Why we need to get over the Medicare Locals disappointment

Many people are still getting over the disappointment of Medicare Locals. I get that. Although some MLs were able to make a difference, too many were not. The new Primary Health Networks (PHNs) may be a different kettle of fish. One thing is for sure: they are here for the long haul.

There is an enormous opportunity for PHNs to add value where they support quality primary healthcare services to the community. For that reason the RACGP is keen to work with the new organisations. I believe there are at least three areas where grassroots support from local PHNs can make a big difference.

Working together

The first area is relationship building and teamwork. We all know there are too many silos and tribes in healthcare. On the other hand, long-term relationships positively influence knowledge exchange, understanding and trust.

Where possible, health providers should be freed up to have the option to discuss clinical care with each other. This is important all for health professionals, and even more so for those working in rural and remote areas.

We should ensure that non-clinicians do not get in the way of effective inter-collegial communication. For example, referral letters have to contain the necessary information to allow the next health provider to do their job properly, but we must avoid overly bureaucratic referral rules. A clinical override mechanism of these rules must always be available.

PHNs could assist, for example, with developing shared clinical priorities and organising site visits, breakfasts, lunches, dinners and conferences that cross disciplinary and organisational boundaries.

Continuity of care

The second area is improving continuity of care. This is not a catchphrase, but a crucial element of general practice with numerous proven long-term health benefits. Unfortunately it seems this principle is often sacrificed in new initiatives and models for the sake of short-term results, convenience or commercial interests.

It is helpful to distinguish the three types of continuity of care, as explained by Haggerty et al: informational continuity (sharing data), management continuity (sharing a consistent approach) and relational continuity (fostering an ongoing therapeutic relationship).

Electronic health records will assist with informational continuity, but not necessarily with management continuity and relational continuity.

“New models of care should not further fragment care

There is ample evidence that comprehensive, continuous care by GPs results in improved patient health outcomes and satisfaction. Continuity of care is cost-effective and reduces both elective and emergency hospital admissions.

GPs play a key role in keeping people out of hospital. It is important however that hospital avoidance projects help to build capacity, facilitate access in primary care and respect the principle of continuity of care.

New integrated models of care should carefully be evaluated to make sure they don’t do the opposite and fragment care thereby negatively impacting on health outcomes – often with the best intentions. PHNs can play a big role here.

Data exchange and communication 

A third area where PHNs should assist general practice is electronic data exchange and communication. Because of its central position in primary care, general practice is the natural collection point of clinical information. Direct, secure, electronic communication between GPs, specialists, community pharmacists and allied health providers is beneficial for optimal patient care, but remains problematic in many regions.

“Delayed information from hospitals is still one of the biggest problems

Delayed or absent correspondence from hospitals to referring doctors is still one of the biggest problems for GPs who are frequently trying to deal with returning patients without any information from the hospital.

All necessary information should be supplied in hospital discharge summaries, and it should not be left to the GP or practice staff to chase up any information from the hospital.

General practitioners need to ensure their referrals are of sufficient quality, consistent with RACGP standards, and useful for practitioners who continue the patient care in different settings of the health system. That means the referral information must be complete, accurate and timely.

Hospital referral criteria may require additional, locally agreed-on information, but extensive extra information (such as patient questionnaires) is the responsibility of the requesting institutions, and GPs should not be made responsible for its collection and supply.

There is room for improvement of communication between GPs. Getting the different healthcare computer systems to talk to each other is a big issue in many parts of the country. This is problematic as Australia has a mobile population. Low-cost software solutions such as GP2GP, used in New Zealand and the UK, could solve this.

The MyHealthRecord (formerly PCEHR) is, due to its many technical and medicolegal issues, not yet widely accepted as a reliable clinical tool and we see more alternative, locally developed e-health solutions in the near future.

In conclusion there are substantial opportunities for PHNs in supporting and adequately resourcing general practice and its interactions with other parts of the health system. To quote the National Health and Hospitals Reform Commission (NHHRC): “We believe that strengthened primary health care services in the community, building on the vital role of general practice, should be the ‘first contact’ for providing care for most health needs of Australian people.”

This article was originally published in The Medical Republic.

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.

Don’t google yourself?

“Don’t google yourself,” is the advice from a Medical Defence Organisation in the Medical Journal of Australia, “because you’ll probably find something that you don’t like.”

That’s fascinating. It’s a bit like screening for cancer in people without symptoms. Sometimes screening tests are abnormal even when there is no cancer. This is more likely to happen when the probability of cancer is low.

The topic of the MJA article was reputation management. So I wonder, if an MDO tells us not to screen our online reputation, does that mean the probability of finding something we don’t like is low? Or is it because we can’t do anything about the unpleasant things we may find?

The same article mentions:

But the past 12 months have seen medical defence organisations (MDOs) experience a sharp rise in concerns about growing online threats to individual doctors’ and practice reputations.

In that case, telling doctors not to Google themselves is like saying to someone with a strong family history of diabetes: “Don’t test for diabetes, because you’ll probably find an elevated blood sugar level.”

When I blogged about the MJA article earlier this week, Dr Ewen McPhee commented:

Interested to know why you wouldn’t google yourself, how will that protect your reputation?

I think he is right. Isn’t it in the interest of the doctor and the practice to know what’s out there on the web? Especially since the concerns about online reputation are rising? In this case it is also right to screen because there is a ‘treatment’ available.

Google has a simple tool, called Me on the web. It can be activated via the Google dashboard, and the service lets you know when new online information appears about you or your practice. If you have concerns about the information or you feel it is incorrect, the content can in some cases be removed with Google’s help.

Find more information about how to manage your online reputation with Google.