHALA: Yes, we sure are. So the second question for today ‘is how confident do you feel when new technology is adopted by your practice? Are you… very confident? Somewhat confident? Not confident? Or not applicable?’ For those not in general practice.

ROB: All right, so 50% somewhat confident, and another 18% very confident. That's good. Maybe that's reflective of the type of people who select to go onto these webinars in finding out more. It's good to see some of them admitted to not being confident.

So hardware and software requirements.

What should you consider when you've got a new or an existing practice? What should you consider when you've got a new or an existing practice? There's a lot to think about, we've got various guides, the RACGP has developed a range of short guides which help you determine what your practice needs for your IT systems which help you purchase hardware and software relevant to your practice. The guides, which you will see a link to in your control panel, include recommendations from existing resources, eHealth resources, relevant government resources and explanatory notes on each topic, including a checklist that you can use to form part of your practice policies.

So please note that these guides do not substitute getting specific IT advice for your own practice. And we recommend that you consult an IT professional when you're implementing new technologies to figure out what you really need and what you may not need.

So the initial and ongoing costs are obviously a big thing and ongoing costs includes software upgrades, annual subscriptions, and on- and off-site support, peripheral devices (and the outright costs or leasing the whole thing), training and support. It’s very important that all staff in the general practice are trained in the use of those technology that is being implemented, and we see it commonly that new staff members will come on and they're not adequately trained to use things and mistakes are made.

Contracts. It's very important to try to understand the contract, what's involved and how to deal with third parties when they come into your premises to do maintenance. You can find a lot of advice about how to deal with third parties and external providers in the RACGP Information Security in general practice resource.

Compliance. There's a lot of things to consider these days when you're complying with various rules around Australia - The Australian Privacy Principles, the RACGP accreditation standards and guidelines, particularly the Information Security in general practice resource and Standards for general practices (5^th edition).

There are ethical and legal requirements produced by the AMA, AHPRA (has a code of conduct) and the Health Insurance Act to cover Medicare. Government programs must also be considered with compliance to do with Medicare, health identifier service, the national eHealth record system, you know, My Health Record. So you need to contract or contact an IT professional for advice, at least, and possibly for ongoing support – that’s probably a good idea. Gone are the days when you can do all this yourself. I think the small one-man practice or a one-person practice with one computer, I think are long gone. It's now complex systems of networks with complex connectivity to external providers as well.

You need to also consider the business continuity and redundancy to make sure that things don't stop when your practice is affected by power outages or disasters. You need to know with data management how you are going to store and backup and archive your data. Mission critical information and mission critical devices - you need to think about how to cope, as we said before, if there's a natural disaster or power failure. It may be a paper backup, but you need to have plans in place so people know what to do in the event of these situations.

Redundancy. It's useful to have mission critical devices that are multiple forms of the same device so that if one fails you can switch over or plug-in another. These are all expensive things though, but they all need to be considered in the overall software and hardware plan. And then, as I said, you need to consider the emergency management and disaster recovery, and you need to prepare for that.

And then there’s governance roles and responsibilities - who in the practice or who outside the practice is responsible for managing all these different areas. Privacy requirements, obviously very important, the privacy of a patient's personal information must comply with privacy legislation such as the Australian Privacy Principles and each State and Territory zone variation of that, and then security that also links into privacy. You need to have a secure computer and information management system. It's essential to protect business and clinical information. Businesses we see are being attacked these days and held to ransom, and so we want to try and avoid that at all costs. And then you have to look at the various software and hardware and how to set it up. So we go to the next slide.

So now we're going to look overall at technology to assist, and one of the things is a follow-up system. We need to look at having recalls and reminders in our practice and how we're going to manage that. For example, people might want to come back to the practice to discuss the test result or undergo a preventative activity like a cancer screening. So they're different things with different mechanisms and failure to recall a patient may result in an adverse outcome. And this could mean that the practitioner is responsible, aswell, for the outcome and face medico-legal action. We've seen cases where people have failed to return or been unable to be contacted because systems in the practice aren't very good at maintaining contact details. So the RACGP has worked with medical defence organizations and vendors, software vendors who provide these clinical information systems, and they’ve created a guiding principles for clinical follow-up systems in general practice software as a report.

The report clarifies the definitions of recall and a reminder. A recall is issued after human intervention has occurred and is based on a GP making the decision that the patient needs to be reviewed within a specified time frame. Whereas a reminder occurs due to the patient being added to a recommended preventive activity list. It is generated and actioned on a periodic basis, for example cervical screening or immunisation… They may be in your reminder list. Whereas recall is generally considered if you receive a notification on discharge from the patient that they need to be followed up and they haven't as yet made an appointment. You may wish to recall that, or you might recall them because you've found an abnormal result on an X-ray or a blood test and you have pre-arranged a follow-up appointment. So it all needs to be considered when you're doing these things, that you can't automate everything - the doctor or nurse needs to consider how we're going to proceed next, you can’t just leave it to the computer to manage it. And you can read the guiding principles for reminder systems and follow up systems in general practice, it's on the RACGP website and there is a link in the in the chat box.

So we go to the next slide, and that's on using email in general practice. Now this is a complex area and we're talking about how can you make it safe, and should you always use secure systems? GPs are often asked by patients, other health professionals and sometimes third parties to send information by standard email, which is not encrypted. Using unsecured or unencrypted email to communicate can create some risks to the privacy and security of the patient's health information such as sending the email to the wrong recipient, or email is accessed on portable devices like phones, laptops or tablets which can be stolen and then accessed by people who weren't meant to access it. Emails can be forwarded without the knowledge or consent of the original sender. And email is vulnerable to interception by unauthorized third parties as it moves through the various servers around the internet.

Now, these issues are not necessarily restricted to email but we must be aware of them and not assume that email is all safe and more secure. Of course there are problems with faxes also going to the wrong place… It's much harder to access the fax whilst it's in transit, however. And there's also issues with plain mail being intercepted as it travels through the postal service and can also be misaddressed or delivered to the wrong place by the postal service. So we need to be mindful and figure out what how sensitive information we’re sending is… and also we need to make sure that we've got the consent of the patient as to how they wish to receive information directly, or how they wish their information to be transmitted to other parties. And I think it would be wise to document that in the record. In some areas, I know that some of the software providers like Best Practice and Medical Director are building into their systems [a] consent matrix, or consent system, for the front desk staff to ask when a patient registers. Or even when new technologies become available, whether they wish to be communicated with by email, or by text, or by telephone directly. Even telephone, we've always had concerns about ringing people at home. And if somebody else picks up how do you identify and not breach the patient's privacy and that they've attended you.

With emails we need to consider how emails become part of the medical record. How are the email systems that you're using? Are they integrated into your record system or do you need to copy and paste them? Or are you just going to leave them hanging separately and then find it difficult to find later? And so that's an area where some of the newer systems are better that incorporate directly into the clinical record system so that you've got an audit trail of what sort of communication you've had. So to respond to all this complexity the RACGP has developed the following resources to assist practices. There is the guiding principles on using email in general practice as well as a privacy and security matrix, and this is a decision-making tool to help you determine if it's appropriate to use email.

And this resource is currently being updated and will be released in coming… re-released in coming weeks. There is still information on the RACGP website, but bear in mind that it will be altered, and keep an eye out for the eHealth newsletter, which will let you know when it's released. So I think there's a there's a link there on our chat box.

So if we go to the next slide on secure electronic communications. So the college advocates communicating and working towards implementing two-way secure electronic communication, particularly with official clinical bodies such as hospitals, colleagues, referrals, and allied health professionals. It's something we would like to work towards, and we are working towards, and I know the [Australian] Digital Health Agency’s also working towards improving the interoperability of the various secure messaging systems.

As I mentioned earlier, these are the things that link into your clinical information system or clinical record system and keep a record within the system of what's been sent and how it's been sent. So that should be the preferred method of communication. But in the meantime, if email must be used, as I said, you must consider documenting getting consent from the patient and make sure… it's a bit like consent for medical procedures, I think in a lot of ways - do the patient's really understand what they are consenting to? You have to be very careful of that.

So if we go to the next slide again on secure electronic communications.

MAHALA: Sorry Rob, I’ll just interrupt you for a moment for a polling question.

ROB: Oh yes, sorry we’ve got a polling question don’t we.

MAHALA: That’s alright, so the next question is ‘does your practice use secure messaging?’ Yes, no, unsure or not applicable.

ROB: Okay. Well that's encouraging. Nearly 50% definitely do and 6% don't get all. Unsure... Well, yeah and look… I reckon that's the way it should be. I don't think most GPs should know whether they use it, they should just be able to click on a button, send information, and it should happen securely. Hopefully, that's the what's happening there. But maybe it's not, and maybe their practice doesn't use it and you're not aware of the option. I think the other thing with that is to know that sometimes we are receiving secure information. Quite often we are, and most practices would be receiving secure transmission of pathology information and imaging reports. We don't realize that that's actually happening behind the scenes in a secure fashion, not using plain unsecured email, but it's a matter of whether you send information out, it’s really what we're talking about here and how you send that out.

So the RACGP supports the following principles for electronic communication between general practice and other healthcare agencies. And this is actually been also mentioned in the AMA, and they are advocating for this as well in that all electronic communication templates and systems should use existing data and information from general practice clinical information systems to pre-populate documents and forms.

I'm sure we’re all very annoyed by the ones that we have to go online and re-enter patient data, demographic data and then even down to medications and so forth. And all communications should be created and sent from within the general practice electronic clinical software system, and automatically received into the local patient electronic health record via the clinical software systems inbox. And this is standalone systems like email can be problematic. All electronic communications to external healthcare providers and agencies should be sent securely using secure messaging to align with best practice data privacy handling principles to protect patient privacy and confidentiality. As we said, that's obviously ideal but sometimes it's not efficient or the other receiving body doesn't have systems in place and we need to negotiate how we're going to do that safely and with the patient's privacy in mind. You know, being information managers for patients… other healthcare organizations must also provide reliable information to us and the sending of it securely, directly into our systems is our preferred method.

So we go to the next slide, we move on to a different topic now. So there’s an information sheet provided also through the College on Online appointment technologies, the fact sheet. And it talks about the various systems that can be used. The College actually does recommend this is a good idea for routine, non-urgent appointments only and if you do adopt online appointment technology, you should continue to advise patients to phone to the practice directly for urgent non-routine appointments. And we also want to reiterate that it does not replace the role of the medical receptionist. The fifth edition Standards for general practices says that the practice must have a flexible system for determining the order in which patients are seen to accommodate patients who need urgent care, non-urgent care, complex care plans, chronic disease management, preventive healthcare and longer consultations. So, not all of those are going to be managed or handled very well by the current online appointment systems. And also we've got to think of other factors. So it can be useful because it makes it more efficient, it may even improve the efficiency for reception staff who can spend more time doing face-to-face and telephone information. Whereas the simple appointments can be booked securely, and the patient has the advantage of being able to do this at any time, day or night not needing to wait for business hours. And they can select from a broader range of appointments as I often hear the toing and froing from the reception desk of “how about Thursday at 4 o'clock? No? How about Friday?” A patient can actually handle this themselves if they comfortable using that technology. So if we go to the next slide…

Yeah, there we go, online appointment technology. There is various things that need to be considered and I think particularly you've got to remember that patients also need to be considered in this, there will be many patients who aren't very IT literate, particularly the elderly, and others who are disadvantaged may not have access to online systems.

So it's very important to consider all of those things that you can see on the screen in front of you, and figure out how you're going to manage errors. One problem I’ve found with our system, is a patient thinks that they only need a standard appointment when they pop in with a form that actually is a full medical assessment and it could take a lot longer. That may have been caught earlier at reception if they had phoned up, so these systems are great for most of the time, but they can have problems if the person whose making the appointment may even use it as just a way to get a foot in the door, and then they think ‘I’ve just booked an appointment and they'll spend ages with the doctor, I've got a whole lot of things I want to cover including a medical check-up’. So, you know, it's the same sort of thing we deal with every day where they may not have told the receptionist that, and we all end up running behind because people think that their problem is either the most important or that it’s only going to take five minutes, as we all think it will.

So we move on to the next slide, technology in the consultation room. So if we move on, this is about first of all, we've got telehealth video consultations. So I think we got a polling question here too, haven’t we?

MAHALA: Yes, let's try that again. So this is our last polling question for the webinar. So the question is do you use telehealth video consultations within your practice?’ Yes, no, my practice uses telehealth but I don't, unsure, or not applicable.

ROB: Okay, it's more than I thought we must have perhaps more rural people involved here, because it's primarily a rural thing I think. It's much harder to use in other areas. Well, yeah.

Well telehealth has great potential but unfortunately doesn't fit in with the business practices of many practices at this stage. And we've got some resources, the RACGP telehealth resources. And those been recently reviewed and consolidated into a single guide, which is now available on the RACGP website. And I suppose, some aspects to think about if you wanted to implement telehealth is, is it right for your practice? So you have to think about patient safety, clinical need, clinical effectiveness, patient preference, location of the practice and are other specialist and allied health people willing to be involved? The willingness of your staff, and training and skills of your staff, and also the equipment hardware and software and the budgeting. So, you know, what type of telehealth service will your practice offer? And you know, as I just said there's Medicare funding for rural areas - and recently in some situations of counselling in rural areas - but then there's also the option of doing it independent of Medicare like other things and offering it as a service to patients. Whether that be consulting with the patient directly or whether it's consulting with a specialist in a different location. And some people have been trying to get this implemented for using telehealth into nursing homes to save visits. But again, you've got to look at the funding model there because currently there's no Medicare based funding for that and many people are not prepared to pay for the extra. However, we've seen some businesses actually rise up doing online consultations using telehealth and patients have been prepared to pay for that.

And you might think well maybe we should offer that within our own practice to see if we can compete with these entrepreneurial types. One of the other areas if you've used - I have tried using it, and I'm in an area that has until recently been considered rural for this purpose -and some of the specialists are willing to be involved, but it's very difficult to coordinate the specialist, the patient, and the practice which may include the GP or the nurse. And trying to get everybody together is really difficult with them in real time. You've also got to consider information security and privacy - which systems you're going to use, the privacy within the teleconferencing room is like any consulting room (is a too close to other outside people?) and you've also got to think about policies within the practice how you're going to manage the risks of tele-consulting. But as I said, there's going to be a webinar later on in September this year specifically on this topic. So if you want more information, you might want to sign up to one of our eHealth webinars on telehealth.

So we go on to the next slide.

And we’re talking here about mHealth or ‘mobile health’ in general practice. So that includes mobile phones, tablets, laptops that you take out of the surgery, patient monitoring devices. So the mHealth is a planned and strategic way that you can help support, complement, and enhance the way your practice delivers care and the way it communicates and engages with patients. I don't know that in the future we'll talk about it as ‘mHealth’, that'll just be part of what we do. People will have various apps, patients might have their own apps to have consultations with you using the telehealth as we talked about just earlier, There might be apps just for accessing information and resources anywhere, at anytime for you when you're out on the road, perhaps doing home visits, or working from home - you gain immediate access to patient records, of prescriptions when you're out in aged care facilities, using video conferencing for remote diagnosis.

And that's the Telehealth were talking about. Monitoring patients remotely through video or information collected by their devices or apps. It’s a bit difficult how you're going to manage all this information coming in, you need a structured way of managing all this. And supporting patients to adhere to medication schedules, perhaps by sending direct or personalized reminders or providing them with mobile devices that do that for them. So the mHealth toolkit provides information and instructions for anyone who's considering incorporating mobile technology into your practice as well as practices already utilising it, again with an opportunity to review and enhance their systems. So if you're interested in looking at that the link in the chat box and that will also be available after this webinar.

So another area where mobile devices is, next slide… and that is using mobile devices for clinical photos.

In years gone by, I remember trying to manage a film based camera and getting it developed. It was just impossible really, because you couldn't figure out who was who and people forgot to write down who the photograph was of. These days you can take photographs and identify who it is with them. Even a handheld device like your phone, and it's a useful tool but you should use it with caution particularly when they're taken on your personal mobile device – it belongs to the clinician and is used outside of the workplace for other purposes. You need to consider do your photos save to the cloud and then become visible to others? If it's a shared cloud site and if your device is stolen or accessed by other people, are the photos visible to them?

So do you take a photograph and send it via email to your practice? Is that secure? All of these things need to be considered and you need to consider how you're going to get things from the device into your clinical record system. So we're going to have a soon-to-be released resource providing information on how to manage clinical photos more broadly, in particular focus on images captured on your personal devices. And again, we'll let you know when the resource is released via the eHealth newsletter and NewsGP.

So if we go to the next slide, so this is talking about the end of life of the technology. What do we do?

What is e-waste from you…

So I think we all got an idea of what e-waste is. Particularly, it includes your computers, laptops, tablets, digital cameras, and USBs, but it also includes televisions, mobile phones, as we just said, printers and photocopiers and fax machines. And you need to consider how you're going to get rid of these things at the end of their life. Whether you've replaced them while they're still working and you want to donate it somewhere, or whether it no longer works and you want to dispose of it fully. So there was an effective solutions for e-waste in your practice, [it’s] a guide that was developed by the RACGP in 2012, and it's recently had an update to make it more succinct and to bring it in line also with some of the regulatory changes about disposal of the e-waste. And I know now in Victoria it’s illegal to put the e-waste in the general landfill and it needs to be taken separately to waste collection areas.

And there may be similar things coming into each state and territory. And then if you go to dispose of it, you've got to look at how to you securely removed data. So you need to make sure that everything is removed from the device. It can be a problem for identity theft and we carry on our information systems, lots of personal details, apart from the clinical details, there's also the personal details of patients which could be used for identity theft. And then there's also the information about the business of your practice, and so not removing this data from the electronic devices could breach patient information and privacy and security and also put your business of risk.

So you need to think about things like hard drives and the even little USB flash drives – you’ve got to be careful about how they are disposed of and make sure they're carefully erased.

And just deleting the files is not enough. So just dragging them and dropping them into the rubbish, the recycle bin, is not a good enough way to get rid of them. There are secure systems that have are for erasing data and destroying equipment. Higher levels of sanitization, we call it, include wiping the disc and using a secure erasing tool or destroying the equipment with subtle measures like a hammer. That's been utilized in my practice in order to break the disks before we've sent them away.

So on the next slide, we look at the disposal of the e-waste and there's some really good websites around [like] ‘Recycling Near You’. It's a great website, it provides great websites to visit on recycling electronic goods, particularly for the new television and computer recycling scheme by the Australian government. ‘Mobile Muster’ - I think we've all heard of that, [it’s] about getting rid of mobile phone handsets, batteries, and charges. And there's also, when you're thinking of your printers – cartridges, for ‘Planet Ark’ which gives advice on how to dispose or recycle them.

And I think if we go to the next slide, it's really useful to think about having an e-waste policy for your practice. Generally you probably should have a waste policy for your practice and e-waste is just another form of waste. And I think you could generally consider e-waste, potentially if you’ve data on it, as contaminated waste but I don't think your contaminated waste disposal company will take it. So you've got to have a different policy in place on how you're going to decontaminate that so that it has no data on it, as we just talked about, or whether you need to destroy it and smash it up before it's sent off. And you could even have a policy in your practice to encourage staff to bring in their old mobile phones, laptops and tablets for recycling, you know, if you wanted to be part of the change of improving the way e-waste is handled and you could be an e-waste drop-off centre. Perhaps you wouldn't want it for the whole of a patient population, but maybe assisting your staff might be a service you can offer, or maybe not depending on how you feel about what they might bring in, you don’t want televisions coming in I suppose, again make it clear in your policy.

So we'll move on to the next slide which is looking at some of the technologies that resources that we've got in the RACGP.

So we've already mentioned a few times the Information security in general practice resources, and it supports the fifth edition Standards [for general practices] and replaces what was the old Computer Information Security Standards [CISS]. It's a very, very, useful and very easy to read guide particularly for practice managers who are online but also for practice owners and people who are interested in… Even practice contractors and employees, to understand how to carefully manage information as it comes in and out, and also how to be aware, as we are all supposed to, be aware of the emails that might be phishing to download some malware into your system, and then you won't be very popular if that occurs. Then there's a resource on the secondary use of general practice data and it may help you to make a decision about whether you're going to release the de-identified health care data at the request of some external organization.

As we stated earlier, there's a telehealth guide and there's going to be a full webinar on telehealth as I said, in September.

There's an excellent notifiable data breaches resource. That was a factsheet that's been developed to assist GPs to appropriately assess and identify a notifiable data breach and to know what the reporting under the new national notifiable database breach scheme.

There's also a resource called General practice business toolkit - Owning and managing a general practice. We're in the process of updating this and it'll be re-released in the in the next few months and it's been renamed ‘owning and managing a general practice’.

The Social media guide for general practice has only been recently updated, just in May this year with the latest information regarding social media platforms and their tips for use with in general practice. Whether it's your own practice’s social media platform or whether it's you as an individual engaging in social media and how you engage, whether you identify as a doctor and compete with other people with different views. So those resources are all available on the website or going to be soon released re-released, but they are still there now.

So we also want to do talk about the RACGP Technology Survey. This has been going annually since 2015 and it's getting bigger each year with more information and people very kindly participating. And the survey report from last year is now available. And if you want to click on the link, you can download it. The RACGP Technology Survey will be open later in 2019. Usually it's released around the time of the RACGP conference, GP19. We use that to try to get as many people who are going to that to complete it. It doesn't take terribly long, and it gives us some really good insights on how people like yourselves are using technology in practice, and that gives us an idea of where we should be focusing our efforts and resources for guides for all of our members.

So the next slide… We are just going to say that this webinar series that you have participated in today, there are upcoming topics. In August there is one on privacy and managing health information in general practice, as we mentioned earlier the telehealth one - telehealth video consultation in September, and then in October secondary use of general practice data, and we've got more topics to come. We’re just trying to decide which ones to use and when. And just remember that they are accredited for two Category 2 Quality Improvement and Continuing Professional Development [QI&CPD] points for the 2017-19 triennium for RACGP members.

And other topics we've already covered is the Notifiable Data Breaches Scheme, medico-legal concerns and My Health Record, and the Information security in general practice, SafeScript, and improving health data quality.

So I think we've reached the end and we've got a bit of time for questions now.

MAHALA: Yes, that's correct. Thanks Rob and thank you for a great overview of technology in general practice today.

ROB: That’s alright, and I hope people are still engaged as there was lot to cover, as we said, in a very broad area. But as some of this will be covered in more detail in future webinars.

MAHALA: Yes, certainly. So as promised we now have time for Q&A. So if there's a question you have from today's presentation or generally about practice technology and management, please let us know in your chat box, but we have few questions waiting here.

So Rob the first question I have, it's about secure messaging. So they’ve said the main barrier for us is interoperability. When will the situation change?

ROB: Yeah well, that's a good question.

The [Australian] Digital Health Agency is working on the interoperability now and they've done very successful technical implementations of this. And some of the software will be released in the latest versions of your clinical information systems, [they] will have an address book that helps you decide whether you can send this referral for example, using secure electronic systems. The various providers of secure messaging have got together and agreed to share their address books, if you like, and so when you click on the new aggregated address book it will tell you that you can send it to somebody else using a different system. So what that means is somebody who's using Argus will be able to refer to somebody who's using Referral Net and vice versa. You won't have to know what the other person is using. It'll just be a link within the address book. So I think we're finally making progress. This has been a big drawback for a long time.

And it looks like… I would suspect we will see some action within our own systems pretty soon and then we need to continue talking with the specialists that we communicate with, and the allied health providers that we communicate with, and hospitals to try to get them on board. And I think if we as GPs at a grassroots level keep pressuring and saying ‘why can't we send these referrals to you using this system’, eventually if enough GPs do it, people will make change - specialists will change their behaviour if they think they're going to get more referrals. And hospitals, well, they are, under various states, are under instruction to start using these systems.

And so I think we're starting to see more secure electronic discharge summaries and outpatient letters coming to us using secure messaging systems. Referring-in is more difficult to get change in these big institutions, but the Digital Health Agency’s working with all the state jurisdictions to try to get them on board with this so, I think it's being recognized as a big priority and I think we're finally going to start seeing some traction. Hopefully by the end of the year you'll see it within your software as an option. And then we need to start pushing to get our colleagues to use it.

MAHALA: Thanks Rob. So the next question I have here ‘is fax considered as secure as electronic messaging? My understanding is that fax can still be hacked?’

ROB: Um my understanding is that it's harder to hack faxes if they are in transit, but I might be wrong and some technological person here might know that they can be, but my understanding is that they're much harder to intercept because they go point to point. They don't tend to go through multiple servers like email does. But then you've also got the issue of faxing. Are you sending it to the secure endpoint? You don't know sometimes what's at the other end. Is it sitting on the desk of reception? And so anybody who's looking over the desk can see these faxes coming in. Or is it even worse in a more public place?

I suppose these are the things you've got to always wonder is how faxes are being received, and also ensuring, like you do with email and like you do with any system, making sure that you've actually sent it to the person who you thought you were sending it to. Making sure their fax number is right for a fax, or that you've got the right email address, and as we just talked about, the right specialist address, hospital address. We've always got to be careful. Nothing can be taken for granted. We're all human and we all can make mistakes, but we're got to try to be aware that we’re risk of making mistakes.

MAHALA: Thanks, Rob. I've got another fax related question for you here. ‘I've heard that faxes are being phased out. Is this correct?’

ROB: Now there is a move around tips to try to phase out faxing. The college is certainly keen to move away from it. With the move to the NBN, it's made faxing more difficult because the NBN doesn't carry faxes as easily as the old copper telephone system because of its digital nature. So I think we heard the other day that the National Health Service in England is the biggest purchaser of fax machines in the world.

So Australia is not alone in still relying on faxes and health, but there's a lot of pressure to change that and make communication a bit simpler. And I mean, when we say simple, then we go to encryption and use the secure messaging and some would argue that's not as simple. And I think I've always argued, and we keep pushing that, the systems need to be simple at the user interface and sometimes the technical experts developed something that is very clunky and we need to keep pressuring them. If your software is very clunky, I think provide that feedback, they do listen if lots of people are coming back to them and saying ‘look I can't use that, it's too complicated’ instead of just reverting back to what you used to do all the time, saying ‘well I will just fax it, I will just post it.’ Keep on at them, keep providing feedback and people will change. If they don't hear anything, they don't think it's a problem. So yeah, look, I don't think there's a definite date for phasing out faxes, but I think there's a general push away. They have been terms thrown around, I think in the UK they're using a term called ‘axe the fax’ but I think in Australia, we haven't got a definite date yet, but I think the plan is to move away from faxing because quite honestly, it's a bit embarrassing when you're talking to patients and they say ‘really? You use faxes still, that's so 1980s/1990s get to the 21st century.’

MAHALA: Thanks, Rob. So one last question today before we finish up ‘is a recall different to a reminder?’

ROB: Well as we mentioned earlier, yes, according to our, sort of, agreement with the software vendors between the RACGP - a recall is issued after human intervention has occurred and it's based on a GP making the decision that the patient is to be reviewed within a specific timeframe. Whereas a reminder occurs due to the patient being added to a recommended preventive activity list, that has generated an action on a periodic basis.

So the recall is basically if you see an abnormal result and the patient needs to come in, that's a recall. A reminder is if you're going to put somebody on the five years time for a reminder for a cervical screening test, or an annual flu injection, or a review of the lipid profile in two years time, whatever it be - that's a reminder. Whereas the recall is what's used when somebody in needs to come in to see you and discuss something in a short time frame.

MAHALA: So, I think that brings us to the end of the webinar if we didn't get to your question or something comes to mind after the webinar, please email us at ehealth@racgp.org.au and we will get back to you. But thanks Rob for a great presentation today.

ROB: Thanks everyone. I'm sorry it was such a rush to whip around so many different things. I hope that you all got a bit of an oversight, and then you’re happy to come along to future webinars. And if anybody thought this was worthwhile and they want to mention it to their colleagues, we're repeating it on Thursday evening at 8 o'clock?

MAHALA: Yes, 8 o'clock Melbourne/Sydney time.

ROB: Yeah. Thank you.

MAHALA: Yes, great. Hope to see you at future webinars. Thank you and goodbye.