GP2GP In Action - Transferring Patient Records Around New Zealand, Electronically
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The GP2GP system allows electronic transfer of patient records between general practices in New Zealand. It has led to improved patient satisfaction and care continuity. Uptake has been over 90% within 2.5 years. Over 85% of practices are on track to meet the annual target of 375,000 record transfers between practices. Barriers to adoption include some IT infrastructure limitations. Future work includes allowing unlimited attachment sizes and implementing electronic requests for record transfers.
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GP2GP In Action - Transferring Patient Records Around New Zealand, Electronically
- 1. GP2GP In Action - Transferring Patient Records Around New Zealand, HINZ Conference 2014 Paper Presentation 11 November 2014 1 Peter Jordan Solution Architect Electronically.
- 2. Introduction 2010 National Health IT Plan “GP2GP…a project that seeks to provide general practices with the capability to safely and securely transfer patient records electronically, from one practice to another, to ensure a continuum of care when a patients chooses to move between practices.” 2013 National Health IT Plan - Update “a capability that has simultaneously lifted patient satisfaction, clinical safety and health care provider efficiency.” • Methods – the components of CDA • Findings – GP2GP transaction reports • Discussion - service utilisation to date
- 4. Findings: GP2GP Usage Reporting • Reporting Periods • Previous Calendar Month – Practice Level • Current Calendar YTD – Region, DHB, PHO, PMS Level • Previous 12 months – GP2GP At a Glance • Total duration of GP2GP– Total Message Numbers • Reporting Scope • Healthlink Network – c/f Portable Storage Devices • Transactional – acknowledgements linked to transfers • Practice Statistics – ‘Enrolling’ practice belonging to a PHO
- 5. Findings: GP2GP At a Glance
- 6. Findings: Adoption & Movements • Overall - Nationwide 93% • Regional – Central 94%, Midland 87%, Northern 95%, Southern 96% • DHB – 5 at 100%, 12 at 90-99%, 2 at 88%, 1 at 50% • PHO - 17 at 100%, 14 at 90-99%, 3 at 75-89%, 1 at 38% • PMS Vendor - Medtech 98%, MyPractice 94%, Houston 73%, Intrahealth 32% 2014 (Q1 & Q2)Transfers With Location Boundary Changes…
- 7. Practical Discussion Have the project goals been delivered? • Transfer Numbers – > 85% towards target of 375,000 pa – Do all the transfer messages represent genuine patient movements? – 99% of recorded usage are exchanges between enrolling practices • Adoption Influences - Vendors and Practices/PHOs – Barriers: IT infrastructure limitations – Willingness and ability to deploy relevant software updates • Operational & Data Constraints – File size limitation of 5MB – GP2GP v2.1 increased limit to 20MB – Legacy data issues fixed - User-Defined Codes containing spaces – Point-to-point messaging
- 8. Summary Conclusions • Successes - Voluntary system used by over 90% of practices in first 2.5 years - Administrative, clinical and patient satisfaction benefits - Delivery of a key requirement of the National Health IT Plan - NZ leadership in Primary Healthcare IT • Going Forward - Electronic requests (National Enrolment System – Phase 2?) - Unlimited attachment sizes: Alternative technologies (CDRs, REST) • Acknowledgements - Andre Bredenkamp, Andrew Terris, PMS Vendors & Healthlink. “Interoperability is not a boat race. One team can’t win by rowing better than another. We are all rowing the same boat.”
- 9. Reference Sources • National Health IT Board. National IT Plan. September 2010 • Ministry of Health. 2013. National Health IT Plan Update 2013/14. Wellington: Ministry of Health. • Bredenkamp A. GP2P-Overview-Brochure. Patients First www.patientsfirst.org.nz/wp-content/overview-brochure.pdf • Pulse IT Magazine. GP2GP Initiative Achieves Exponential Adoption. November 2012 • HL7. Clinical Document Architecture Release 2. http://www.hl7.org/implement/standards/index.cfm • HISO: Health Information Exchange Structured Documents Architecture Building Block. HISO 10040.3 Version 1.0 April 2012 • Wikipedia. Continuity of Care Document. http://en.wikipedia.org/wiki/Continuity_of_Care_Document at 14/04/2012 • Jordan P. Clinical Document Architecture Implementations - Lessons Learned To Date. HINZ Conference 2012 www.hinz.org.nz/uploads/file/2012conference/Papers/P9_Jordan.pdf • Wikipedia. Extensible Stylesheet Language Transformations (XSLT). http://en.wikipedia.org/wiki/XSLT at 23/06/2012 • Health & Social Care Information Centre. GP2GP Electronic Health Record Transfer. October 2013 • http://www.slideshare.net/HSCIC/gp2-gp-presentation-olympia-conference-2?related=1 • Pulse IT Magazine. GP2GP Sets Records for Medical Record Transfers. July 2014
- 10. Questions & Suggestions • Impact of new HIE standards on GP2GP? • Thanks for attending! peter.jordan@patientsfirst.org.nz
Editor's Notes
- Abstract… The GP2GP Project, facilitating the electronic transfer of complete patient records between General Practice systems, was delivered by Patients First in mid-2011 and has been rolled out by the relevant Practice Management System vendors over the past 3 years. This utility is now used in over 90% of practices with monthly record transfer numbers reaching up to 30,000. After a brief description of the various components of GP2GP, this paper will provide a detailed analysis of its use to date, based on nearly 3 years of transactional data supplied by the service provider used to transmit the message files.
- GP2GP (General Practitioner to General Practitioner) is described in the 2010 National Health IT Plan [1] as “a project that seeks to provide general practices with the capability to safely and securely transfer patient records electronically, from one practice to another, to ensure a continuum of care when a patients chooses to move between practices”. This project was delivered by Patients First, and rollout commenced with a 65 site pilot on 1st July 2011 and, at the successful conclusion of this pilot, general release by Practice Management System (PMS) vendors began early in 2012. By the end of 2012, over 70% of enrolling general practices had participated with 8,000 patient files sent per month and this has steady climbed to a peak in May 2014 when over 32,000 transfers were made with 93% of enrolling general practices having used GP2GP. A subsequent update to the IT Plan [2], released in November 2013, noted that GP2GP was now “a capability that has simultaneously lifted patient satisfaction, clinical safety and health care provider efficiency”. This paper will contain a brief description of the functionality encapsulated in GP2GP, provide summary statistics of its use and adoption – based on analysis of every single message sent by the transport service provider – and draws some conclusions on how, and where, the service has been utilised to date.
- GP2GP was conceived to reduce the administrative burden and potential loss of clinical information that resulted when patients change general practices. Patients First has estimated that “over 375,000 patient files are transferred between general practices as patients move around new Zealand”. [3] Practices using GP2GP can eliminate the need to print and compile entire patient records, before posting or passing them along to the patient to take to their new practice. Under such manual workflows, the recipient had either to scan the record or file in their existing paper archives – in addition to entering all relevant patient demographics into their clinical system, an extra step obviated by electronic transfers. The Business Process The GP2GP process commences when a patient enrols at a new practice and gives authority for that practice to request his or her medical record from the outgoing practice. On receiving this request, the old practice uses their PMS software to extract the patient’s full record (excluding any information they have elected not to be transferred); place it in a Clinical Document and package it, along with any attached documents, in an electronic transport message. This is then passed to the new practice, via a secure messaging service which guarantees delivery to the appropriate electronic inbox. The incoming practice then uses its PMS software to process the message – displaying the human-readable part of the Clinical Document to the new doctor and filing all the ‘atomic’, structured patient data and attachments in the practice database. Patient identification is achieved by the mandatory use of the National Health Index (NHI) number. The sending of an electronic acknowledgement message, to the previous practice, completes the workflow. The Practice Management Systems While a simple idea conceptually and an obvious area for workflow improvement, variations in the four general practice clinical software products used throughout New Zealand, and a lack of defined standards in this area, meant that a significant amount of work needed to be undertaken before the vendors could deliver the GP2GP functionality. [4] In particular, the ‘traditional’ PMS clinical data models of patient demographics, allergies and alerts, encounters, medications, observations, tests, vitals, immunisations, problems, procedures, maternity, documents, etc. needed to be transposed into the Health Level Seven (HL7), Clinical Document Architecture (CDA) structure [5] – the newly-introduced sector standard for Health Information Exchange payloads [6]. The Common Components As a continuity of care requirement, involving the transfer of an entire patient record from one healthcare provider to another, this represented a large-scale implementation of CDA; with each PMS vendor needing to interpret the substantial, and highly complex, Implementation Guide in an absolutely identical way. To resolve the relevant technical, and financial, implications of this, two solutions were adopted – the development of a shared Data Model (based on the internationally-adopted Continuity of Care Record (CCR) and Continuity of Care Document (CCD) [7] standards) and a common software component (NZ CDA Toolkit) to facilitate the creation, packaging and consumption of GP2GP CDA documents. These were developed in a shared source and funding project, led by Patients First, to which all the PMS vendors made major contributions. Further details of the ‘Toolkit Project’, and how the various technical hurdles were overcome, were discussed in a paper presented to the 2012 Health Informatics New Zealand Conference [8]. Transporting the Message CDA is a document, not a messaging standard; raising the issue of how one should transmit a CDA document, and any external attachments, from one Healthcare Facility to another. The answer was to package these artefacts in a HL7 version 2 message file – similar to those used to pass other health data around the sector - and use the Healthlink Secure Messaging Service, widely deployed throughout New Zealand, to encrypt and transfer these messages. This meant that it was relatively simple to configure each PMS to identify and process incoming patient records, as a new item type, from their existing inboxes. The transaction logs of GP2GP messages - which include the message dates, sizes, Electronic Data Interchange (EDI) addresses and names of the sending software applications - have also provided a rich source of data for analysing the usage of GP2GP, as will be illustrated in the following section on usage reporting. These logs also include the acknowledgement messages which contain identifiers that can be linked back to the original transfer message. Displaying the Patient Transfer Record CDA documents contain a human-readable element, notably a Text Section that can be displayed in a web browser (or a browser control on a windows form) using Extensible Stylesheet Language Transformations (XSLT) [9]. This enables a clinician to view, and store, a single document view of the entire medical record received from another practice. At least one PMS vendor has added an additional feature to this Stylesheet that provides clickable links to attached documents passed in the transfer, using their new location in the practice’s electronic file system.
- Utilising comprehensive transaction listings supplied - at the start of each month - by Healthlink, Patients First produces a suite of graphical and tabular reports, each month, depicting the usage and adoption of .GP2GP for the following periods: the previous calendar month the current calendar year-to-date the previous 12 months the total duration of GP2GP usage For obvious reasons these figures do not include any transfers that take place outside of the Healthlink network – for example where the transport message exceeds the maximum size and might have been placed on a portable storage device, such as a memory stick, for the patient to take to their new practice. Unfortunately, no statistical information is available about these GP2GP transfers.
- The following is taken from the “GP2GP at a glance” report that is created after each monthly batch of transactions in processed. It is distributed to the Ministry of Health and published, on an ad-hoc basis, in various sector media. It should be noted that these figures include messages sent from practices that have subsequently closed; merged with others; or do not enrol patients, such as some accident and medical clinics. The number of currently-open enrolling general practices that had used GP2GP on 30th September 2014 was 956.
- These figures are based on a constrained definition of an ‘Enrolling General Practice’ that is a member of a Primary Healthcare Organisation (PHO) or Network which is, in turn, contracted, for patient services, by a District Health Board (DHB). Such a practice tends to have a single database of enrolled and casual patients, a single Electronic Data Interchange (EDI) address – although there are instances of these being shared among practices – and may operate at one, or more, physical locations (facilities). Regional - presents a picture of consistently high, and marginally above-average, adoption rates over Central, Midland and Southern Regions, but a significantly lower rate in Midland Region which is explained by the following Table that lists adoption by District Health Board affiliation: DHB - Although there are only 3 DHBs with adoption rates below 90% - there is a large gap between the recorded for 88% both Waikato and Whanganui and the 50% rate for practices affiliated to Lakes DHB. PMS Vendor - The influence of the figures for each of the 4 major Practice Management System vendors on the national, regional and district adoption rates is illustrated by a combination of the relevant percentages and total numbers of adopting practices. Another insight provided by this transactional analysis relates to movements that cross the various location boundaries within the NZ Health Sector… At first sight, the most surprising figure might be that 45% of transfers occur between practices in the same PHO, although this undoubtedly reflects the increasing urbanisation of New Zealand which results in the majority of movements occurring within the major cities - particularly Auckland. The large cities also contain the PHOs with the largest number of member practices. Another related statistic is that the largest number of inter-PHOs transfers also took place within the greater Auckland Region.
- Extrapolation of the number of transfer messages received for the first half of 2014 would take GP2GP over 85% of the way towards meeting the figure of 375,000 annual patient transfers estimated by Patients First. In the often slow and tortuous path towards health information exchange, that represents substantial progress over a period of fewer than 3 years. Many have questioned how many GP2GP transfers represent genuine patient movements but, despite the fact that the records show some usage outside of general practices (e.g. by Primary Healthcare Organisations and various government agencies), analysis reveals that 99% of transfers, to date, have been between enrolling general practices. Generally speaking, the rate of adoption has been determined by the PMS vendors, in conjunction with the willingness and ability of their clients to deploy the relevant software updates. GP2GP has been implemented as a service that can be switched off and it is believed that a few practices may have done so because of resource constraints on their IT infrastructure. In the adoption landscape depicted in Table 2 above, there is a clear gap within the Lakes District which can be attributed to the fact that none of the 10 practices belonging to the Rotorua Primary Health Services PHO (which has an overall adoption rate of 38%) and using an Intrahealth PMS, have implemented GP2GP. Aside from practices that have yet to use GP2GP, there have been operational and data legacy factors that have limited its use within adopting practices. The most significant of these has been a restriction in the file size that could be sent via the Healthlink Service – although this has recently been raised from 5MB to 20MB as part of updated version of GP2GP that also includes some back-end fixes that handle issues with legacy data, notably non-standard clinical codes. It is believed that the four-fold increase in the maximum message size should cover the vast majority of patient records. In the United Kingdom a new version of GP2GP was planned for 2014, to include an unlimited file size and number of attachments; however, in New Zealand, that would undoubtedly exceed the limitations of the existing infrastructure and processing capabilities of the end-point systems. Other commonly discussed improvements include an electronic mechanism for the new practice to request GP2GP transfers from the patient’s previous practice, although this probably dependent on the development of a directory-style Web Service that enables practices to lookup the EDI addresses of others based on the practice name and location.
- GP2GP has been operating in New Zealand for over two years, allowing general practices to easily transfer medical data when a patient moves out of an area or to a new practice. In May 2014, it set a new record of 32,689 transfers for the month. It is a completely voluntary system, with no financial incentives to use it and yet it has been used by over 90% of enrolling general practices. Former Patients First CEO, Andrew Terris, described its adoption as “stellar” [11], attributing this to the “utility practices found with the system” – saving time previously spent printing, photocopying and re-entering data To these administrative benefits, one must also add the resultant improvements in both clinical safety and patient satisfaction. The successful delivery and deployment of GP2GP has fulfilled a key requirement of the National Health IT Plan, allowing foundation health information to be passed through the continuum of patient care. It has also helped to consolidate New Zealand’s position as one of the world leaders in health information technology.