The eHealth readiness of Australia's medical specialists - Final Report

Diagnostics (radiology and pathology)

Page last updated: 30 May 2011

Although pathology and radiology are grouped for the purposes of this project, at the request of the Department these have been separated into two categories for this section only. Separate discussions for pathologists and diagnostics follow the combined analysis below.

Key insights from eHealth readiness survey – diagnostics

The data and analysis in the following section combines pathologists and radiologists as diagnosticians unless otherwise indicated.
  • Given the large volume of information that diagnosticians are expected to share regularly with other practitioners, these specialists face strong incentives to computerise. As a result, diagnosticians are strong eHealth users and are especially likely to use computers to record and exchange health information. For example:
    • Over 90 percent use computers for storing records, and among these, 80 percent store patient health records in a computer-readable format
    • 57 percent use computers to view or record information during consultations (versus 38 percent of all medical specialists
    • 50 percent use computers to enter patient notes after a consultation (versus 30 percent of all medical specialists)
    • 49 percent share health records with other practitioners (versus 24 percent of all medical specialists)
    • 46 percent use computers to record event summaries (versus 33 percent of all medical specialists)
  • Of all specialties, diagnosticians are the most likely to be using telehealth (24 percent currently use, versus 9 percent of all medical specialists). The most common uses for telehealth include holding consultations with other practitioners (14 percent of all diagnosticians) and training (11 percent). This is consistent with work practices, as diagnostic specialists frequently consult with practitioners in external locations to discuss test results
  • Similarly, of those interested in telehealth, 69 percent are interested in using it for training and 63 percent are interested in consultations with other practitioners. Just 33 percent are interested in using telehealth for consultations with patients
  • Diagnosticians work in environments where computer use is prevalent. They are significantly more likely to agree that they are expected to use computers in their sector (96 percent strongly agree) and that most practitioners in their professional network use computers (91 percent strongly agree). They are also more likely to agree that the use of computers reduces errors in their sector (57 percent strongly agree) and express interest in computerised access to a shared patient summary (69% strongly agree)
  • In addition to environmental influences, diagnosticians are relatively self-motivated to adopt and use new technology: 41 percent strongly agree that they like to be early adopters of new computer systems for their practices (versus 28 percent of all medical specialists)
  • As expected, given their existing levels of eHealth use, diagnosticians are overwhelmingly positive towards eHealth benefits as compared with medical specialists in general. They have found ways to use eHealth to improve both the efficiency and the quality of care delivery in their speciality. Relative to other specialists, they are especially likely to agree that eHealth will:
    • Improve quality of care (61 percent versus 33 percent overall)
    • Improve continuity of care (60 percent versus 42 percent overall)
    • Improve their practice’s efficiency (56 percent versus 38 percent overall)
    • Improve their care delivery process (53 percent versus 30 percent overall)
  • As avid computer users who frequently exchange information electronically, diagnosticians are especially concerned about maintaining compatibility with existing systems, which was cited as the most significant barrier to adoption (45 percent strongly agree), and with systems used externally (29 percent of diagnosticians strongly agree). Although less concerned about system reliability than medical specialists overall, 21 percent of diagnosticians strongly agreed that concerns about system malfunctions and downtime was a barrier
  • As compared with medical specialists in general, diagnosticians are especially likely to be influenced by professional bodies (29 percent strongly agree) and by other practitioners (23 percent strongly agree).

Exhibit 31 depicts practice attributes for both pathologists and radiologists combined. Relative to radiologists, the pathologist respondents:
  • Have lower patient volumes. They are more likely to see 5 or fewer patients per day
  • Practise at a fewer locations. They are much more likely to practise at just one location
  • Practise almost exclusively in the public sector. Nearly all respondents reported that 75 percent or more of their income derived from the public sector. In comparison, some radiologist respondents reported that 50 percent or more of their income was sourced from the private sector.

EXHIBIT 31
(D)

Diagnostics – pathology

General overview

Description of specialtyPathologists study the nature and causes of human diseases. Pathology underpins every aspect of medicine, from monitoring of chronic diseases, to genetic research, to the diagnosis of every detected cancer in the world.

Sub-specialties include: Anatomical Pathology, Chemical Pathology, Genetic Pathology, Forensic Pathology, Haematology, Immunopathology and Microbiology.

NumberThere are just under 1000 pathologists registered to practice in Australia12.
Gender mix36% female, 64% male.

Pathologists and eHealth

Examples of relevant eHealth applications

  • Some example uses of eHealth that pathologists could benefit from include:
    • If a new eHealth imaging or ePathology system works properly, it could greatly reduce the unnecessary duplication of imaging and pathology tests which are costly, potentially unsafe, and are an inefficient use of time
    • The introduction of the health identifiers into pathology systems has the potential to greatly reduce errors incurred during the processing of samples and reduce unnecessary duplication of tests
    • Pathologists also mentioned that computerised decision support for test ordering helps ensure that practitioners are ordering the most appropriate tests for their patients.

Current eHealth ‘position’

Pathology is a highly technically competent and ‘eHealth’ ready specialty due to the automated nature of pathology work. The recently signed Pathology Funding agreement for 2011 has a number of references to eHealth initiatives to be implemented.

There are laboratory information systems marketed specifically to pathology laboratories in Australia, there is however a desire to improve these in consultation with the vendors as none are completely adequate for their purposes.

Seventy percent of pathology reports are currently delivered electronically using secure messaging, although some laboratories do not have the capacity to do this even now. It is mostly the public laboratories that are lagging behind – fixing this issue has not been a priority for some State and Territory Governments, although Queensland seems to be the leader.

There is considerable variation among medical specialties as to which groups are able to receive pathology reports securely electronically. The best are GPs because their standard practice software like Medical Director enables this.

The laboratory information systems are funded by the pathology businesses and not by the Government, so the college does have some concerns about future costs. It is not just the acquisition of appropriate software, but the training, maintenance and implementation that will be very expensive for the laboratories to maintain.

The college has a position that the PCEHR must not be selective in any way and must include all previous pathology records. To do otherwise is potentially dangerous and will lead to unnecessary duplication of tests. Despite this advice, however, a selective record has been recommended, which they do not support. They believe that access to the record should be controlled to protect privacy, not the content of the record. They do not believe that the potential size of a complete record will be a real issue as large amounts of storage are now available even on memory sticks, and up-to-date search functions are very sophisticated, enabling quick retrieval of relevant information from a document. They claim about 70 percent of the EHR would be pathology results.

The college is also deeply opposed to a system where the patients would have access to the pathology results before the referring doctor as this would lead to a lot of misinterpretation and unnecessary distress, particularly where cancer marker levels, e.g. PSA and CA125 are being measured.

The college is currently undertaking a joint project with NeHTA on the structured reporting of cancer into registries using the transfer of atomic data and not just blocks of text. Due to a lack of capability at the registry level, host registries and host laboratories have been hard to find and the pilot has yet to start. Most cancer registries are currently paper-based and very unsophisticated in the level of detail they collect.

In terms of where the laboratories are up to now and future readiness, the introduction of the unique health identifiers is seen as a huge step forward, which will greatly reduce error rates in the reporting of tissue specimens. Ideally they would like to introduce a system using secure messaging where they can flag when important results sent out are not ‘read’ and implement a protocol to try and contact the referring doctor. They are also keen to implement audit and training mechanisms using eHealth.

Key insights from eHealth readiness survey – differences for pathologists

Survey results that differed significantly between pathologists and radiologists are highlighted below. (The margin of error when results are viewed for just radiologists or just pathologists increases to +/- 17 percent at the 95 percent level of confidence.)
  • A number of eHealth application are not relevant for pathologists, namely transferring prescriptions (approximately 70 percent responded that they don’t use or need computers for prescribing), ordering diagnostic imaging (~40 percent don’t need), patient booking and scheduling (~40 percent don’t need), and patient consultation-related activities
  • Similarly, of those interested in telehealth, just 33 percent are interested in using telehealth for consultations with patients, which was driven by stronger interest from radiologists than from pathologists
  • Relative to radiologists, pathologists are especially likely to agree that eHealth will improve their ability to collaborate with other providers. Patient relationships are less relevant for pathologists, given the nature of their work
  • Access to IT support was a much stronger barrier for pathologists than for radiologists.

Characteristics and practice attributes

General workforce trends

Pathologists generally work in approved pathology laboratories which can be funded by the public sector attached to public hospitals, the corporate sector or as small/medium enterprises owned by pathologists. In contrast to diagnostic imaging, pathology is a smaller workforce, which is ageing, and significant workforce shortages in some of the sub-specialties are emerging.

Education, registration and accreditation

The Royal Australasian College of Pathologists (RACPA) is the organisation responsible for training pathologists and maintaining standards in Australia.

Royal College of Pathologists of Australasia
207 Albion Street, Surry Hills NSW 2010
T: 61 2 8356 5858
F: 61 2 8356 5828
www.rcpa.edu.au

The Royal Australasian College of Pathologists accepts applications from registered medical practitioners with a minimum of one year’s postgraduate experience, who wish to become specialist pathologists. The trainee must be employed in a training position in a laboratory accredited by the college prior to application

Pathology training takes a minimum of five years, including examinations. Training can be undertaken in General or Clinical Pathology or in one of the following single disciplines: Anatomical Pathology, Chemical Pathology, Genetic Pathology, Forensic Pathology, Haematology, Immunopathology or Microbiology.

Sources of financial reimbursement/role in the healthcare ecosystem

Diagnostic services provided to patients out-of-hospital and private hospital in-patients in Australia are remunerated on a fee-for-service basis under Medicare as outlined in the Medicare Benefits Schedule (MBS). Pathology outlays are managed through an agreement with the peak bodies, the Pathology Funding Agreement.

The Medicare rebate is paid at 85 percent of the scheduled fee for out-of-hospital services and 75 per cent for in-hospital services. About 86 percent of services are bulk-billed for pathology. In most cases, a request from a medical practitioner is required. The only exception is for a very small number of specified tests which can be requested by Nurse Practitioners and Midwives. There is also a small group of pathology tests which a medical practitioner can perform themselves, which do not require a request.

Diagnostics - radiology

General overview

Description of specialty
A radiologist is a medical specialist who has had specific postgraduate training in performing and interpreting diagnostic imaging tests and interventional procedures or treatments that involve the use of X-ray, ultrasound, and magnetic resonance imaging equipment. Radiologists are trained to assist other doctors and specialists to treat their patients by making a diagnosis and providing treatment using medical imaging.

Radiologists can choose to work in various sub-specialties of radiology such as breast imaging, interventional radiology, musculoskeletal imaging, cardiac imaging, or paediatric (children’s) imaging.

NumberThere are approximately 1500 diagnostic radiologists and a further ~260 radiation oncologists registered to practice in Australia.13
Gender mix22% female, 78% male.

Radiologists communicate the results of diagnostic and interventional imaging through a written report sent to the referring doctor. Radiologists work as part of a clinical team so that they can participate actively in decision making about imaging tests.

There are three types of radiology – diagnostic, interventional and therapeutic (called radiation oncology):

Diagnostic:

  • Diagnostic imaging uses plain X-ray radiology, computerised tomography (CT), magnetic resonance imaging (MRI), ultrasound and nuclear medicine imaging techniques to obtain images that are interpreted to aid in the diagnosis of disease.

Interventional

  • Interventional radiologists treat as well as diagnose disease using imaging equipment. Interventional radiologists may sub-specialise further so that they only treat abnormalities of the brain or spinal cord (neurointervention), or of the blood vessels elsewhere in the body (angiointervention). Interventional radiology is a minimally invasive procedure using X-ray, magnetic or ultrasound images to guide the procedures, usually done with tiny instruments and thin plastic tubes called catheters inserted through an artery or vein.

Radiation oncology

  • Radiation oncology uses radiation to treat diseases such as cancer, using radiation therapy. These specialists are not called radiologists, but radiation oncologists, even though they belong to The Royal Australian and New Zealand College of Radiologists.

Radiologists and eHealth

Examples of relevant eHealth applications

  • Some example uses of eHealth that radiologists could benefit from include:
    • Electronic reporting of results and online access to images is a highly efficient and convenient service for practitioners, especially among those consulting with patients in remote areas
    • Electronic ordering is not yet widely used, but is anticipated to improve accuracy and efficiency.

Current eHealth ‘position’

Radiologists are among the most advanced specialist groups in terms of eHealth. The RANZCR believes that radiologists are more technically advanced and more eHealth ready than the other specialties by a factor of 50–80 percent, as all their workflows are currently digitalised.

Their main challenges are as follows:
  • Lack of readiness of referring doctors
  • Lack of appropriate infrastructure to send and store large files in appropriate formats
  • Ensuring that standards for viewing digital images are consistent and adhered to.

The College has developed its own solutions to the issues raised above, however there is a need for national leadership for things to progress any further. The lack of connectivity is a major issue even within hospitals, as many operating theatres and outpatient areas do not have the proper equipment to view digital images. There is also disagreement between radiologists and other specialists who use imaging about what the standards for viewing digital images should be.

Ultimately there will be a transition period in moving to a purely digital world, as no-one is able to scan all the old images in existence on to a digital record. The type of medical record they want to see will contain images and the radiologists’ reports, a central data repository with centralised but controlled access, in an environment where the privacy issues have been dealt with. The PCEHR currently does not address these issues as it may contain images at the moment, but not the referrals. They think that appropriate incorporation of the diagnostic imaging is infeasible in the time allocated to implement the project – the infrastructure to support this does not exist.

They also have issues with the potential ownership of images. At the moment patients are sometimes given a memory stick and a CD, and sometimes the images are sent to the referring doctor. This raises the question of who is responsible for them in the long term, as a lot of data is currently lost and scans are duplicated unnecessarily, which irradiates the patient and could potentially be harmful.

The equipment on which images are viewed is not consistent. This has been raised as a concern by the medical indemnity providers as a source of errors resulting in medicolegal claims. Sometimes when a CD is put into a public hospital computer it cannot be opened without administrator rights. Some hospitals also do not accept CDs as legitimate patient records when they come with a transferred patient, as they do not contain a doctor’s signature – this should be improved with the introduction of the patient health identifiers.

The College (RANZCR) is also considering the appropriateness of the Medicare rebates for diagnostic imaging, as currently a rebate is not payable until a report is provided, the provision of images alone is insufficient – this may need to be reviewed in the light of the eHealth changes.

Key insights from eHealth readiness survey – differences for radiologists

The eHealth readiness discussion in the preceding section included radiologists as part of the ‘diagnostics’ segment. Results that differed significantly between radiologists and pathologists have been highlighted below. The primary differences between these two groups are in the ways that they use computers and eHealth solutions, rather than their perceptions of eHealth benefits, barriers, and adoption drivers. (The margin of error when results are viewed for just radiologists increases to +/- 17 percent at the 95 percent level of confidence.)
  • Radiologists are more likely to use computers to share health records with patients, for patient booking and scheduling, for billing and patient rebates, to show patients health-related notes during a consultation, to view and/or record information during consultations, and to enter patient notes after a consultation
  • Radiologists are also more likely to rely on computerised records (~45 percent of respondents store patient histories and records entirely on computers)
  • Radiologists expressed stronger interest in using computers to transfer prescriptions to the pharmacy and to complete event summaries or specialist reports
  • Of those planning to use telehealth within the next three years, radiologists were more interested than pathologists in holding remote consultations with patients. Interest in other telehealth applications was relatively similar between the two groups of specialists
  • Radiologists were less likely to agree that eHealth will improve their ability to collaborate with other providers, and also less likely to agree that access to IT support is a barrier.

Characteristics and practice attributes

General workforce trends

Most radiologists work in a public or private hospital or private radiology practices. Independent practice is rarely possible because of the capital costs of the equipment required. The advent of digital imaging has meant that radiologists are able to report on films from locations that are a great distance from the practice – sometimes even overseas. Diagnostic radiology is a relatively popular specialty due to regular working hours and a reliable income, and workforce issues in rural and remote Australia can usually be addressed by radiologists operating from a distance as previously described.

Education, registration and accreditation

The Royal Australian and New Zealand College of Radiologists (RANZCR) is the organisation responsible for training radiologists and radiation oncologists and maintaining imaging standards in Australia.

The Royal Australian and New Zealand College of Radiologists
Level 9, 51 Druitt Street, Sydney NSW 2000
T: 61 2 9268 9777
F: 61 2 9268 9799
www.ranzcr.edu.au

To enter training in diagnostic radiology or radiation oncology, the trainee must have successfully completed a medical degree and the one year internship program.

The current Radiodiagnosis curriculum, introduced from 1 December 2009, is a five-year program conducted in two phases:
  • Phase 1 – three years of general radiology training
  • Phase 2 – two years of systems–focused (as distinguished from sub-specialty) rotations for advanced radiology training.

The current Radiation Oncology Training Program, introduced from 1 December 2008, is a five-year program conducted in two phases:
  • Phase 1 of between 18–24 months duration
  • Phase 2 of approximately 36–42 months duration (depending on the trainee’s progress through Phase 1).

There are examinations at the end of both phases of training.

Sources of financial reimbursement/role in the healthcare ecosystem

Diagnostic services provided to patients out-of-hospital and private hospital in-patients in Australia are remunerated on a fee-for-service basis under Medicare as outlined in the Medicare Benefits Schedule (MBS).

The Medicare rebate is paid at 85 percent of the scheduled fee for out-of-hospital services and 75 per cent for in-hospital services. About 73 percent of services are bulk-billed for imaging. In the case of diagnostic imaging, a referral is not required for all services, as specialists can self-determine in their area of specialty. A wide range of allied health professionals can also refer for specified imaging services.


12 AIHW Medical Labour Force Survey 2008, published in 2010.
13AIHW Medical Labour Force Survey 2008, published in 2010

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