Dec 2017

Chalkeyes presents…
Tackling frustrations…
by
Dr Mike Mair*
Ophthalmologists are not surprised at the
ongoing difficulties the District Health
Boards (DHBs) are having with timely
ophthalmology follow-up appointments. ‘Fight
the queue’ has always been a challenge for all
eye clinic workers, made worse by the advent
of anti-VEGF treatments, which have massively
increased clinic work. Government directives
that departments would be penalized if they
did not see new patients within defined time
intervals forced administrators to bounce followup
appointments in favour of first specialist
assessments, creating a now well-known
backlog of unserviceable follow-up loads, and a
forced ‘denial of care’ for many distressing eye
conditions.
This is now hopefully being addressed. But,
in my view, the state of our medical records
remains a serious impediment to improving care
and efficiencies in our DHB clinics. Apart from
‘contracting’ clinics, DHB clinics are still creating
paper notes in manila folders. For some, the
number of folders and paper within them has
accumulated to such a degree that retrieving one
nugget of relevant patient information is often
not practicable given the time constraints of a
typical clinical interview. To try and bring some
order to this, some DHBs insert a piece of paper
into the patient’s folder with different ‘boxes’
printed on it, to be filled in by hand each time a
patient attends a clinic. This is truly expensive
in paper space and doesn’t solve the underlying
problem; in fact, it exacerbates it.
A debilitating inability to access today’s
screening tools
In most DHBs, there are also no ‘on-screen’
electronic representations of images or reports
from today’s all-important assessment devices
which are now used routinely to help diagnose
and monitor our patients. Often these can only
be retrieved by going to the device directly and
browsing manually, or sorting through paper in
overloaded manila folders!
This lamentable hybrid mix of paper and
up to five ‘online’ programmes, which do not
interoperate, is a great hindrance to the practice
of efficient ophthalmology in DHB public clinics.
Contracting clinics mostly use modern electronic
health record (EHR) and practice management
systems and, unsurprisingly, don’t have a
floating population of un-dedicated follow-up
appointments and the, well-publicized, morbidity
which results.
There are few complainers in New Zealand public
clinics, however long the clinic gap has been and
even when there has been a dramatic worsening
of the patient’s condition as a result. The best
expression of quiescent patient attitudes came
from one person I met, who said: “I know it’s none
of my business doctor, but am I going blind?”
This Kiwi-way also causes a problem with the
Clinical Priority Assessment Criteria (CPAC) cataract
prioritisation system, where elderly people often
underplay their difficulties and thus slow their path
to surgery when there is clearly a need.
But back to this lack of images in today’s DHB
systems; it is an anachronism for professional
guardians of the eye to be handicapped by only
having paper images or, worse, no images at
all. An ophthalmologist without images is like a
radiologist without x-rays! In most DHBs, with the
exception of onsite OCTs, there are no on-screen
images accessible at all. My impression today is
there are even less photos being taken in DHB
clinics than we had in the ’70s, when patients
with retinal problems always had a sleeve of
filmstrips to view with high plus glasses, enabling
a 3D view of discs and maculae.
Concerto – an easy fix?
Health software firm Orion supplies its system,
Concerto, to nearly all the country’s DHBs. The
company’s South Island manifestation is called
Health Connect South (HCS) and it’s certainly a
significant achievement to have one information
portal to allow potential interoperability between
DHBs, so there are many virtues to this product.
But Concerto does not yet file images or reports
from devices.
I believe that modern ophthalmology, with
today’s abundance of scanning and assessment
technology, cannot be well managed except by
a paperless practice. Frustratingly, this could be
achieved with the Concerto software platform, if
its ‘clinical document viewer’ was given the ability
to file reports and images from different devices.
And, as I understand it, this is an easy fix for Orion
to make. So why hasn’t it been done?
Claire Harman, the Ministry of Health’s (MOH’s)
senior communications advisor, said it is up to the
health provider which software it chooses and, in
many cases, a health provider will use multiple
products to meet its needs. Thus, she said, the
problem should be referred to Orion.
So I made a formal proposal to Orion to improve
the functionality of HCS/Concerto by getting it to
display images and reports. I was kindly supported
in this by the executive committee of the New
Zealand branch of the Royal Australian and New
Zealand College of Ophthalmologists (RANZCO).
But Orion said I should address my concerns to
the South Island’s Clinical Informatics Leadership
Team (the group’s acronym is CILT). Timaru’s chief
medical officer Steve Earnshaw chairs this team,
which is part of the MOH’s South Island Alliance
(SIA), which looks after the HCS programme.
The block of bureaucracy
I have since been told that, yes, this proposal has
been approved and it is “something that the HCS
should do”, but it currently rests with the group’s
‘Eyecare advisory group’. Apparently, there are
many demands on Orion for Concerto at this time,
particularly from Canterbury DHB, and it cannot
take any action unless CILT tells it to! And so, we
go round.
As noted above, lying behind CILT is the South
Island Alliance (www.siallance.health.nz).
Procedurally, CILT decides what functionality will
be included in a regional information system – at
present HCS in the South Island, or Concerto by
another name – so Orion cannot independently
develop functionality like filing images and
reports, however crucial it may be. So, it appears
my proposal, even with RANZCO’s support, is stuck
in a bureaucratic maze.
Cost, politics and the lack of alternatives
Further private enquiries to people within Orion
about how much it would cost to include image
and report functionality in Concerto revealed it
would require hiring the services of a business
analyst. However, they also admit Concerto
already has the functionality to display images,
but it has been turned off! Informal estimates,
from three independent members of Orion’s
team, have suggested the cost for turning it back
on is little more than a few hours’ time. But, Orion
cannot move on this, until told to by CILT. So, care
of our patients’ sight continues to be handicapped
because no one’s taking responsibility for pushing
the button!
From my understanding of this sad situation,
this problem is compounded by the fact that the
politics and cost of implementing an alternative
image displaying software system across our
DHBs appears to be prohibitive. Christchurch
has the Synergy product from Topcon and, of the
four private clinics contracting to the DHB, three
run Best Practice’s ophthalmology system. The
rest hold their images and reports on paper or
in the camera, or in software that is not actually
being used. Some DHBs also have software from
Zeiss and Heidleberg Engineering, but appear
to be using it ineffectively, and there’s seldom
a designated photographer available to take,
maintain and share patient image records in
clinics. Confusingly, Christchurch also appears to
have plans for another imaging access system
called, ‘Weblogic’. But why, when there is no
real technical reason why our DHB departments
can’t have their cameras hooked up to Concerto
to access, share and display images as and when
needed? If we had this, we would then be able
to teach and encourage more clinic personnel to
take pictures and this would greatly facilitate the
clinical process. In the meantime, however, this
obvious enhancement is on the back burner and
nothing is being done!
Concerto also has the capabilities to function as
an efficient EHR system, especially as a new and
better version of its Winscribe dictation system
has been released, which means medical staff
could now just dictate their notes directly into
Concerto. But again, this isn’t being rolled out
yet nor is the basic system being used as it could
as DHBs remain wedded to their paper filing
systems. Perhaps everything is being deferred on
the assumption that some sort of big technological
bang is around the corner. Unfortunately, this is
unlikely to produce anything new, so it is a dubious
expectation without foundation.
I think it undeniable there is a toxic hybrid of
hard-copy and non-interoperable software in our
DHBs, compounded by a lack of willingness to
change. This fatal combination creates an iceberg
that cannot be safely navigated around. As a
first step we, collectively, have to acknowledge
that there is a way forward, and it’s staring us in
the face, literally looking out at us from our HCS
screens. Concerto has the capability, we just have
to authorise and embrace the changes needed. ▀
*Dr Mike Mair is a South Island locum ophthalmologist, having
retired from private practice in 2015 after three decades as
director of Timaru Eye Clinic. A progressive thinker, and an early
adopter of EHR, he is a passionate believer in technology and
improved processes to better serve the needs of both patients
and the eye health community in New Zealand. He has no
commercial interest in any companies mentioned in this article.
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26 NEW ZEALAND OPTICS December 2017