Background

PAMS clinics use Communicare as the patient information recall system (PIRS).  The PIRS has been run with different work practices over the years.  Most recently the PIRS appliance server, leased from Communicare, was located at the largest clinic in Jigalong.  The remote clinics of Parnngurr, Punmu and Kunawarritji ran Communicare off-line.  Synchronisation of the data bases could only be performed by sending the laptop computers back to Jigalong on the Friday mail plane and then returning the laptops on the Tuesday mail plane.  Although each clinic has a satellite connection to the internet speeds and connection quality were not capable of supporting the data transfers required for Communicare data synchronisation.   The process of sending the laptops with Communicare off-line via the mail plane worked but clients were moving between the clinics faster than their data was being synchronised and the mail plane was not always able to reach all the communities, especially in the wet season.  Gaps in  access to Communicare of a number of days required maintaining paper records with subsequent transcription, placing additional demands on the already very busy nursing staff.  Visiting GP’s were also not able to view records of a client when either returning with them to their community or when a person was being med-evac’d from a community different from their normal residence.

Re-configuration

To enable access to more timely client data PAMS upgraded the satellite communications infrastructure to support more reliable links and increase the bandwidth of the links.  The same satellite equipment was installed in each of the communities (click here for details).

The Communicare appliance server has been re-located to Newman where there is access to ADSL-2 land connections.  Two HP ProLiant ML-150 servers with 4GB of memory, dual power supplies, 350GB 3G SATA disks operating as a Smart Array with one 160GB SAS tape driver for back-ups.  One of the servers operates as a terminal server (Microsoft Terminal Services) with ThinPoint clients, and the other as the Domain Controller. An ethernet connected UPS is available for the servers along with a Skywire router, 24-port Cisco switch and Netgear Wireless router.

Delivery to the clinicians is over a Virtual LAN (VLAN) via Toshiba and Dell laptops, all of which have been upgraded to operate on Windows7 Professional.  An alternate fixed IP address has been established to enable the ThinPoint clients to by-pass the VLAN if performance is affected by other VLAN traffic.

Current PIRS operational environment

Clinicians, at all service delivery locations, access the single instance of the Communicare data base and application via a ThinPoint client over the PAMS network.  Back-ups of the system are performed nightly with weekly back-ups to an external hard disk that is stored off-site.

The new configuration also allows for more timely reviews and submissions of Medicare billings.

Links to PathWest have been re-directed to provide pathology reports for all locations and the Global Diagnostic links are also being upgraded so that medical images Xrays, CT, MRI and ultrasound can now be viewed over the secure network at all clinics with the Specialists’ reports being linked to patient records; image viewing is conducted by a web based viewer, external to Communicare.

Monitoring and Evaluation

Each of the components of the PAMS patient information support system is being monitored.  The satellite links, VLANs and power are monitored and supported by Ursys in Sydney, the Domain and Terminal Services servers and ThinPoint Clients are monitored and supported by Immensedata in Katherine and the Communicare Appliance Server is managed by Communicare Systems in Perth.

PAMS will be receiving monthly reports from the monitors to evaluate the performance of the system and to tune the components on an as needed basis, within our budget.

An evaluation of the system will be conducted on an on-going basis with independent reviews conducted by practitioners within the sector and researchers at UWA.

Results of the monitoring and evaluation will be compiled on a quarterly basis for the PAMS Board meetings.  Results will be published on the PAMS website.

Future linkage to provide PCEHR capacity for clients

PAMS, with strong community support at the General Meeting preceding the Annual General Meeting held in Jigalong 16th November 2010, will be progressing with Shared Individual Electronic Health Records (SIEHR), or, as they are now referred to by the Commonwealth government, Personally Controlled Electronic Health Records (PCEHR).

PAMS has been working with the University of Western Australia, Centre for Software Practice, to use the Medical Messaging Exchange (MMEx) as the standards compliant enabling technology for the PCEHR.  Indeed one of the key drivers for the up-grade of PAMS’ communications infrastructure and Patient Information and Recall System has been in preparation for participation in the PCEHRs, other e-health applications including Secure Messaging and tele-health.

MMEx offers a highly functional web-based clinical information and recall system as well as shared web services to support PCEHR, other e-health, secure messaging and tele-health access requirements.  The PCEHR functions are in-line with the current National eHealth Transition Authority (NEHTA) standards and specifications, and requirements defined by the Aboriginal Community Controlled Health Services in WA.  The web-services architecture of MMEx provides a versatile platform for the incorporation of additional functionality as requirements change and for interoperability with other standards compliant PCEHR repositories.

PAMS will continue to use Communicare for clinical client records with upload facilities to the PCEHR/MMEx.  This arrangement retains PAMS’ investment in Communicare, staff and locum training and Practices and Procedures while enabling clients, with their consent, to participate in, and to gain the benefits of, PCEHRs within WA and the adjacent jurisdictions of the Northern Territory and South Australia.

Developing capacity for regional connectivity to enable shared health records, other e-Health and tele-health functions and COAG C-T-G Program Support

Jigalong is the centre for Western Desert peoples’ Lore Ceremonies.  People from the West Pilbara, Kimberley, Central Desert and Northern Goldfields come to Jigalong during Lore Time.  In January 2011 over 70 “out of area” clients presented at PAMS’ Jigalong Clinic.  The additional workload on staff was exacerbated by the time taken to contact ACCHS and other providers in WA and the NT to obtain Health Summaries, including allergies and current medications, by phone and fax.  Transcription of data and adding scanned documents was a nightmare; creating new imprests and supplying medications was similarly fraught.

A salutary thought is that as the people moved to other communities for Lore, for example Roebourne (Mawarnkarra AMS), the same process would be repeated, time spent, service provision delayed and records replicated.

A further salutary thought is that when the transient clients of PAMS and Mawarnkarra reach home in the Kimberley or the NT those Services will be contacting PAMS for details of any interventions that occurred when their clients were attended to by PAMS medical staff … and then by Mawarnkurra … and all the other communities and regional centres through which they have passed during the two month Lore Time.

There has to be a better way for our health information systems to facilitate the Patient Journey and provide continuity of care for all people especially for those with chronic disease(s), co-morbidities and our Mums, Bubs and children.  Such improvements in consistent Service Provision are encompassed in the Commonwealth and State Goverments’ Closing the Gap initiatives through COAG.

PAMS and other ACCHS, in collaboration, are therefore being proactive, not just within the Pilbara but in the whole of NW of WA and adjacent jurisdictions, to assist in the development, testing, implementation and adoption of web-based NeHTA compliant technologies, as opposed to older desktop and client-server technologies.  Web-based systems will provide the basis for enhanced functionally flexible and extensible enablers, with secure information flows, to deliver timely services to our clients.  PAMS will be trialling stand-alone client shared electronic health records in MMEx on an iPad so that observations can be entered on the way to, and at, the airstrip as the RFDS plane arrives, then synchronising the client data over satellite internet so that client data is up-to-date with their status at hand-over.

Keeping culture alive, and keeping alive those knowledgeable in Australia’s cultural history in the Desert Region and indeed across the country, can be assisted through the Health Services using current, leading and emerging technologies based on the web and national standards for interoperability.

As this entry is being written (16th Feb. 2011) a tropical low pressure system is pounding the east Pilbara desert country with torrential rain.  Communities and staff are isolated by rising rivers and extensive local flooding, airstrips are out of commission, Med-Evacs cannot happen!  The dire situation here will not be reported on the evening news.  Meanwhile, PAMS’ new satellite links are still functioning, with the occasional drop outs in the satellite comms links only lasting for 4-7 minutes as intense cells of the storm pass through different communities in the service delivery area. There is no back-up network, no 3G, no 4G, no copper; until the National Broadband Network (NBN) reaches our communities … what we have, is it!  The clinics are open, if (at this time of day) on after hours call, torrential rain persists and those staff and locums due for incredibly well deserved and needed leave wait anxiously to see if there is going to be a way out to operating airports hundreds of kilometres away; winches are being checked, shovels stowed, sat-phones charged, a convoy organised and alternative routes across country planned … health service delivery in most of Australia is not just about Medicare billing, but people safety and well-being …. clients and providers.