eReferral – Product Assessment and Recommendations

David Hutcheson

Business Analyst - FMPML

17 May 2013

CONTENTS PAGE NO.

(Click on headings to navigate to relevant section of the document)

  1. Executive Summary3
  1. Background to eReferral Project4
  2. The importance of eReferral in an evolving healthcare environment4
  3. The benefits of a cohesive approach to eReferral adoption4
  1. Key Requirements6
  2. Requirements gathering across the stakeholder community6
  3. Formulation of key requirements for vendor assessment7
  1. Vendor Assessment8
  2. Approach to Vendor Engagement8
  3. Vendor Assessment Matrix9
  4. Contextualising the Results12
  1. Environmental and Organisational Context13
  2. The Barwon experience13
  3. Partners in Recovery14
  4. Miscellaneous considerations15
  1. Conclusions and Recommendations16
  2. Key Recommendations16
  3. Final Conclusions17

Appendix 1 – Projected costs for recommended eReferral solutions18

  1. Executive Summary

The establishment of the National E-Health Transition Authority (NEHTA) in 2005 was designed to encourage the adoption of a variety of eHealth initiatives by healthcare providers. One of the foundations of an effective eHealth environment is secure electronic messaging which enables the transfer of patient information, principally for the purposes of referrals between care providers. This process is commonly described as eReferral.

With NEHTA standards being adopted and tested by prospective vendors in recent times, Frankston Mornington Peninsula Primary Care Partnership (FMP PCP) were keen to explore this marketplace and recommend product options to their members to facilitate the growth of eReferral within their catchment. Frankston Mornington Peninsula Medicare Local (FMPML) were also quick to recognise the importance of facilitating the uptake of eReferral capability across the FMP region, and funded a business analyst resource to undertake the project activities described in this document.

This report outlines the three steps taken to identify one or more vendors who would be an appropriate fit for the specific requirements of FMP PCP and its members:

1)The gathering of key requirements from key users and stakeholders;

2)Engagement with vendors on their product offerings and associated capabilities; and

3)Recommendations on vendor suitability and proposed next steps.

A number of PCP members were consulted on their eReferral requirements, and all nine NEHTA-approved Secure Messaging vendors approached to be a part of the vendor assessment process. This was important to ensure that any product/vendor recommendation was in line with national eHealth standards (as outlined by NEHTA) to guarantee interoperability and sustainability.

The key recommendations and proposed next steps as outlined in this report are:

1)ReferralNet (Global Health) and AllTalk (LRS Health) are recommended as the products of choice for secure messaging/eReferral across the catchment.

2)The creation of a project management and system implementation function within FMP PCP and/or FMPML to co-ordinate the procurement and adoption of secure messaging across the catchment.

3)Global Health and LRS Health to be invited to respond to a selective tender on the rollout of their respective secure messaging capability across the FMP region, to include discussions on licensing/subscription options for a whole-of-catchment implementation.

4)The identification of ‘early adopters’ within all key care provider sectors (as appropriate) to enable a phased approach to implementation.

It should be noted that if FMP PCP/FMPML undertake to run and fund a co-ordinated procurement and rollout of the selected eReferral capability (as per the Barwon ML model and as recommended in this report), that steps 2) – 4) would be the foundation of this process. If this is not feasible, then the product recommendation would be ReferralNet as it can be adopted by individual care providers at low cost (AllTalk is only really suited to a larger procurement because of the nature of its server-based offering). It is, however, recommended that central procurement and co-ordinated rollout across the catchment is the approach taken because of the likely benefits it will provide.

  1. Background to eReferral Project

The facilitation of secure electronic messaging between healthcare providers was identified early by NEHTA as a core component of an effective eHealth environment. The increased use of specialist and community care, the growth of care co-ordination and the complex health journeys that many patients experience require timely, effective and secure exchange of information between healthcare professionals. FMP PCP recognised this and were keen to explore options for the recommendation and adoption of eReferral software that would dramatically enhance current eReferral systems and processes.

  1. The importance of eReferral in an evolving healthcare environment

There are a number of practical and organisational benefits to the adoption of electronic referral through the use of secure messaging, principally in reducing costs and improving efficiency within any healthcare provider. There is no need to print, fax and/or post referrals and it eliminates the inefficiencies and time delays involved in the administration of paper-based processes. Many secure messaging products also promise seamless integration with existing client management systems (CMS), reducing the time the care provider needs to spend in generating and sending the referral in an appropriate format as well as improving how they receive referrals and how these are automatically attached to the patient record.

In addition, one of the main benefits of implementing eReferral capability within any healthcare environment is that of data security. Health records can contain particularly sensitive information about an individual and the removal of postal and/or fax communications from the referral process should eliminate a large element of risk around the inadvertent exposure of any personal details. Secure messaging systems can also provide confirmation of delivery of the referral – thereby satisfying the referrer that the documentation has been successfully received and should be acted upon promptly.

As the healthcare environment in the FMP region, and Australia as a whole, continues to evolve there is a strong probability that the demand for secure messaging will grow. Patients require increasingly specialised care plans in a variety of areas, from mental health to chronic disease to other conditions that require a joined-up approach to treatment. The volume of interactions and communications between healthcare providers will only increase, perhaps exponentially, as a result. This is not news to the vast majority of people operating within the healthcare arena, but the question is how to implement a capability that can turn a traditionally fragmented sector with multiple systems and processes into one where information can be exchanged rapidly, seamlessly and securely without wholesale change to its component parts.

  1. The benefits of a cohesive approach to eReferral adoption

The use of secure messaging products for eReferrals is not a new phenomenon – indeed there are many regions of Australia (and beyond) that have successfully integrated this into their respective healthcare environments. Within the Frankston-Mornington Peninsula area there are already pockets of eReferral capability and some referrals (or similar messages) being sent using various secure messaging products.

There are a number of reasons why this has not been extended significantly across the FMP region (and why various other regions are falling well short of full-scale eReferral). The principal reasons are:

  1. The interoperability – or lack thereof - of secure messaging products (i.e. if one practice/organisation has a particular secure messaging product then they can only send eReferrals to other organisations who also have the same messaging product); and
  2. Negative experiences with current secure messaging capabilities (e.g. products can be unreliable and they aren’t integrated well with client management systems).

These issues were revealed during stakeholder discussions and are therefore explored in more detail in section 3 below.

As outlined above, one of the main challenges is to examine how best to facilitate and implement eReferral capability across a region with minimal effort required by the user community. Any minimisation of cost would also be welcome, while maintaining the primary aim of adopting a cohesive approach that enables healthcare providers to benefit from the new capability rapidly and easily.

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  1. Key Requirements
  1. Requirements gathering across the stakeholder community

In order to gather system and user requirements it was important to engage with as many key stakeholders within the FMP PCP community as possible. A number of PCP members were visited during this stage of the process, including:

  • Frankston City Council – Communities/Aged Care
  • Peninsula Health
  • Peninsula Health Community Health
  • Frankston Mornington Peninsula Medicare Local
  • Brotherhood of St Laurence
  • Mind
  • Peninsula Support Services
  • Royal District Nursing Service
  • Headspace Frankston

Project scope and time constraints prevented further stakeholder engagement, but these discussions revealed some key themes in relation to current referral processes that were relatively consistent across the PCP membership. These were:

  • Some eReferral processes are being used, including ConnectingCare and S2S, but there is a relative lack of consistency across the region – particularly in relation to ConnectingCare, which many users say they have little confidence in;
  • Care providers use different systems for client management, care co-ordination and other organisational requirements – they do not want to replace or amend these simply to enable eReferral;
  • These systems do not generally integrate well with their current eReferral capability (if they have one) – it is not a seamless process to refer electronically from a client management system, and there is often some manual data entry required that increases the time involved (as well as levels of frustration); and
  • Costs for any new system or capability should be kept to a minimum, as well as any time/effort needed to integrate it with current systems and processes.

In addition, a number of stakeholders expressed a desire to access ‘patient journey’ information – i.e. a summary record of the points of care that a client has accessed through the various referral processes operating across the care provider community. This is important toenable better understanding of the care journey that an individual has taken, including what referrals have already been made and perhaps additional information on patient response to the care provided. This would not only enhance information sharing across the healthcare community but it should also improve the patient’s experience, particularly as they would not need to repeat information they may have already been asked to share with one or more care providers.

With these high-level requirements gathered,a set of requirements and key criteria against which to measure all prospective vendors was formulated.

  1. Formulation of key requirements for vendor assessment

As outlined above, there were some key requirements elicited from the stakeholder community that could be directly translated into vendor assessment criteria – which were framed as follows:

  • Integration with clinical systems (to ensure interoperability with the variety of systems across the PCP community)
  • Automation of generate/send/receive referral (to reduce/eliminate the manual element of preparing referrals)
  • Flexibility to meet future needs (particularly the development of the patient journey capability)
  • Costs (Initial/Future)

Additional considerations included whether or not the vendor has experience in this region before (local and state), which were translated into the following requirements:

  • Regional experience and knowledge (experience of implementing their product within Victoria)
  • Footprint across the catchment (are any care providers within the FMP region using their eReferral products already)

Finally, a set of criteria was designed to ensure confidence in the vendor as a provider of quality products and services that the FMP PCP would be comfortable in recommending to its members. There was then direct engagement with all key vendors during this process (as outlined in more detail in section 4 below), who were measured against the following criteria to complete the assessment phase.

  • Verbal presentations/web demonstrations (how convincing were they during product demonstrations and related discussions specific to FMP PCP requirements).
  • Past performance and related engagements (what is their history in providing products and services related to eReferral, and do they have strong references).
  • User/system support arrangements (how comprehensive and effective does this appear to be).
  • Breadth of offerings (do they have additional products that users/stakeholders could benefit from adopting should they desire).
  • Customer engagement and transparent approach to service provision (how comfortable are we with their view of how any future client/vendor relationship may work, and whether or not pricing models are sustainable or susceptible to change).
  • Training and knowledge transfer (what training is required, and how good are their knowledge transfer processes).

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  1. Vendor Assessment

At the core of this project was an exploration of the secure messaging marketplace, as redefined under NEHTA guidelines and standards. This section describes the approach taken (and why), and includes an assessment matrix designed to measure how well current vendor products and services match up to the current (and future) requirements of the catchment. The results from the vendor assessment matrix are then contextualised in an attempt to inform final recommendations.

  1. Approach to Vendor Engagement

NEHTA manages a national eHealth Product Register on behalf of the Australia healthcare community, which provides a register of medical software products and organisations that meet the requirements of the Practice Incentives Program (PIP). Secure Message Delivery is one of the core components of eHealth and has a dedicated product register, the introduction to which states:

“The Secure Message Delivery (SMD) Australian Technical Specification published by Standards Australia defines a set of interfaces and associated applications ensuring that health information exchanged by healthcare providers is protected against malicious interference. Health messaging software systems listed here have been independently assessed for conformance to the SMD specifications. The assessment was performed by testing laboratories accredited to perform SMD conformance testing.”[1]

It is important that any software vendor recommended for FMP PCP operates in line with SMD standards, and is therefore an approved vendor under this part of the product register. This formed the initial list of vendors that were approached to engage with this assessment process, who were (secure messaging products are in brackets):

  • Database Consultants Australia (Argus)
  • HTR Business and Technology Services Pty. Ltd. (HTR Telhealth)
  • CSC Healthcare Group - iSOFT Aust Pty Ltd (PractiX)
  • HealthLink International Limited (HealthLink Messaging System)
  • Medical-Objects Pty Ltd (Medical-Objects Capricorn)
  • Global Health (ReferralNet Agent)
  • University of Western Australia (MMEx)
  • LRS Health (AllTALK)
  • Alcidion (Miya Platform)

It should be noted that ConnectingCare and S2S, two current referral products being used by selected PCP members, do not appear on this list. Neither solution is a true secure messaging products (they operate by users logging in to a separate system rather than sending directly) and are therefore not capable of delivering a message directly to another provider as stipulated under SMD protocols. They are both capable of providing a type of electronic referral, but not one that complies with NEHTA standards and are therefore not considered as part of this assessment.

Attempts to engage with University of Western Australia and Alcidion were unsuccessful, and initial analysis of open source material indicated that their solutions may not have been an ideal fit. CSC Healthcare did respond to an initial query, but confirmed that their secure messaging solution only integrated with their own clinical software – making it unsuitable for this catchment.

The prospective vendor list was therefore amended to contain six vendors, each of whom were approached individually to arrange for in-depth discussions on their product and service offerings. Telephone discussions, web demonstrations and/or face-to-face meetings were then conducted depending on availability, and information compiled to allow for measurement against the criteria described previously.

  1. Vendor Assessment Matrix

Typically, if an organisation is looking to procure a software product to solve a problem it would first assess the basic requirement – can this product do what we need it to? In this case, the products have been extensively tested and are generally in operation across parts of Australia doing exactly what is required – delivering eReferrals through the use of secure messaging.

The focus of the assessment was therefore the requirements outlined in section 3 above, namely:

  • Integration with clinical systems
  • Automation of generate/send/receive referral
  • Flexibility to meet future needs
  • Costs
  • Regional experience and knowledge
  • Footprint across the catchment
  • Verbal presentations/web demonstrations
  • Past performance and related engagements
  • User/system support arrangements
  • Breadth of offerings
  • Customer engagement and transparent approach to service provision
  • Training and knowledge transfer

Weightings were then attached to each of these criteria based on their importance to an effective implementation of eReferral capability across the region, as follows:

  • 2.5 – Essential (poor capability in this area would prevent success)
  • 2 – Important (poor capability in this area would impact significantly)
  • 1.5 – Desirable (poor capability in this area would have some negative impact)

These weightings are based on requirements gathered from PCP members and key stakeholders as well as an understanding of the broader business and system requirements appropriate to an IT implementation of this type. In a larger project with less restrictive timescales there would have been more scope for testing and ratifying the matrix criteria and particularly the allocation of weightings. It is, however, unlikely that any amendment to the weightings would fundamentally alter the conclusions reached through the assessment process given the relative strengths of each vendor/product.