In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, feel free to contact me. Last week members of the GPs Down Under (GPDU) Facebook group posted their red tape bugbears. Melbourne GP Dr Karen Price, who is an admin of the group, suggested to blog about the issues that slow doctors down.
Patients are often understandably frustrated about waiting times. A couple of years ago I blogged about the reasons why I run late, including the daily healthcare bureaucracy doctors have to deal with. I’m sad to say the amount of red tape hasn’t changed.
Australia is not making good use of its medical workforce. Example: An estimated 25,000 patient consultations are lost every month while doctors are making phone calls to the PBS authority script phone line.
Instead of reducing the amount of paperwork for doctors – so they can see their patients quicker – other professionals are asked to take over parts of the clinical job.
There are of course other reasons why doctors run late, but the focus of this post is on healthcare bureaucracy. So here is a summary of the GPDU Facebook discussion on the abundant red tape that slows doctors down, summarised in 12 points.
This acronym stands for ‘Get A Note From Your Doctor’. Medical certificates for all sorts of issues seem to be increasingly popular, and every day thousands of doctors issue tens of thousands of notes.
This is not only a significant cost to Medicare, it also increases waiting times. Doctors have no problem issuing a genuine sick certificate as part of a consultation, but often people come in when they are getting better, just to get a certificate at the request of their employer.
Sometimes medical certificates seem to be used to shift liability when doctors are asked to declare that someone is fit for certain (recreational) activities. And, do we really always need a medical certificate when our children cannot attend daycare or school?
#2: Provider numbers
Medicare provider numbers are a bugbear for doctors and registrars, and have been for years.
One GP said: “Repeated applications for provider numbers through Medicare with the same information are such a waste of time. Surely they have my name, address, e-mail and multiple provider numbers already. An online portal with a ‘click’ application or submission of paperwork for would be amazing.”
Another GP: “For practices employing a new rural doctor there are at least 14 different forms across Commonwealth and State/Territory jurisdictions – some forms online, some scannable, some mailed, yes, with a stamp, some faxed. Software that would streamline at least some of those forms – even going to different destinations but auto-filled – would encourage practices to take more registrars and more prevocational doctors.”
#3: PBS authority phone line
Another major bugbear: Australian doctors have to ring this phone line before they can prescribe common medications. They must ring every time a script runs out, even if the patient has been taking the medicines for many years. The line is often busy and doctors and their patients are kept waiting. A short consultation can easily become a more expensive long consultation as a result of the waiting time.
Removing some medications from this scheme to a streamlined electronic procedure has not changed prescribing habits, which seems to indicate that the phone line doesn’t really serve a purpose. Also, some countries without a script line have lower antibiotic resistance patterns than Australia.
The approval process is bizarre. Doctors are asked the daily dose for an adrenaline emergency auto injector or have to spell the name of the drug as call centre operators have no clue.
A GP said: “After 5 minutes of waiting I’ve run out of small talk with the patient. By 6 minutes I’m almost considering to talk my patient out of starting Champix. And by nearly seven minutes waiting my usually cheerful manner with the call centre operator is gone.”
Another GP: “Sitting on the phone waiting for authority – why do I need permission from a bureaucrat to prescribe something?”
#4: Medicare and Centrelink
Medicare and Centrelink take up a lot of valuable time. The MBS criteria for example have been a constant source of confusion and stress for doctors. The endless paperwork is a challenge for doctors and practice managers.
One GP said: “Centrelink manages to outsource a tremendous amount of form filling in. Surely it contributes to green house gasses…”
Another GP: “Medicare forms… Some you can scan and e-mail back, some must be posted, others can be faxed but not emailed.”
#5: Handwriting charts, notes and scripts
Nearly all GP practices are computerised. Still we get requests from organisations to handwrite important documents.
Residential aged care facilities and community nursing teams often require handwritten medication orders, and don’t accept a printed chart generated by GP desktop software.
Some nursing homes and most hospitals ask that doctors, including visiting GPs, handwrite their notes. This also includes shared antenatal care. One GP said: “While I agree that the handheld obstetric records are exceptionally important, doubling up and having to write in them plus your computerised notes is inefficient – or print out your notes and have multiple loose prices of paper floating around each time.”
“I have some intellectually disabled adult patients in a group home and the script situation is tedious,” a doctor said. “Every panadol, every small change to prescribing, has to be documented and faxed to the chemist, and every consultation requires a form to be filled out and the consultation notes to be printed.”
The law requires doctors to handwrite opiate scripts underneath the printed text – and on both copies of the script – to reduce the risk of forgery. This has become obsolete for many practices as an electronic copy of the script can be sent to the pharmacy to avoid fraud. Other innovative developments such as real-time prescription monitoring will further make handwriting scripts unnecessary.
#6: Working with kids, working with elderly, working with vulnerable elderly checks
These new requirements for AHPRA registered doctors seem unnecessary. “I have to get not one single police check, but three checks,” said a GP. “‘Working with kids’, ‘Working with elderly’ and ‘Working with vulnerable adults’ checks before can work in country hospital, all at my expense. I work in an already highly regulated industry, I am trusted with scalpels and mind-altering drugs, and have an annual AHPRA registration renewal, but must do all this foolishness every few years.”
#7: Proof of AHPRA-registration
Doctors often have to provide a copy of their AHPRA registration, but registration details including the expiry date can be easily looked up by anyone on the APHRA website (Note: From a security point of view some doctors are concerned about the fact that certain data, such as their AHPRA registration number, is publicly available).
A GP said: “Filling out Patient Assisted Travel Scheme forms for rural patients is getting more tedious: We now have to write a letter stating exactly why our patients need an escort. Ticking the box isn’t enough.”
GPs are concerned about the medical services provided by pharmacies.
One GP said that a pharmacy happily managed her patient’s blood thinners, but when the INR results were outside the normal range they referred back to the GP. “Apparently this service is more ‘convenient’ as well as lucrative for the pharmacist. Until the INR level is more than 2.5…Then, late Friday afternoon, the pharmacy demands I manage the warfarin dose. So then it’s suddenly my problem. They get paid lots of money for a service I do for free.”
A common bugbear of GPs is the ‘owing scripts to pharmacy’ problem. Some pharmacies provide ongoing medications even if the script has run out. As a result patients miss their check-ups with the doctor and request an ‘owing’ script from their GP at a later stage.
One GP expressed concerns about the never-ending accreditation requirements: “Not the principle, but the realities. Broadly speaking: Individual clinicians need to be accredited multiple times, not just by AHPRA, but by government (working with children checks etc), local hospitals, regional training providers (to be supervisors) etc.”
“Practices need multiple accreditations – separate ones to be training practices for example – and all very painful. Regional training providers need to go through hoop jumping accreditation processes by the colleges, the colleges by the Australian Medical Council. Never-ending and so much time wasted.”
#11: Care plans, EPCs and mental health care plans
The rules designed by Medicare to manage chronic care in general practice have been the topic of heated debates. For example: Patients with a chronic illness cannot claim their Medicare rebate when the GP does a care plan and treats an acute problem on the same day. This means that many patients have to come back on another day, further increasing waiting times.
“Care plans and mental health plans interrupt my patient contact and workflow,” one GP said. “If a GP was rewarded more this templated rubbish would be done anyway as part of usual care by the good doctors.”
Another doctor said: “Did you know that people used to actually pay to see allied health professionals prior to GP care plans? Now it seems all allied health contact is required to be limited to five free visits per year.”
#12: Hospital bureaucracy
And sometimes we get a glimpse of what goes on in hospitals.
Referring a patient to hospital can be time consuming: “I used to work 15 minutes from a tertiary hospital. Lets say a saw a kid with, for example, periorbital cellulitis in my office. I would ring the paediatric registrar on call: On hold for 15 minutes.
Registrar: ‘Are you sure it’s periorbital cellulitis?’
Registrar: ‘Well I need to assess. So your patient has to go through ED.’
I call ED: On hold 15 minutes.
ED: ‘Well if you’ve made a diagnosis they can’t come through here. Call the registrar back.’
Me: ‘I can’t do that they said to call you.’
ED: ‘We aren’t doing it.’
Patient’s parent: ‘Am I paying for this consult?’
Me to ED: ‘You know I could just be the GP that gives patients a letter and never rings you know?'”
Making an appointment for a patient can be impossible. One GP said: “The hospital ‘outpatients direct’ won’t let me help organise an appointment for a patient without them being with me at the time, because of confidentiality. But I wrote the referral and need to know the date of the appointment to arrange transport or they won’t get there.”
Other hospitals have decided not to accept GP referrals until their criteria are met: “Queensland public hospitals have extensive referral criteria. They don’t accept GP referrals that don’t tick their boxes – often checked by non-medical staff.”
Hospitals can really slow GPs down with extra paperwork requirements: “The orthopaedic outpatient department doesn’t accept a GP referral until we have provided them with a completed 3-page ‘hip & knee questionnaire’.”
Sometimes hospital doctors send a patient back to the GP for a referral to another hospital doctor. Many GPs feel that an internal referral with a copy to the GP is much more efficient.
Rural GPs often work in hospitals and emergency wards. Transferring sick patients to a bigger hospital is a challenge in some states: “Western Australia has a long way to go: I first have to call the RFDS, then the hospital and speak to the accepting team – if lucky one call, if unlucky several calls. Then I need to call the ED to inform them about the expected patient. I have to call the RFDS for an update. Then the registrar calls back after speaking to their boss. Then the hospital bed manager calls and lets me know there are no beds available, so I need to go to another tertiary hospital etc. I hardly have time to look after the patient and talk to their next of kin.”
One GP said about requesting investigations: “To organise a CT-scan at the hospital from a rural ED, I have to make phone calls to the radiologist, the CT tech, the ED consultant, the specialty registrar (if applicable), and the bed manager. If one of those phone calls is missed… hoo boy, you’d think that I’d killed Santa Claus.”
Thanks to Dr Karen Price for the topic suggestion.