Allegations not proven – but still published?

Would you visit a doctor who has, next to his or her name in the public register, a mention of a court proceeding or tribunal hearing?

Or would you prefer to see another doctor, even if the small print on the register stated ‘allegations not proven’?

I often find the legalese speak on AHPRA’s website difficult to understand. A recent report recommended that the register should include web links to published disciplinary decisions and court rulings – which AHPRA has been implementing.

However, and this is not immediately clear from the explanation on the website, apparently proceedings will also be published when a doctor or other health practitioner was found not guilty.

Complaints that have been dismissed in a tribunal as without merit will still be listed with a link to the relevant court or tribunal ruling, according to this article on DoctorPortal. The issue was also flagged at the national AMA Conference last month.

This measure is meant to ‘build trust between doctors and patients’. I’m not sure it is protecting the public but I can imagine that publishing complaints that have been dismissed is confusing for the public – and can also be misinterpreted.

It has the potential to not only affect the reputation of health professionals unfairly, but also their mental health and general wellbeing.

We need to have another long hard look at this.

Amendment 27-07-2018:

“The Medical Board of Australia (the Board) has decided to publish links to serious disciplinary decisions by courts and tribunals on the public register of practitioners only when there has been an adverse finding against the doctor.

The Board will not publish links from an individual doctor’s entry on the register to public court and tribunal decisions when no adverse finding against the doctor has been made.

The Board has removed links to tribunal decisions in which there was no adverse finding about the doctor that had been published on the register since March 2018.”

http://www.medicalboard.gov.au/News/2018-07-27-board-refines-policy-publishes-disciplinary-links-only-with-adverse-outcomes.aspx

Mandatory reporting of health professionals: 4 options

If you are an Australian health professional and you have a health problem, there is a risk that your job is on the line if you seek medical assistance. But help is on its way…

As a result of mandatory reporting obligations under the National Law doctors and other health professionals may avoid seeking help or treatment for fear of being reported to the Australian Health Practitioners Regulation Agency (AHPRA) by their treating practitioner.

The reporting requirements were originally developed to protect the public against practitioners who have e.g. a health problem, an impairment or engage in serious misconduct.

Concerns have been raised repeatedly that health professionals are not seeking help and this has been flagged as a risk to the public in itself. Practitioners have also argued that their treatment should be kept confidential, just like every other Australian who seeks care.

Western Australia is the only state where these mandatory reporting guidelines are not applicable. Sadly, there is anecdotal evidence that this has created interstate traffic by practitioners in need of medical assistance.

Four options

The good news is that health ministers have reviewed this issue last month. The discussion paper ‘Mandatory reporting under the Health Practitioner Regulation National Law’ by the Australian Health Ministers’ Advisory Council (COAG) provides 4 options – of which 3 are new ones.

Option #1

This is the least favourable option as it would mean no change. This option would treat impairment matters and other notifiable conduct identically, requiring treating practitioners to report any notifiable conduct as is currently the case.

Option #2

This is likely the most favourable option from the perspective of health practitioners as it provides a complete exemption for treating practitioners from the requirement to report notifiable conduct in respect of their practitioner patients – similar to the Western Australian model.

Practitioners would have the same rights as any other Australian to seek care, without fear of being reported by their treating practitioner and recognising the importance of confidentiality.

This option would entrust the treating practitioner to make a voluntary notification in accordance with their professional and ethical obligations to protect the health and safety of the public.

When a patient poses a serious risk to the public, professional and ethical obligations require treating practitioners to report (even in the absence of a requirement to do so) and to encourage the practitioner that they are treating to self-report.

Other practitioners including colleagues and employers remain under a mandatory obligation to report impairment and other forms of notifiable conduct.

Option #3

This option would only exempt treating practitioners from the requirement to report an impairment matter if it will not place the public at substantial risk of harm.

All other types of notifiable conduct, current or past, must be reported by a treating practitioner. This means that practitioners with for example a mental health or addiction problem may not disclose issues to their treating practitioner, or may avoid seeking help.

Option #4

This option would exempt treating practitioners from reporting impairment matters and to only require reporting of other forms of notifiable conduct where there is a current or future assessment that the notifiable conduct is likely to occur.

This option creates problems with regards to for example risk assessment which is often based on past conduct. Health practitioners may not fully disclose health matters and avoid seeking help under this option.

The WA model

I expect that most practitioners will prefer option 2. This option allows full disclosure of health issues, facilitating diagnosis and treatment. It respects the confidentiality of the patient-doctor relationship which is the basis of a successful road to recovery.

The COAG discussion paper reports that an independent review found no evidence that the WA model impacted on notification rates, further supporting option 2 as the preferred nationwide solution.

RECOMMENDED FURTHER READING: Mandatory reporting of health professionals: has COAG delivered on its promise?

The doctor will see you… never. Issues with online referral services.

There are many benefits of online health services and they can complement traditional face-to-face GP visits. But there are also examples that raise questions.

The young woman was in tears. When she came in she had initially asked for a referral to a surgeon for a breast augmentation. During the conversation it turned out that her partner had made it clear her breasts were too small.

We ended up having a chat about relationships and body image. At the end of the consultation she decided she needed some time to think things over and talk to good friends, and that she would come back if she needed further assistance.

The problem with online referrals

At first sight, the Qoctor website seems an easy, convenient online medical service that provides sick certificates and referrals.

The site tells visitors: “(…) we understand that a well person who simply needs a letter to see a specialist should be able to get one without requiring a GP consultation.”

I’d like to challenge that. The woman in the example above was well but did she need a referral to undergo an expensive procedure that would change her body?

There are many issues with a system that allows access to specialist care without a review by a primary care doctor. Unnecessary referrals, increased costs and further pressure on the hospital system are just the beginning.

Once a visitor has selected a specialist the system asks a few simple questions about allergies and previous surgery and there are some boxes to tick (see image). I wonder how many people will just enter through to get to the section where you pay and automatically receive the referral letter (as pdf file).

How many people will just enter through to get to the section where you pay and receive the referral letter?

Good telehealth principles

Sometimes writing referrals is a straightforward process but often it is not. What is missing here are the safeguards with regards to other management options, coordination of care, the communication between the usual doctor and specialist, and follow-up. What about whole patient care?

Interestingly the service seems to assume that – after automatically cashing in the online referral fee – the patient’s usual GP will be responsible for the follow-up if required.

The Royal Australian College of General Practitioners (RACGP) has developed some common-sense principles for telehealth services, including on-demand online health services. These principles include the following:

  • On-demand telehealth services should preferably be provided by a patient’s usual GP or practice
  • On-demand telehealth services to unknown patients should only be provided when the patient’s usual practice cannot provide care for them, either in person (at the practice or by a home visit) or online, and no other general practices are physically accessible
  • Patient notes should always be sent to the patient’s usual GP or practice (with the patient’s permission). This ensures continuity of care and centralises patient records.

Commercially enticing 

I suspect that most people are aware of the risks of online health services and will consult their GP first. At the same time there will always be people who are attracted to these services because they are quick and easy. It is also commercially enticing: if you sign up for Qoctor you may win a $100 Coles Meyer gift card.

The patient testimonials on the website, which probably go against AHPRA’s advertising guidelines for regulated health services, seem positive. The question is usually: are these real testimonials?

As always with disruptive technologies there is the convenience aspect for consumers – but is bypassing the most efficient and cost-effective part of healthcare by printing out an online ticket to the expensive part in the best interest of Australians? I doubt it.

The (patient) case discussion in this blog post is fictional and based on similar consultations. Disclaimer and disclosure notice. Follow me on Twitter: @EdwinKruys.

The daunting revalidation dilemma

The Medical Board of Australia is well aware of the daunting revalidation dilemma: how to identify underperforming doctors without subjecting the rest to time-consuming and needless procedures?

The percentage of underperforming doctors is low. Nevertheless, in the UK all doctors undergo regular appraisals and are ‘revalidated’ every five years if they are deemed up to date and fit to practice.

The UK revalidation system has received its fair share of criticism. A common complaint is that the collegiate appraisal process has been ‘dumbed down’ as it changed from a formative to a summative process.

Other criticism includes the heavy time burden and paperwork, the negative impact on doctors’ wellbeing (while the profession already works in a highly stressful environment), the creation of a tick-box mentality, and a situation where some doctors are avoiding complicated situations and high-risk patients that could get them into trouble.

The good news is that the Australian Medical Board does not seem to want to copy the UK model and instead appears to be looking at countries like Canada or New Zealand, where the focus lies more on self-regulation as opposed to external regulation.

Expect the introduction of some sort of revalidation model in the next two to five years. The question is of course: are we heading in the right direction?

The purpose

Interestingly, there is still discussion about the purpose of revalidation of doctors (see picture). The overarching principle seems to be improving patient care, but whether it’s about ensuring public safety, ‘catching dodgy doctors’ or making good doctors better, is not always clear.

Some say it’s a bit of everything, which may be true but the problem is: how are we going to develop a revalidation system that does ‘a bit of everything’?

Differing message about the purpose of revalidation
Differing messages about the purpose of revalidation in the UK. Source: The Kings Fund

According to the Medical Board of Australia the fundamental purpose of revalidation is to ensure public safety. The Board has proposed a two-pronged approach to achieve this, namely improving continuous professional development (CPD) and identifying at risk doctors:

  1. To maintain and enhance the performance of doctors practising in Australia through efficient, effective, contemporary, evidence- based CPD relevant to their scope of practice.
  2. To proactively identify doctors who are either performing poorly or are at risk of performing poorly, assess their performance and when appropriate support their remediation of their practice.

To be fair, I agree our CPD model could be a lot better, focusing more on where we need to improve instead of what we want to improve.

At the same time there are concerns about the Medical Board proposal, especially with regards to the method of finding the underperformers. The Medical Board has recognised many of the issues and is currently consulting with the profession.

Strengthened CPD as proposed by the Australian Medical Board. Source: Medical Board
Strengthened CPD as proposed by the Australian Medical Board. Source: Medical Board of Australia

Two issues

The overarching problem is that there is little evidence to show that revalidation improves patient outcomes. I can see at least two other major issues:

  1. Externally enforced actions have less impact than internally-driven change in a collegiate, supportive environment. The colleges, rather than the Medical Board, AHPRA, employers or other parties, should be supported with data and resources to provide skilled remediation.
  2. The proposed profiling of doctors (e.g. over the of 35, male, trained overseas, previous complaints) appears to be a blunt approach. The tools should be sharpened, focusing more on behaviour and performance. To identify underperforming doctors we need a good screening tool. As Wilson and Jungner outlined fifty years ago, there are several criteria to be met first, to make sure we’re not doing more harm than good, especially as the percentage of underperforming doctors is low and at this stage we’re not 100 percent sure what kind of doctors we are looking for. We should also be careful not to confuse screening and assessment tools.

The way forward

The starting point should be a supportive, non punitive solution. Only when the desired outcomes through collegiate processes are not achieved, should regulators become involved. Any model must be fair, evidence-based and not create large amounts of paperwork.

Here are seven principles I believe are important when moving forward:

  1. The focus of revalidation should be heavily weighted towards self-regulation and strengthening collegiate education and remediation processes;
  2. Self-initiated gap and learning needs analysis are effective tools to direct life-long learning, supported by evidence;
  3. Peer review, performance review and outcome measurement could be used to strengthen QI&CPD but will require further evaluation;
  4. Data exchange between agencies and organisations, keeping in mind confidentiality and privacy, could identify underperformers earlier;
  5. Under performing doctors must be supported, not only via remediation but also looking after the wellbeing of the doctor involved;
  6. There needs to be clarity and transparency about potential medicolegal use of data collected during the revalidation process;
  7. The costs involved should not be carried by the profession alone.

And lastly, we really need a less punitive term instead of revalidation.

Do we trust our doctors? Why UK-style revalidation in Australia would be a big mistake

Australian doctors are kept on a short leash. I recently renewed my registration with the Australian Health Practitioner Regulation Agency (AHPRA). This annual ritual is always interesting.

Like thousands of other doctors, I first had to fill out an online questionnaire. As usual, AHPRA wanted to know if I had a physical or mental impairment, disability, condition or disorder – including substance abuse or dependence – that would detrimentally affect my capacity to work as a doctor. They reminded me I’m required by law to declare any impairments.

I had to answer questions about my criminal record, compliance with the law, continuous professional development, indemnity insurance, work history and even immigration status. If I did not give the required information, I could lose my registration.

Finally, I had to make a declaration that I spoke nothing but the truth, and I dutifully transferred the required $724 into AHPRA’s bank account.

High professional standards

The yearly AHPRA registration procedure symbolises the way doctors are controlled in Australia. Contrary to common belief, we’re allowed little freedom.

Before we can prescribe medications, we have to ring up Medicare to get approval. Our prescribing habits are being watched. We are audited randomly to make sure our billing practices are not out of line with our peers. We may be prosecuted by the PSR if we deviate from the average. In most states, doctors have to report colleagues who underperform.

At the same time, professional medical standards in Australia are high. Take the accreditation standards of the Royal Australian College of General Practitioners, or the CPD requirements. Both quality assurance programs have become more robust over the years and are continuously being reviewed and improved by the College.

The RACGP ‘Standards for General Practice’ ensure safe and high quality care, and are used by over 80 per cent of Australian general practices for accreditation. The QI&CPD Program recognises ongoing education to improve the quality of everyday clinical practice by promoting the development and maintenance of General Practice skills and lifelong learning.

Is there a problem?

So why is there still talk about revalidation of doctors? Is the public concerned about the quality of Australian doctors? It appears that the opposite is the case.

The national AMA patient survey indicated that GPs are considered by the public to be trustworthy, knowledgeable and experienced. A large patient satisfaction survey endorsed by the RACGP found there was a very high level of satisfaction with General Practice in Australia.

Another study published in the MJA also showed that patients reported high levels of satisfaction with GP care, and for many years Australian doctors have been in the top three most trusted professions in the annual Roy Morgan research.

Based on numbers from Canada, AHPRA estimates that 1.5 per cent of Australian medical practitioners are performing ‘unsatisfactorily’. I’m not sure Canadian figures can be applied to Australia, but 1.5 per cent of unsatisfactory performers in any group is low. It appears that any potential problem lies with a significantly small minority of doctors.

Carpet-bombing the profession

There are many revalidation models – from strengthening CPD to targeting those at high risk of complaints, to the full- bore version rolled out in the UK. But if the AHPRA tries to identify substandard doctors, carpet-bombing the whole profession is problematic.

Dr Steve Wilson, Chair of the AMA (WA) Council of General Practice, questioned in the Medicus magazine whether revalidation would address those who failed to practise to agreed levels. And if it did, he asked, would that be a sign of impairment or does it reflect personal style, or lack of time, training, experience or adequate remuneration? Excellent questions indeed.

Competency checks of doctors may sound appealing to the public. I’m sure some politicians will love the rhetoric. But simply copying the UK’s revalidation system would be a big mistake.

About 5,000 doctors a year are considering leaving the UK, and many come to Australia. Bureaucracy is one reason they emigrate. The last thing we need in Australia is more regulation, red tape and stressed-out doctors.

Existing quality systems

In recent years, our healthcare system has seen enough unsuccessful concepts not supported by evidence. Think for example about the super clinics program and the accompanying cost blowouts, delays and disappointing results. It will be easier and cheaper to build on existing quality assurance systems.

This article has previously been published in Medicus, the AMA(WA) magazine.

Competency checks on doctors could become a costly mistake

Competency checks could become a costly mistake
The last thing we need in Australia is more regulation, red tape and stressed-out doctors. Image: Pixabay.com

The Medical Board of Australia could be about to make a costly mistake. Regular testing of competency being introduced is not a matter of if, but when, said the new boss of the NSW Medical Council, Dr Greg Kesby, in an interview with Australian Doctor magazine.

Dr Kesby also said there needed to be a process to instil confidence within the community that all doctors’ knowledge was up-to-date.

On the face of it, competency checks of doctors sounds appealing. I’m sure some politicians will love the rhetoric. But at the same time, alarm bells were going off when I read the interview.

Many unanswered questions

Does Dr Kesby imply that the Australian public has lost confidence in its health practitioners? Are there concerns about the quality of Australian healthcare? There are many other unanswered questions too.

Is there any evidence that the current quality assurance systems, such as accreditation and CPD, are insufficient? Is recertification or revalidation — such as has been implemented in the UK — an efficient way to improve the quality of healthcare? Is it possible to design a system that reliably differentiates between good and bad practitioners? And how do we define competency?

Based on numbers from Canada, AHPRA estimates that 1.5% of Australian medical practitioners are performing ‘unsatisfactorily’. I’m not sure Canadian figures can be applied to Australia, but 1.5% of unsatisfactory performers in any group is low. There are numerous models: from strengthening CPD to targeting those at high risk of complaints, to the full-bore version rolled out in the UK. But if the board tries to identify these substandard doctors, carpet-bombing the whole profession is problematic.

An expensive solution

One thing is for sure: UK-style revalidation is expensive. The process takes 1-2 working days per practitioner. Imagine thousands of Australian doctors having to take a couple of days off work to fulfil revalidation requirements.

Imagine the enormous effort it will take to manage this process. Think about the additional cost of the training, time and wages of the appraisers — who, I assume, will be doctors too — and the admin staff, extra regulation, log books, documents, IT etc.

According to the UK’s Pulse magazine, the revalidation of doctors has become a colossal enterprise, costing taxpayers £97 million (about $207 million) a year. This figure does not include revalidation of other health practitioners. Critics of the UK system have said it will not detect poor doctors, as its main purpose is to gain patients’ trust. Others feel it mainly serves to demonstrate what good practice looks like.

Policing the profession

A former UK GP-appraiser, now working in Australia, mentioned on the GPs Down Under Facebook group that appraisals used to be fun, interesting and mainly pastoral. Under revalidation, they became a form of policing the profession, he said.

Professor Kerry Breen, adjunct professor in the department of forensic medicine at Monash University, wrote in the Medical Journal of Australia last year that there was little evidence to support the idea of transposing the UK system to Australia.

He said that despite some local failures of medical regulation and hospital governance, the community had not lost faith either in its doctors or regulatory system. Indeed, it appears the public is largely content with its healthcare practitioners: Australian doctors, nurses and pharmacists have been in the top three most trusted professions for many years in the annual Roy Morgan research.

More recently, Dr Steve Wilson, an AMA WA representative, questioned in the AMA’s magazine whether revalidation would be able to address those who failed to practise to agreed levels. And if it did, he asked, would that be a sign of impairment or does it reflect personal style, or a lack of time, training, experience or adequate remuneration?

Don’t follow the UK

About 5000 doctors a year are considering leaving the UK, and many come to Australia. Bureaucracy is one reason they emigrate. Simply copying the UK’s revalidation system would be a big mistake. The last thing we need in Australia is more regulation, red tape and stressed-out doctors.

In recent years, our healthcare system has seen enough unsuccessful concepts not supported by evidence. Think about the super clinics program or the PCEHR, and the accompanying cost blowouts, delays and disappointing results.

It will be easier and cheaper to build on existing quality assurance systems.

Let’s look, for example, at refining CPD and accreditation. As they say, the main difference between a wise man and a fool is that a fool’s mistakes never teach him anything.

Developing an expensive new system with little or no supportive evidence failed in the case of super clinics and e-health, and it will fail with revalidation too.

This article was originally published in Australian Doctor Magazine.

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

Revalidation of doctors, or how to spot the bad apples

Revalidation of doctors, or how to spot a bad apple
Image: Pixabay.com

Wouldn’t it be great if we could spot the bad apples before we consume them? Or even better: before they become bad? In recent years medical regulators around the world have been exploring ways to identify doctors who are performing poorly.

In the UK all apples are tested once a year via a process called revalidation. But some have said it will not detect poor doctors as its main purpose is to gain patients’ trust. Others say it is meant to demonstrate what good apples look like. But one thing is for sure: Revalidation is labour-intensive and expensive.

“There is indeed an additional time cost,” said GP Dr Paresh Dawda in Australian Family Physican. “The appraisal meeting was usually 3 hours in length, and on average it took another 5 or 6 hours to collate the evidence and complete the forms, which is in keeping with an average of 9 hours found in the revalidation pilots.”

Then there are the training, time and wages of the appraisers, usually doctors too, the administrative staff, extra regulation, log books, documents, IT… Revalidation has become an enormous enterprise, costing £97M ($186M) a year, mainly because of added pressures on doctors’ time.

It seems logical that, before a country embarks on an operation like this, the problem it is trying to solve has been defined and the solution is effective.

So what’s the problem?

According to the Medical Board of Australia, evidence from Canada shows that 1.5% of doctors are not good enough. The Board has translated this figure to Australia, and thinks that over 1,350 doctors could be performing unsatisfactorily. Other research indicates that just 3% of doctors are the source of 49% of complaints.

“Where is the evidence that further regulation is needed?

Several safety mechanisms are already in place: At the moment Australian doctors must meet the Medical Board’s mandatory registration standards, including for recency of practice and continuing professional development. Doctors can be subjected to random compliance audits.

Although a majority of Australian doctors seems to support competence checks, there are serious questions about the UK-style revalidation process.

Revalidation screenshot
Screenshot: Example of questions UK doctors have to answer during the revalidation process.

AMA(WA)’s GP Dr Steve Wilson in this blog post: “Where is the evidence that further regulation is needed, which will be preventative and ultimately beneficial to the profession and the community?”

“Will it address those who fail to practise to agreed levels, and is that a sign of ‘impairment’ or more about personal style, lack of time, adequate remuneration, or lack of care, training, experience, sheer demand and workforce numbers?”

At a conference in 2013 Medical Board of Australia Chair, Dr Flynn admitted that ‘the problem that a revalidation-style system would help solve was not yet defined’.

But Dr Flynn questioned the current continuous professional education system: “Can you assure me that everyone who has done your CPD program is actually competent and practising at a reasonable standard? (…) My sense is that, for most CPD programs, they don’t do that, or at least, not to a high enough level of certainty.”

After meeting Dr Flynn in 2013, the RACGP commented in Australian Doctor magazine: “The meeting provided an opportunity for the college to discuss the strength of our current QI & CPD program, and the necessity of adding yet another mechanism to identify underperforming doctors, when processes are already in place – such as the medical boards, health quality and complaints boards and indemnity insurers.”

What’s the Medical Board up to?

“We started a conversation about revalidation in Australia in 2012,” said Dr Joanna Flynn in last week’s media release, “as part of our commitment to making sure doctors in Australia maintain the skills to provide safe and ethical care to patients throughout their working lives.”

The board has asked the University of Plymouth to answer some questions on revalidation. At first glance this seems a sensible approach.

Dr Flynn: “We have commissioned this research to find out what is working well internationally, what is in place in comparable health care systems, and what principles the Board should consider in developing revalidation in Australia. (…) this research will help make sure that the decisions the Board makes in future about revalidation are effective, evidence-based and practical.”

The aim of the project is to:

  • establish the existing evidence base for the validity of revalidation or similar in countries comparable to Australia
  • identify best practice and any gaps in knowledge for revalidation processes
  • establish the validity evidence for revalidation’s effectiveness in supporting safe practice
  • develop a range of models for the Australian context for the Board to consider.

It seems to me the research questions are broad and several steps are taken at once. For example: ‘Establishing the evidence for revalidation’ and ‘developing a range of revalidation models’ are entirely separate processes.

It appears the Medical Board has already made up its mind. The research findings will be considered by the Board in the second half of 2015. I am certainly looking forward to the results and conclusions, as well details about cost and setup of the study.

The Camera revalidation research website of the University of Plymouth doesn’t give any answers away: “The research team is currently undertaking an ambitious programme of research involving three interlinking studies to explore and understand revalidation in all its complexity.”

Putting the cart before the horse

The question is of course: Is revalidation the right solution? Are there other options? One could argue that this should have been considered before spending tax dollars on an overseas research project.

Professor Breen, from the Department of Forensic Medicine at the Monash University in Melbourne, said in the Medical Journal of Australia: “There is little to support the idea of simply transposing the UK system to Australia. Despite some local failures of medical regulation and hospital governance, there has been no widespread loss of faith of the community either in its doctors or in the regulatory system.”

“Is there a problem with medical registration in Australia that needs attention, and, if so, what should be done to fix the problem?

“The Medical Board of Australia would be wiser to start afresh by asking and answering two questions — namely, is there a problem with medical registration in Australia that needs attention, and, if so, what should be done to fix the problem?

“The medical profession in the UK appears to have accepted revalidation, albeit reluctantly, as representing the price to be paid for maintaining the existence of the GMC and for regaining public trust after a series of regulatory failures.”

“It has been claimed that revalidation will not reliably detect poorly performing doctors, and many commentators have pointed out that revalidation would not have identified Dr Harold Shipman.”

Immediate past president of the AMA, GP Dr Steve Hambleton had second thoughts too. In MJA Insight he said: “We need to make sure we maintain our currency and continue to improve health outcomes, but in terms of value for money, making everybody go through a 5-yearly process of 360-degree evaluation is not needed in the Australian health system.”

Both Professor Breen and Dr Hambleton suggested there are better ways to deal with the bad apples. Database analysis could be one solution. Other options are targeted revalidation and a revamp of the existing CPD program and accreditation. Some have argued that the focus should be on the workplace, not just on health professionals.

Journalist Paul Smith from Australian Doctor magazine was, as usual, spot on when he wrote: “(Doctors) may argue that targeted revalidation has greater merit than what they may see as carpet-bombing the entire profession.”

Red-tape stress

“Recently I cried at work,” posted Dr Adrienne Garner on the BMA blog. “Why? Because the evening before I’d been notified that my appraisal, submitted after hours of work, had been unsubmitted by my appraiser as it was ‘not sufficient for revalidation.”

“I was gutted. My mind churned with a mixture of thoughts ranging from anger to fear, through frustration and disappointment. Sleep had been impossible.”

“Under revalidation appraisals became a form of policing the profession.

Many studies show that doctors are more likely to experience psychological distress and suicidal thoughts than the general community, and there is a high rate of burnout. Pastoral care and self-reflection are important. But when they are part of a policed regulatory framework, they become a stressor in itself – which defeats the purpose.

Former Coventry GP Dr Gaurev Tewary, now working in Australia, posted on a social media platform: “I was an appraiser in the UK. My overall impression is this: Appraisals used to be fun and interesting and mainly pastoral. You did them to help people and I enjoyed supporting the profession. Under revalidation it became a form of policing the profession.”

About 5,000 doctors a year are considering to leave the UK, and many come to Australia. Bureaucracy is one of the reasons they emigrate. We must become better at dealing with bad apples, but healthcare is already a highly regulated industry and the last thing we need here in Australia is more regulation, red tape and stressed-out doctors.

I hope the Medical Board will work with the colleges and the AMA to explore better options.

Follow me on Twitter: @EdwinKruys

Revalidation

Why doctors run late: 12 red tape challenges

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.

#1: Sick notes

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.

Why doctors run late

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

#8: Travel cost assistance 

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.”

#9: Pharmacies

Pharmacies can add value in many ways, but when it comes to collaboration there is room for improvement.

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.

In defence of the pharmacy: doctors are not always on time with sending scripts to the pharmacy.

#10: Accreditation

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 organisations 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

Making an appointment for a patient can be challenging sometimes. 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.”

Many hospitals have referral criteria and they’re not aways flexible: “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 in some (especially urgent) cases an internal referral with a copy to the GP would be 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.”

We need ongoing conversations with each other, managers and decision makers to avoid unnecessary red tape and improve the patient journey across various parts of the health system.

Thanks to Dr Karen Price for the topic suggestion.

Participatory healthcare has only just begun

Participatory healthcare has only just begun
Image: pixabay.com

Imagine you’re at a friend’s party in your neighbourhood. You recognise a few of your patients. As you join the conversation you continuously blurt out phrases like: “Make sure you vaccinate your kids,” “Our practice has opened a skin clinic; it is important to get an annual skin check,” and “Here’s a copy of our latest newsletter.” When one of your patients tries to start a friendly conversation you say: “Sorry, I don’t befriend patients,” and you walk away to chat with a colleague.

You would make a complete fool of yourself.

Still, that’s how many health practitioners behave online. We often use our professional websites and social media accounts as promotional channels and we’re told not to accept patient friend requests on Facebook. When receiving positive feedback from our patients we have to be careful not to share or re-tweet it as this could be interpreted as a patient testimonial by AHPRA.

It’s awkward.

At the same time there is an unstoppable digital patient movement happening. Health consumers are getting smarter and better organised. The ePatient is empowered by digital technology and social networks. Their disease-specific knowledge matches that of health practitioners – and is often superior. Powerful peer-to-peer networks help consumers to make better decisions about their health care.

And this is only the beginning.

Ignoring digital technologies is not going to help. This will create a digital divide between consumers and health care services. We have to find a way to accommodate participatory healthcare. I don’t believe this means that health consumers should e.g. have the ability to remove or hide information from their electronic health records – but if they want they should be given access and, together with clinicians, take responsibility for their care and the quality of their healthcare data.

We must get over our social media fear so we can start to listen to health consumers online and take part in discussions.

We’re trained to deliver care in the one-on-one situation, but in the near future health practitioners will also engage with online communities. An attitude change towards digital technologies is needed. E-health should improve the interaction between clinicians and consumers. This requires their input at all levels of development.

And, instead of warning students and clinicians about the dangers of social media, they need to be trained to integrate these networks in their day-to-day work.

Is your organisation ready for social media?

Is your organisation ready for social media?
Image: pixabay.com

This article appeared in MDA’s Defence Update in April 2014. Original title: ‘Social media in modern medicine’.

Is social media a help or a hindrance in modern medicine? Dr Edwin Kruys, a GP from Queensland’s Sunshine Coast, provides a personal perspective on the subject.

Should medical professionals engage with social media?

Social media is here to stay. A lot of registrars and young doctors have one or more social media accounts, and I have yet to meet a medical student who is not on Facebook. Patients are already sharing online (health) information via Facebook, Twitter and other social media accounts – so sooner or later health professionals will need to decide whether or not to participate.

What are the potential benefits of using social media in the medical profession?

Social media is increasingly used for medical education, and sharing knowledge and information such as tips, resources, literature and links. It’s also useful to build an online community. Clinics can share health information and other practical information.

Social media is more interactive than a website and you can reach a wider audience in real-time. Another benefit is the value of health promotion and lifting the profile of a medical practice or organisation. I’d like to mention the use of blogs, pictures and videos. I find they are a great way to communicate a message, and I use my social media accounts to let my followers know when I’ve posted something new.

How can doctors make the most of social media?

Organisations need to be prepared to put aside time to manage their online presence, and there is no easy way out here. It takes time to post useful material and interact with others. Social media is a two-way street and not just another promotional channel. If you use social media for branding or promotional purposes only, you may lose followers.

Your online presence should have a consistent approach. Too many organisations set up a Facebook account without first developing a clearly defined strategy. It is recommended to take some time to plan and figure out the purpose of the social media campaign, which medium to focus on, and how to keep it sustainable and current. This usually requires a motivated person within the organisation.

Preparation is key, and implementing a social media policy should be part of the preparation. Some things to include in the policy are, for example, how to respond to negative feedback and/or complaints received via social media; and how to comply with AHPRA regulations.

The AMA has a useful document that outlines the risks. I also felt that the social media workshops organised by MDA National are an excellent way to become familiar with the common pitfalls.

Is social media for you?

Due to the time commitment, and the effort it takes to set up and maintain social media accounts, it may not be ideal for everyone.

For those who want to contribute to online health promotion or interact and share health information with their patients or other health professionals, social media is not without risks, but it can be an effective tool if used wisely.

Cutting red tape in healthcare: how you can help

Cutting red tape
Image: pixabay.com

Years ago I did a locum in a rural town. As the town’s only doctor went on holiday for a week, I was supposed to look after the hospital and the adjacent GP practice. 

On the first day, just as I was applying a plaster cast to a farmer’s broken hand, a secretary came in to the emergency department and told me I was not allowed to work.

“What do you mean?” I asked surprised.

“Your Medicare provider number hasn’t come through yet,” she said. 

So I spent most of the week reading novels and sight-seeing the lovely area.  

Apparently it was busy in the hospital. The amazing nurses were holding the fort. They had to call the poor doctor on his holiday address to discuss patients and get phone orders.

The provider number came through on the afternoon of the last day.

I know many doctors across the country have had similar experiences. Why doctors have to apply for a new provider number every time they move to a different place, is beyond me.

The flood

We are drowning our health care professionals (and each other) in a flood of often poorly thought out regulations. 

The recent AHPRA advertising guidelines fiasco is one example.

The national authority script hotline is another: every time a patient’s script runs out, a doctor has to ring the government to get approval for a new script – and is usually put on hold. If you want to know how wasteful this system is, watch the video at the end of this post. I made the clip a year ago and the audio is a real-time recording of what happened when I made a call. Nothing has changed since.

What you can do

The Australian Medical Association is now calling for action (see below). Please send the department and the minister an email, even if you’re not a doctor. The government needs to hear the consumer voice. Your help to cut red tape in healthcare is much appreciated.

PBS Authority system (Source: AMA)

To keep the pressure on DHS to properly resource the phone line service, please report delays via email to:

customer.feedback@humanservices.gov.au

You can make sure the Minister for Health and the Minister for Human Services have a clear picture of the impact on doctors by copying them into your email.

Minister.Dutton@health.gov.au

minister@humanservices.gov.au

 

 

Wrap-up: 3 things I have learned from AHPRA

And so the AHPRA Action came to an end this week. The Medical Board announced on Wednesday it would work with the other Boards to change the advertising guidelines.

The media statement“(…) practitioners are not responsible for removing (or trying to have removed) unsolicited testimonials published on a website or in social media over which they do NOT have control.”

Hats of to the Medical Board and AHPRA for listening to the feedback. I have learned three things:

#1: We now all know the rules

The media attention and focus on the law and advertising guidelines has made the road rules clearer than ever. Testimonials mentioning clinical care & used in advertising are out, and unsolicited comments including thank-you’s are in. Of course we will have to wait for the final revision, but it seems we all know where we stand.

#2: Consumers and health care professions united

The controversial advertising guidelines united not only health professions, but also consumers and professionals. This should happen more often. Some have already raised ideas to bring the health care social media community together on a more structural basis – watch this space.

#3: Big government should involve stakeholders

Consumer health advocate Anne Cahill Lambert noticed that AHPRA had not received consumer submissions during the guidelines revision. In this Crickey Blog she wrote: “Genuine consumer participation is sometimes difficult. But it should not be dismissed out of hand because of its difficulty.”

AHPRA has already started engaging and listening via Twitter. Here’s hoping that AHPRA will genuinely engage all stakeholders during future guidelines and policy revisions – without further increases in registration fees of course.

 

 

New AHPRA Action campaign kicked off on Change.org

AHPRA Action logoEDIT 28/03/14: SUCCESS! THE MEDICAL BOARD ANNOUNCED ON WEDNESDAY THAT IT WILL CHANGE SECTION 6.2.3 OF THE ADVERTISING GUIDELINES. THANK YOU FOR TAKING PART IN THE AHPRAaction CAMPAIGN!

The AHPRA Action campaign has stepped up a notch. Medical Observer is now media partner, the protest action has a new logo (see image) and a new public petition kicked off yesterday.

A Parliamentary Inquiry found that the National Registration and Accreditation Scheme, managed by AHPRA “remains a large and complex bureaucracy with potential confusion over lines of responsibility and accountability.”

AHPRA’s new advertising guidelines are exposing Australian health professionals to unnecessary risks and create more red tape and confusion.

AHPRA regulates over 600,000 Australian healthcare practitioners and charges registration fees. Lawyers said about the new guidelines: “(…) the very broad wording in paragraph 6.2.3 of the updated advertising guidelines potentially exposes all health practitioners to a risk of breaching section 133(1)(c) of the National Law.”

Enough is enough – the advertising guidelines must be changed.

Sign the petition here

Why it is important for AHPRA to get this right

Why it is important for AHPRA to get this rightWorking in health care is often a balancing act. Everyday I am walking a fine line between, for example, not requesting too many CT scans for people presenting with a headache, and at the same time not missing that rare brain tumour. If I fail in the first case Medicare will know where to find me, in the second case AHPRA may be knocking on my door.

God forbid that I ever find myself investigated by AHPRA’s Medical Board. But it could happen of course. We all have our bad days and make mistakes or judgmental errors.

If that happens I need to be sure that the Medical Board knows what it’s doing. This also means AHPRA’s policies and procedures must have no obvious flaws or loopholes.

Yesterday AHPRA published a 5-page long document with frequently asked questions and answers regarding advertising – which is very much welcomed. It helps to understand where AHPRA is coming from. However, the initial comments I read on Twitter and several blogs (see here and here) were not unanimously positive. Many health professionals and consumers feel the document is contradicting the advertising guidelines, and I can see why.

I’ll give an example:

The first page of the FAQ document states that the advertising guidelines ‘do not apply to unsolicited online comment over which practitioners do not have control.’ But… AHPRA’s advertising guidelines say on page ten (Section 6.2.3) that practitioners should have testimonials removed ‘even if they appear on a website that is not directly associated and/or under the direct control or administration of that health practitioner and/or their business or service. This includes unsolicited testimonials.’

Australian health professionals certainly have the right to scrutinise AHPRA’s work and demand clarity.

AHPRA should make amendments to the advertising guidelines now – not in three years time – to make an end to the confusion and maintain its high quality standards – and the trust of consumers and health professions.

Sign the petition here.

I just received this interesting response from AHPRA

AHPRAIt looks like the last word has not been spoken about the AHPRA advertising guidelines.

I gave AHPRA the example I used in this blog post about what to do when a patient posts a comment on my Facebook page stating that I gave excellent treatment. Here is the answer I received today from a legal services inspector at AHPRA:

Dear Dr Kruys

Thank you for your enquiry received at AHPRA on 10 March 2014. Please be advised that neither AHPRA nor the National Boards are able to provide advertisers with legal advice about their advertising, or approve advertising, and the guidelines are not a substitute for legal advice.

As stated in the Guidelines, once a practitioner is made aware of a testimonial (which contains a statement about the quality of clinical care) on their website, or in your example, Facebook, they must take reasonable steps to remove it. AHPRA staff in each state and territory will warn individuals twice to cease conduct which may be in breach of a holding out offence prior to commencing a prosecution.

The revised guidelines went through a  public consultation process and submissions were received during that process. The Guidelines for advertising of regulated health services will again be revised in the next 3 years and you are encouraged to make any submissions next time around.

So, as I suspected, we will be prosecuted if patients post friendly comments about us on social media sites, even though AHPRA said this in a media statement last Friday:

(…) there is a clear difference between advertising – which requires an intent to promote the health services – and unsolicited online comment over which practitioners do not usually have control (…). The Board recognises that practitioners are unable to control what is written about them in a public forum.

This is why AHPRA should change the guidelines immediately and not rely on media statements to clarify their ambiguous regulation.

AHPRA’s guidelines: Can someone tell me what just happened?

AHPRA social media policyFor those who haven’t followed the lively debate about the revised advertising guidelines for Australian health professionals, this post from last week explains it all. In summary, the Australian Health Practitioner Regulation Agency now says in its new guidelines that practitioners can be fined if patients post online testimonials praising the clinical care they received.

Last Friday, it seemed as if AHPRA had backed down on the harsh regulation. But is this really the case?

What does AHPRA say?

First of all, here’s a quote from the current guidelines:

a review (…) that states ‘Practitioner was quick to diagnose my illness and gave excellent treatment’, is a testimonial which references clinical care and is considered in breach of the National Law.

The guidelines also state that health practitioners must take steps to remove unsolicited testimonials appearing on any (social media) website not under their control. However, last Friday the medical board put out a media statement on the AHPRA website saying this:

The advertising guidelines apply to testimonials in the context of advertising (…) there is a clear difference between advertising – which requires an intent to promote the health services – and unsolicited online comment over which practitioners do not usually have control (…). The Board recognises that practitioners are unable to control what is written about them in a public forum.

The full statement can be found here.

3 unanswered questions

Indeed, this sounds a lot better than the official advertising guidelines – the medical press have used the words ‘backflip‘ and ‘backdown‘. However, the guidelines have not been updated, which leaves the following three questions unanswered:

1. If a patient posts a comment on my Facebook page stating that I gave excellent treatment, this is still considered in breach of the National Law according to AHPRA’s guidelines and I may be up for a fine if I don’t delete this friendly post. Will I be able to defend myself by referring to the media statement posted on the AHPRA website on 7 March 2014? If AHPRA is serious, the guidelines should be changed in accordance to their statement.

2. Health professionals need to know why our feedback about exactly this issue has not been taken on board in an earlier stage. The first draft guidelines appeared in 2012 and health practitioners were not impressed. The rules were already clear: we knew that testimonials in advertising are a no-go (and I don’t mean unsolicited Facebook comments from patients) – and of course this applies to websites, social media, the classroom, the elevator and anywhere else.

In AHPRA’s udated draft guidelines (2013) the issue of patient feedback vs testimonials had not been addressed, which again led to a storm of online comments as well as another lot of official submissions. See also this post (April 2013). As we know, the final version was published last month and positive patient feedback is not allowed, but then again on Friday the board seemed to think that patient comments are not advertising.

3. As the advertising guidelines are common to all national boards (e.g. dental, nursing & midwifery, psychology etc) we need to know if and how the statement by the medical board will be applied to the other 13 disciplines.

Don’t get me wrong, I’m happy with the clarification by medical board chair, Dr Joanna Flynn, and I agree it is a step in the right direction. But it still seems unnecessary government interference, and, after three revisions, the guidelines leave important questions unanswered.

Social media in healthcare: Do’s and don’ts

Facebook in health care
Image: pixabay.com

‘Reputation management’ was the topic of an article in the careers-section of this month’s Medical Journal of Australia. As I have blogged about reputation management before I was asked a few questions about the way my practice has used Facebook.

I think Facebook and other social media have the potential to improve communication with our patients and colleagues and make healthcare more transparent – if used wisely of course.

Unfortunately the Australian Health Practitioner Regulation Agency (AHPRA) has scared the healthcare community with their social media guidelines. Doctors are now being told by medical defence organisations to be even more careful with social media, but I’m not sure I agree with the advice given.

Do’s & don’ts

Here are the do’s and don’ts as mentioned in the MJA article:

  • “Do allow likes and direct messaging on the practice Facebook page, but don’t allow comments. This will avoid any dangers associated with comments classed as testimonials by AHPRA. It also avoids problems such as bullying that may occur when comments are made about other comments.”
  • “Don’t respond to negative remarks online, as it risks falling into the category of unprofessional conduct if brought before the medical board.”
  • “Don’t befriend patients on Facebook if you are a metropolitan practice, Avant’s Sophie Pennington advises, so as to keep some professional distance. She says that in regional and rural areas it can be unrealistic to have this separation.”
  • “Do link your Facebook page to your website, LinkedIn and any other profiles you have set up online. This will help to ensure that these options appear higher on the search-page listings when others look for your name.”
  • “Don’t google yourself!”

Negative vs positive feedback

I think negative comments online are a great opportunity to discuss hot topics (such as bulk billing and doctors shortages) and to engage with the community in a meaningful way. Positive feedback by patients is wonderful and should not be discouraged, as long as it’s not used as a way to advertise health services.

Health practitioners should be supported to communicate safely online. But not allowing Facebook comments is defeating the purpose of social media.

eHealth: The good, bad and ugly

E-health: good, bad, ugly

We’ve come a long way with technology in general practice. Technology should make our lives easier. However, in health-IT a good idea can easily go bad. But the opportunities are mind-boggling and we’ve got exciting years ahead of us.

Let’s have a look at the good, bad and ugly in eHealth, including cyber insurance, liability issues, telehealth, mobile apps, social media and of course the PCEHR.

PCEHR

The PCEHR has gone ugly. Sidelining doctors and clinical leads didn’t do the project any good. A basic requirement of a successful project is effective stakeholder management. Healthcare evolves around GPs, and if the main stakeholders are not on board for 200%, the project will fail. Meanwhile, the government has started data-mining our patient’s eHealth records. A colleague recently said on an IT forum:

I demand legislation that simply states something like: Information stored in the PCEHR can exclusively be accessed by health professionals directly involved in the patient’s treatment and exempt from access by any other third-party including by means of subpoena

I’m not holding my breath here but it’s a clear message, shared by many GPs. By failing to listen to doctors the PCEHR will be added to the already impressive global scrap heap of major health IT fiascos.

But the good news is: there are alternatives. Instead of wasting more tax dollars, we should adopt one of the already fully functioning, cheaper Australian shared record systems, like RecordPoint from Extensia.

Telehealth

Video consultations between rural patients and specialists save time and travel costs. But some patients would benefit more from Telehealth access to their GP. The RACGP budget submission to fund Telehealth for people living with a chronic disease was a great suggestion.

Initiatives like Telederm where GPs can get send a picture of a skin condition to a dermatologist and get advice, are worth their weight in gold. And eventually we really have to agree on a simple, but professional alternative to Skype that cannot be accessed by (foreign) governments or other third parties.

Social media & mobile apps

Whether we like it or not, social media is slowly becoming part of mainstream healthcare. We’ve figured out how to use social media wisely. More and more GP conferences now include workshops and session about how to sign up for Twitter, linkedIn or WordPress.

Registrars use Facebook and Twitter for e-learning. A new launching pad has been created to assist GPs interested in the professional use of social media.

Mobile and sensor-based technologies enable our patients to monitor just about anything, and with a push of a button this data could come our way – from blood pressures to continuous holter monitor results. GPs will have to figure out a way to deal with this data. This will be a challenge, but ignoring it will not make it go away.

Security & legal issues

When we introduced free WIFI for patients in our practice we discovered security risks that had to be mitigated first. The explosion in cyber crime fueled by cloud computing results in more data breaches, and GP practices are not exempt as we’ve seen not long ago in Queensland.

Technology in health care always creates liability. Recent national concerns about e-dispensing alerts and the doctor’s duty of care are a good example. New national privacy legislation will include mandatory breach notification. This means GP practices have to report all data breach events, even the minor ones, and failure to do so will incur high penalties.

AHPRA didn’t want to stay behind and introduced a social media policy, as well as a revised Code of conduct, revised Guidelines for advertising and revised Guidelines for mandatory notifications – which now include social media clauses.

The problem with regulations like this is that it further increases liability for doctors, already operating in a highly regulated industry. We don’t need more regulation. Risks are: less innovation and progress, a defensive attitude by doctors, higher legal and insurance costs, increased AHPRA fees and eventually higher costs for patients.

Insurance

It’s not surprising that cyber insurance is going to be the next hot topic. Cyber insurance should cover us against threats like cyber extortion, identity theft, crisis management, business interruption and disaster recovery. The PCEHR already has it’s own legal pitfalls. My indemnity insurance now provides cover in case of:

  • PCEHR privacy breaches.
  • Allegations of negligence for failing to detect critical patient information contained within the PCEHR.
  • Loss or corruption of electronic documents or data.
  • Intellectual property disputes.

The insurance policy does not cover fines and civil penalties related to the PCEHR – another reason why our practice will not sign up. IT security upgrades of practice systems as well as connected home and mobile devices will be unavoidable, and GPs and practice managers may have to do some upskilling to get their heads around this.

This article has previously been published in AMA(WA)’s Medicus Magazine, June 2013.

AHPRA’s draft social media policy

AHPRA social media policyThe 2012 draft social media policy by the Australian Health Practitioner Regulation Agency (AHPRA) caused a lot of upheaval. Health professionals expressed concerns it was too prescriptive. Now there’s a new version and the organisation is requesting feedback.

A 76-page consultation paper has been posted on the AHPRA website and it includes drafts of the social media policy, revised Code of conduct, revised Guidelines for advertising and revised Guidelines for mandatory notifications.

It looks like AHPRA has taken the feedback on the earlier version on board. The new draft Social media policy is less prescriptive. Health professionals have to follow strict professional values, no matter if they’re in the elevator at work, the pub, or on Twitter or Facebook.

What does it say?

Most of it is common sense, but I thought these two changes were worth mentioning:

  • Health practitioners are expected to behave professionally and courteously to colleagues and other practitioners, including when using social media (Code of conduct 4.2c).
  • Testimonials on Facebook and other social media networks have to be removed by health practitioners (Guidelines for advertising 7.2.3).

I’ve read all 76 pages but it’s not entirely clear to me what exactly a testimonial is and whether I’m now required to remove my LinkedIn testimonials and endorsements by colleagues from around the world.

Also, it will require some explaining when removing or refusing friendly, unintended testimonials from our patients on e.g. Facebook, and worse, it may even put health practitioners off social media. I won’t mention Google testimonials – they are impossible to remove. It would be great if AHPRA can provide some clarification and reassurance here.

Interestingly, an issue that causes heated debates has not been mentioned, namely anonymous posting on social media networks by health practitioners who are identifying themselves as such, but are using a pseudonym instead of their real name. Some say it’s important for e.g. whistleblowers to be anonymous, others say health professionals always have to be identifiable. But perhaps it’s a wise decision by AHPRA not to open this can of worms.

Good or bad?

The problem with regulations like this is that it increases liability for health professionals and practices already operating in a highly regulated industry – especially against a backdrop of the recent national eHealth developments and the legal issues that health providers are facing when signing up for the PCEHR. Some of the risks are: less innovation and progress, a defensive attitude by practitioners, higher legal and insurance costs, increased AHPRA fees and eventually more costs for patients.

That brings me to the risk management paragraph in AHPRA’s draft Code of conduct, which states that it’s good practice “to be aware of the principles of open disclosure and a non-punitive approach to incident management”. I wonder if AHPRA is going to follow this advice when a practitioner breaches a social media clause. Something tells me that the regulator will follow a punitive approach if we forget to delete Mrs Jones’ friendly Facebook recommendation.

AHPRA is requesting feedback via guidelinesconsultation@ahpra.gov.au by close of business on 30 May 2013.