The man appointed by Malcolm Turnbull to transform the Commonwealth’s digital public services has said if he was Australian he would probably opt out of the Government’s controversial online health database.
Partridge Street General Practice is all about professional, comprehensive, and empowering General Practice care by our GPs. When we refer our valued patients for treatment elsewhere we promote the same high standards, values, and communication that we provide. A letter, referral, or phone call is just part of the standard Partridge Street General Practice service – it’s good clinical handover. Dr Nick Tellis recently collaborated with some excellent GPs in writing an article for the Medical Journal of Australia’s online Insight Blog on ways to improve communication during these times and stressing the importance of better clinical handover. It’s another one of the ways Partridge Street General Practice provides Better Healthcare for our valued patients. Read on.
This is the third article in a monthly series from members of the GPs Down Under (GPDU) Facebook group, a not-for-profit GP community-led group that is based on GP-led learning, peer support and GP advocacy and was originally published at the Medical Journal of Australia (MJA) Insight Blog here.
“PASSING the baton” describes what health care professionals try to achieve as care of patients is transferred between providers in our complex health care systems. The topic of safe and effective clinical handover comes up repeatedly in discussions on GPDU.
It is apparent that the impacts from delayed or poor clinical handover on patient care across the country are significant, under-reported, and have a profoundly negative effect on the care patients receive.
Dropping the baton
First-hand accounts of treatment delays, duplication of testing, medication errors, and unplanned readmissions are frequently discussed by GPs. Recent clinical case discussions have included a patient in palliative care being transferred to a hospice on a Friday afternoon with no clinical handover, and a 3-month delay in the completion of a discharge summary for a truck driver who was admitted with a myocardial function.
The safety concerns related to poor clinical handover are not new: it’s a problem the health care industry and doctors as a profession have been grappling with for decades. Poor clinical handovers are wasteful of limited resources. How can we improve patient outcomes and “drop the baton” less often?
Rules of the game
The National Safety and Quality Health Service Standards (NSQHS) and the Australian Commission on Safety and Quality in Health Care (ACSQHC) define clinical handover as; “the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group”. Appropriate clinical handover is a requirement of the NSQHS. The ACSQHC notes the importance of “transition of care” that “ends only when the patient is received into the next clinical setting”. The Australian Council on Healthcare Standards EQuIP National Standard 12, in particular, specifies the planned provision of transfer information, including results of investigations.
Breakdown in the transfer of clinical information has been identified as one of the most important contributing factors in serious adverse events, and is a major preventable cause of patient harm.
Why is clinical handover from hospitals to GPs done so inconsistently for patients transitioning from our major private and public institutions? The benefits of passing the baton smoothly are clear. It’s time to coach the team to get it right.
Timing is everything
Health services continue to debate the appropriate timeframe for communicating with the GP who is continuing the patient’s care. Timeliness of clinical handover is a topic that comes up frequently. Hospital targets for transfer of care communications vary widely. A recent discussion on GPDU identified several targets within one small geographical area, ranging from “at the point of discharge”, “48 hours after discharge” and “5 days after discharge”.
The reality is that few patients leave hospital with an effective clinical handover. Some will be received within the hospital’s current targets; however, many clinical handovers are not received for weeks, months or, as one post highlighted, years after the patient care is transferred. Some never occur.
Many GPs are asking whether these targets are consistent, appropriate, acceptable or safe. A robust discussion took place after GPs were approached to complete a survey that included a question asking what conditions should warrant a discharge summary on discharge, and what the acceptable timeframe for receiving a discharge summary should be.
The overwhelming consensus was that the gold standard should be clinical handover on discharge for all patients. Many were frustrated that this question even needed to be asked. Some GPDU members wondered whether this was a trick question aimed at moving the goalposts further away from quality patient care.
Services promoting clinical handover to GPs on discharge were highlighted. The Sunshine Coast Hospital and Health Service was identified as a provider that was actively trying to effect positive change. They received plaudits from the wider GP community simply by having a discharge summary management policy specifying complete discharge summaries available at the time of patient discharge.
It is well known in GP circles that starting late ensures that you will run late all day. Timely discharge summaries aren’t late. Timing is everything when you want to be a frontrunner.
Don’t fumble the handover
The consensus among GPs is that well timed, efficient, effective and safe clinical handover, at or before the point of transition of care is essential. Alternative strategies risk adverse outcomes. Clinical handover must be a standardised process between clinicians.
Returning to the athletics track, we can see a clear difference between a handover, a throw, and a drop. Highly trained athletes accept nothing less than a smooth handover – nor should highly trained clinicians. Delegating the handover to non-clinicians, including nurses and medical students, is not good enough. Supervision and ongoing coaching of clinicians is vital.
The baton is passed between people not machines
Imagine the difference electronic systems could make to this smooth handover. Sadly, this smooth electronic handover exists only in the imagination.
In the real world, GPs are grappling with being thrown links to hospital electronic records through systems such as “The Viewer”. Investigations are likely to be uploaded (after a delay) to MyHealthRecord. These are raw data, unfiltered and disorganised, and more of a throw than a handover. Being thrown raw data and being expected to catch them in this way is akin to a hospital doctor being given the login to the GP clinic’s patient management system and being expected to extrapolate a referral.
Personal bests are set; medals are won
The late Sir Roger Bannister ran the 4-minute mile and reset the expectations for all that followed him. GPs and their discussions can highlight outstanding clinical handovers and applaud initiatives and hospitals that are doing it right. Feedback and constructive criticism can be passed back to hospitals that are raising the bar. Medal-winning performances show the possible and provide a model for future improvement. GPs are uniquely placed to spot the talent and report the score widely and rapidly.
Eyes on the prize: what’s the next goal?
If we can normalise the clinical handover to young GPs who are the future of general practice, it will encourage them to demand it of their hospitals.
Hospitals are incredible places, but the aim is for patients to return home to their communities and trusted GPs. They come home. Their GPs are waiting, willing and able. We can do better, and we will. We extend an open hand to our amazing hospitals. Pass us the baton – we won’t drop it.
Dr Katrina McLean is a Gold Coast-based GP, Assistant Professor in the School of Medicine and Health Sciences at Bond University, and a GPDU administrator.
Dr Michael Rice is past-president of the Rural Doctors Association of Queensland, an educator of students and registrars, a long term resident and rural GP in Beaudesert. He’s a keen user of social media.
Contact Dr Nick Tellis at email@example.com or 0882953200 if You are a Great GP and want a Better Place to practice great medicine!
We’ve written about the Patient Controlled Electronic Health Record (PCEHR or MyHealthRecord) before – you can have a look at the links below.
Today we’re going to talk about how NOT to have a MyHealthRecord. Perhaps you don’t think it’s private, perhaps you’re opposed to it for some reason. Perhaps you just don’t want one. Read on.
The Australian Government is expanding My Health Record for all Australians in 2018.
By the end of 2018, a My Health Record will be created for every Australian unless they choose not to have one.
How can I opt out?
If you decide that you don’t want a My Health Record created on your behalf, you will have the opportunity to tell us during a three-month period.
This period will run from 16 July to 15 October 2018. It’s not possible to opt out of having a My Health Record before this period starts on 16 July 2018.
Want to be part of the Partridge Street General Practice team? Contact Dr Nick Tellis at firstname.lastname@example.org or 0882953200
We’ve just celebrated the Chinese New Year – the Year of the Dog. People born in Dog years display loyalty and honesty amongst many other good qualities. However it is said that they can also be critical – maybe overly so. Segueing to another Chinese concept, we meet Qi, the vital life force that flows through the body. Let’s put these together.
A wise man once told me that the three pillars (the vital life force) of general practice are quality, service, and finance. All three of these come together in the form of the Practice Incentive Payments (PIP) scheme. You can read about this here but in summary Accredited General Practices are paid amounts of money for reaching certain quality measures. These include planning the management of a proportion of patients with diabetes and asthma, and ensuring women are screened for cervical cancer. There are also Incentive Payments for managing aged care and quality in prescribing.
These payments were due for a change on May 1st 2018. Were they promoting the vital life force of General Practice, were they tick box exercises for busy GPs, or were they overly critical of General Practice, not focusing on true quality? Enter QI – Quality Improvement. Rather than Qi, QI may be an altogether different beast.
The Department of Health has confirmed that the Practice Incentive Program Quality Improvement Incentive will now occur from 1 May 2019.
From their press release:
The Practice Incentive Program (PIP) has been a key driver in quality care in the general practice sector and the PIP QI Incentive will continue to build on this important work, further strengthening quality improvement in primary health care. The additional 12 months will enable the Department, with the support and advice from PIPAG, to ensure that any implementation issues are identified and addressed and that general practices have adequate opportunity to prepare. It will also allow the Department to continue to consult with stakeholders on refining the design of the PIP QI Incentive.
The changed time frame will mean that the following five incentives which were to cease on 1 May 2018, will now continue through to 30 April 2019.
The five incentives are:
Quality Prescribing Incentive
Cervical Screening Incentive
General Practitioner Aged Care Access Incentive
The six PIP Incentives that continue to remain unchanged are:
After Hours Incentive
Rural Loading Incentive
Indigenous Health Incentive
Procedural General Practitioner Payment
What next? Will the new QI beast be reflective of quality in General Practice? Will the measures align with what we as General Practitioners believe is high quality Great General Practice care? Or will it aptly be launched in the Chinese Year of the Pig in 2019?
For what it’s worth, here are my measurements of quality, service, and finance in General Practice – the Qi of GP:
I would love to hear other views on this. We are all professionals or patients or both and we can always improve. Let me know here on the blog (or on our website) – or, if you’re a GP, on the fantastic GPDU FB Group – where GPs are invited to a festival of education and collegiality (#FOAMed – #GPDU18) May 30 – June 1! My last quality ltip – for personally better Qi – is below!
Get a Great GP!
(Here’s some we made earlier)
We look forward to seeing you soon!
Mental health and depression are serious issues. GPs see, treat, and support people with these issues everyday but who looks after the GPs? We can see that doctors are only human and suffer the same stresses as everyone else. Sadly, sometimes, it is too much.
I wrote previously about how to detect depression in patients. ‘Listen to the patient’, ‘How do they feel?’, ‘How do they make you feel?’. Experienced GPs can spot depression a mile off…in other people. How many turn that acumen on themselves? How many have their own GP to care for them?
I also wrote ‘American studies show patients are scared of psychiatric referral. Australian GPs are also scared of psychiatric referral’ and ‘Untreated depression is associated with decreased quality of life and increased mortality. Depression can be successfully treated and treatment is effective. The earlier the better!’. This is as true for GPs and doctors as it is for every other person.
So GPs, doctors, and others – Exercise, diet, psychotherapy, GP counselling, reducing drug and alcohol use, getting more and better sleep are all options. These take time and effort so give yourself permission to spend these on You. Your friends, family, and colleagues are here for you. They will #bekind.
Depression is not just a chemical imbalance. No pill can defeat the entirety of the patient’s life and circumstances pushing them in the wrong direction. Consider the your environment and be aware of the particular pressures of medical work and life. GPs have a fantastic and privileged therapeutic relationship with their patients, and they can use this to capitalise on the essential window of time before delivering medical advice. This “privileged moment for change” prepares people to be receptive to a message before they experience it. Robert Cialdini has coined the term ‘pre-suasion’ to describe this. The therapeutic relationship allows pre-suasion, and therapeutic change can then be addressed, with consideration of motivation, opportunity, and ability.
Dr Eric Levi has literally stepped forward online with the #crazysocks4docs / #socks4docs hashtags. It’s a lighthearted way of getting us to acknowledge a serious topic. I’m in!
The equally dapper Terry Cornick has been kind enough to contribute his story to my blog – and I hope it gives some of you hope, a good read, and another option for you and your patients.
Terry is a Healthcare Consultant, Mental Health Advocate and Freelance Writer.
His professional background includes Consulting in Healthcare and he loves creating, research, technology, and communications. Daily he deals and develops relationships with Doctors so knows a little about them too and the unique stresses they are placed under.
Initially as a hobby, Terry created a grassroots men’s mental health support network named “Mr. Perfect” that is growing by the minute. Although it does not pay a cent, it pays handsomely in purpose. You can check it out at www.mrperfect.org.au
Known sarcastically by his wife as “Dr Terry” he lives on the North Shore of Sydney with his young family and is currently contemplating his next move professionally, navigating the ever challenging and life-threatening dilemma for men of “providing” yet being “Mr. Perfect” personally too.
Trying to summarise and reduce my story to a blog is a challenge to say the least. Although a relatively spritely 33 years old, the increasing grey hairs and wrinkles around my eyes and my “old soul” remind me daily this life is a battle. And the battle is ultimately with yourself (hands up I have paraphrased this from a song I once heard, I just cannot remember which).
I love to compartmentalise and segment so my mind can attempt to process things, ideas, events, thoughts, feelings. Broadly speaking I did this with my life; pre-25 years old, 25 to 30 years old and 30 years old and beyond.
The first stage can sometimes appear as a blur. But perhaps an easier way of me dealing with it. It was a painful period for the majority of it. A challenging upbringing, tragic events, abuse and trauma pushed me so far into a shell that I never thought I would emerge from it.
During the okay times, this was okay with me. My introverted character and lack of self-esteem meant hiding was easier and far less painful. Until the occasional explosions. But life then returned to the blur.
A couple of moments in my early Twenties truly made me question my sanity. So at 21 years old I googled “Depression”. I matched 6 out of 8 symptoms. So clearly I was fine. I closed the laptop and the cycle of darkness continued as did the periodical suicidal meltdowns (behind closed doors of course).
Then the “Great Escape” took me to the other side of the world travelling. Less than two years later I was back in Australia for good, despite this being the deepest, darkest scene of my life. After a night out on the Gold Coast I stood on a balcony peering and leaning over contemplating that this was a good time to jump and end the pain. I felt so weak and thankfully, eventually, stepped back.
Somehow, after a few more substantial blips and obstacles, my life starting to become what others saw as “success”. More money that I knew what to do with, travel, a waterside apartment and a beautiful partner. One of my best mates teased me at work and called me “Mr. Perfect” regularly, not knowing 1% of my history or what was going on in my complex mind.
Behind the acting and those curtains and backstage was a chaotic scene. Anxiety, PTSD and Depression drove me to the edge. But approaching my 30th year on this earth I made some changes. As I was about to get married, my absent dad passed away in the UK. I was sick of my job and when we started to talk about having a family, I could imagine putting my child through a similar existence.
So I visited my in-law’s family GP. He looked me in the eye and asked “How long have you felt like this?” I paused. “For as long as I can remember.” His usually relaxed face turned serious. “I know a great Psychiatrist I would like you to see”. It took every ounce of energy to do so but once that train was in motion I was getting professional help (lucky enough to have the resources to do this privately) and within six months I felt positive.
I started writing a book and then a blog (I did not show my wife) and Mr. Perfect was born. A chat in the pub with mates, a cursory read of a report about men’s “connectedness” and healthcare professionals I know telling me there was little grassroots support for their male patients, and the Mr. Perfect movement gained momentum.
There have been many blips, I am not “Perfect” after all. From stopping my medication without advice, from stopping my Doctor appointments to then leading back to professional help when the cloudy spells turned into storms and into hurricanes. These weather systems are here for life, and that’s okay, but with the right strategies I can turn this into something impactful for others.
But there is hope. Friends, family and colleagues have all benefited and most importantly my son will arguably be the most loved and supported kid when it comes to talking about his mental health.
Thanks Terry! You can see the themes above of time and a relationship as potent therapy for the management of major depressive disorder in general practice. The initial clinical gestalt and the ongoing therapeutic relationship can be powerful tools for change. Depression is subjective and has been part of the human condition throughout history. This gives us all we need to move forward.
It therefore seems fitting to end with the words of a doctor from another time:
“The three grand essentials of happiness are: Something to do, someone to love, and something to hope for.”
Alexander Chalmers (29 March 1759 – 29 December 1834)
If you are worried about depression, anxiety, or have any other mental health concerns, reach out:
ACIS 131465 (South Australia – Acute Crisis Intervention Service)
Your GP at Partridge Street General Practice
The Australian Privacy Principles, and the recently passed (by the Australian Parliament) Mandatory Breach Notification bills provide various guidelines, which should be adhered to by anyone who handles any electronic medical data. Basically, the principles stipulate that all medical practices must ensure that all necessary measures are in place while saving, accessing and sharing any electronic medical data to keep patient data secure. Lack of compliance to the security standards could lead to large fines for both companies and individuals. Several steps can be followed by medical practices to ensure compliance to privacy standards. These steps include:
Run a complete risk assessment of the practice
Many medical practices adopted electronic health recording systems before there were clear guidelines on what these systems should contain. This means that a practice could be using electronic systems which are not compliant with current standards. To ensure compliance, a risk assessment should be done on the current systems to highlight areas in which compliance is not enforced, and to expose areas in which changes are needed. Ensure the latest version is being used, including any security patches from the vendor.
Prepare for disaster before it occurs
All data handled by a medical practice should be safe both from loss and corruption. One of the main ways of ensuring that data is not lost in case of any mishaps is backing up of medical data daily. Data should be backed up in an offsite location to ensure that in case of incidents such as natural, or man-made, disasters the data backup is not destroyed, as well. Antivirus programs should also be installed on all computers to ensure that data is not corrupted or destroyed by computer viruses, or held to ransom by cyber criminals.
Implement an ongoing employee training programme
Any system is only as strong as its weakest link, and in some cases poorly trained employees, or temporary staff, are the entry point for hackers into medical practices. It is also these staff who are more likely to have an “oops” moment and accidentally release confidential information. A medical practice could have excellent processes and systems, but if the employees don’t use their passwords to securely access records and files the system security is rendered useless, and anyone can gain access to these records. Medical practices should continually train their staff on how to follow the right security protocols, to ensure data integrity and security.
Purchase medical products with security compliance, and compatibility in mind
New equipment bought for a medical practice should be compatible with existing systems and should offer enough security features. With the advent of connected devices, the Internet of Things, it is critical that devices are secure, and kept up to date. Before making any major purchases enough review of the product should be done to ensure both security and compatibility.
Collaborate with affected parties
Changes which need to be made to bring about cyber security and privacy compliance affect many people in the practice. Affected groups should be offered training and management must ensure that staff understand the importance of compliance to everyone involved in the practice. Also, ensure that key staff are trained on what to do in the event of a breach. A comprehensive disaster plan is essential, and must be practiced regularly.
Thanks Paul! He does add, if you would like to discuss a risk assessment of your practice, please visit Cyber Health International to arrange a time that suits you to receive a call. Remember though, a lot of General Practices are small businesses, and a lot of You are the Key People in those businesses. Look after yourselves, see Your GP, get a great workplace, and Good Luck!
I think I can confidently say that I will be following Dr Kruys’ lead on this issue. Very disappointing.
That’s what I wrote 2 years ago. Since then GPs have had multiple pushes and pulls towards the Patient Controlled E-Health Record. What’s happened? See below.
Watch this space. Why would such a system exist if doctors, hospitals, and patients are not enthusiastic about it?
In the meantime, Partridge Street General Practice will continue to provide You Excellent Care via Your GPs.
Karen Dearne, freelance journalist and former e-health writer for The Australian, has produced a review of the PCEHR, on behalf of the Consumers e-Health Alliance.
The conclusion is disappointing: It appears that the government has been successful in uploading non-clinical documents about users, but otherwise our expensive national e-health record system seems to be in a pilot stage.
The full document can be downloaded here. Below are a few quotes from the report.
The numbers are telling
“After two years and more than $1 billion in costs, only 26,332 shared health summaries have been uploaded by doctors to the troubled Personally Controlled e-Health Record system.
While the Department of Health and the National e-Health Transition Authority trumpet their ‘success’ in signing up 1.7 million Australians to date, the truth is that the system holds a mere 288,368 clinically useful documents.
Obviously, if every person who had registered had just one
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