The Danish health IT solution: small-scale brilliance

When his wife attended a conference in Copenhagen, Adelaide GP and RACGP board member Dr Daniel Byrne took the opportunity to find out why Denmark is one of the world leaders in the use of e-health.

One of Australia’s problems is the reliance on paper documents. For example, almost every healthcare organisation designs their own referral forms and we still fax and post a lot of documents. In Denmark a ‘one-letter solution’ was introduced years ago: one electronic form used by thousands of health organisations.

“No patient ever left the surgery with any paper,” said Dr Byrne. “It seemed very well organised with a great e-health network. No faxes were used as everything is connected via secure networks – prescriptions, referrals, pathology and radiology ordering, even email consults.”

E-mail consultations

Dr Daniel Byrne
Dr Daniel Byrne about the Danish e-health system: “The live medication list was too good to be true.” Image: Linkedin.

There are no incentives for Australian GPs to communicate with their patients by phone and email, whereas Danish GPs are paid to to take calls from patients every morning. They are also paid for e-mail communications with patients.

Dr Byrne: “The email consults are excellent. The patient has to send their email via a government secure email system. Every citizen in Denmark has a government email address – maybe similar to our MyGov system.”

“Only simple non urgent requests are done by email. I think the GP has three days to answer. The payment was around $10 per email for the GP and this seemed to work fine. If there is a bit of to and fro with a patient via email the GP asks the patient to come in for a proper consult.”

Shared medication record

National databases exist for medications and laboratory results. Dr Byrne: “The live medication list was too good to be true! Click on the medication list in any GP software or hospital system and within 2-3 seconds up pops the same real-time live medication list.”

“The GP I was with could see the prednisolone dosing schedule for a patient with polymyalgia from hospital and then just take over future prescriptions. Everyone is working off the same list. I am sure it is not perfect but a pretty good starting point compared to our nothing.”

It appears the system encourages continuity of care. After hours medical services use the same computer system as GPs and hospital discharge summaries arrive electronically at the GP surgery within two days. Scripts are sent electronically to the patient’s preferred pharmacy.

Patient access

Compared to many other European countries Denmark has a high public satisfaction with the health care system.

An interesting aspect is the access patients have to the system. Via the Danish National Health Portal patients can access hospital discharge information, laboratory results, the live medication list and waiting list information.

Patients can electronically schedule GP appointments, send e-mails to their GP and renew prescriptions. They can also see who has accessed their health records.

All doctors are allowed to access the health records, but other health professionals require patient consent first. Danish law does not allow the interconnection of IT systems across sectors, such as health and taxation.

Miles ahead

With a population of 5.6 million Denmark is one of the smaller European countries, which may make it easier to roll out e-health. The system is not perfect and there are always issues, such as interoperability.

Overall Denmark seems to be miles ahead of many other countries, including Australia where we still rely heavily on the fax machine. Dr Byrne: “In Denmark it is illegal to fax anything as the system works on a national ID number that has to be kept secure.”

5 questions to ask your doctor (before you get any test or treatment)

The National Prescribing Service (NPS) has made an interesting list of 5 questions patients should ask their doctors. The aim is to be well informed about the benefits and potential harm before you undergo medical tests, treatments, and procedures.

I think the list is useful and I’d encourage people to ask these questions. At the same time I suspect I will not be able to answer all the questions. For example, I don’t know the costs of all available tests, and the exact risks of certain interventions is something I may have to look up.

I have been told NPS is planning to develop resources for doctors so they can better help their patients with these queries. This would indeed be helpful. But in the meantime, feel free to ask! I hope it will lead to less unnecessary interventions.

Here are the 5 questions to ask your doctor before you get any test, treatment, or procedure:

5 questions NPS

Source: Choosing Wisely Australia

3 examples why health professionals should be online

It was an interesting week to say the least. I was so sorry to hear about the death of 21-year Eloise Parru, who accidentally took an overdose of slimming pills she purchased online. The pills contained a dangerous substance, dinitrophenol or DNP.

The amount of online advertising of drugs and medical devices is overwhelming. Unfortunately buying medications over the internet is a risky business. They can be fake, contain too much or too little of the active ingredient, or they may contain toxic chemicals. There is no doctor or pharmacist to give reliable advice on how to take the drugs and what adverse reactions to look out for.

The Therapeutic Goods Administration has an excellent website explaining the risks of buying medications on international websites. My advice: never do it.

Health blogger and founder of a best-selling health app Belle Gibson was a very influential woman – but unfortunately she made things up. In a recent interview she confessed that she never had cancer and wasn’t cured by natural remedies. The media are all over her, and so far she has not apologised for misleading her followers. I wonder what is going on here.

Online health scams are numerous. As the wellness industry is largely unregulated, I’m afraid this will not change.

forced penetration
Image: Sydney Morning Herald

The Australian vaccination skeptics network was in the news again after it compared vaccinations to ‘forced penetration’. A shocking image (see above) was posted on the Facebook page of the anti-vaccination group to convey their controversial message. It has caused a public outrage, which is probably a good thing. I don’t think it has done the group any good.

A while ago I blogged about the 6 warning signs that online health information may be unreliable and as I said before: don’t rely on one source of information and always ask a registered doctor or health professional if you’re not sure.

I believe we need more health professionals and health organisations promoting reliable, evidence-based information in the online space – including social media – to counterbalance the many untrustworthy health messages.

What do you think?

How safe is the patient safety net?

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. Perth GP Dr Jacquie Garton-Smith proposes a change to the PBS safety net to protect vulnerable patients.

“One thing that my patients with chronic disease on lower incomes find difficult,” says Dr Garton-Smith, “is that they have to pay for all their medications until they hit the safety net. Even if people are only paying the lower rate for scripts, it adds up if they are on a number of medications. I have seen it affect compliance at the beginning of the year when they have to decide which medications they need most.”

The general patient safety net threshold is currently $1,453.90, and the concessional threshold $366. When someone or their family’s total co-payments reach this amount, they only have to pay the concessional co-payment amount of $6.10 until the end of the calendar year. Concessional card holders get standard PBS scripts for free after they reach the threshold.

The PBS co-payment and safety net amounts, effective from 1 January 2015:

General patient co-payment: $37.70

Concessional co-payment: $6.10

General safety net threshold: $1,453.90

Concessional safety net threshold: $366.00.

A safer solution

Garton-Smith: “Loading the costs into a few months of the year and then being free the rest of the year for concessional card holders is concerning. My patients tell me the safety net is supposed to help them but doesn’t – until it kicks in. For someone who has diabetes, hypertension, hypercholesterolaemia, arthritis, reflux, depression and sometimes osteoporosis, asthma or COPD, you can see the impact. This is not an unusual scenario.”

“It would be so much easier if the cost could be spread out over the year for people likely to hit the safety net. It would also prevent people attempting to stock-pile at the end of the year. I realise most people don’t get more than 5 scripts a month but those who need to are often managing serious health problems.”

Medication adherence 

Research has shown that when co-payments for medications increase, more people stop their treatment. This includes essential preventive medications, and as a result more visits to the doctor and hospital may be required.

Associate professor Michael Ortiz said in Australian Prescriber: “Some have argued that greater cost sharing does not undermine overall patient health because patients facing rising costs will reduce their consumption of perceived non-essential medications more than their consumption of essential drugs. However, ‘preventive’ drugs are different, because not all patients understand the long-term benefits of taking medicines for conditions such as hypertension and hypercholesterolaemia.”

“Some of my patients need to delay filling scripts they see as less essential

Garton-Smith: “A patient I have seen needs to buy more than ten medications every month at a cost of $85. Sometimes there are extra costs, for example if he needs antibiotics. On a single disability pension he gets $840.20 per fortnight, so approximately 5% of his income is spent on scripts until he reaches the safety net threshold, generally by May. Even though he gets a lot of prescriptions filled just before the end of December, he usually needs to delay filling scripts that he sees as less essential at the start of the year.”

Professor Michael Ortiz in Australian Prescriber: “The current approach to PBS savings is that the Government takes most of the cost savings, but increases co-payments and safety net thresholds each year in line with inflation. Increasing co-payments reduces medication adherence and ultimately may compromise the care of some patients.”

Thanks to Dr Jacquie Garton-Smith for the topic suggestion.

The looming war between pharmacists and doctors

The looming war between pharmacists and doctors
Image: Pixabay.com
The war (…) was an unnecessary condition of affairs, and might have been avoided if forbearance and wisdom had been practised on both sides ~ Robert E. Lee

Separating the medication prescribers from the dispensers has merit. One of the advantages is that doctors and pharmacists don’t get tempted to diagnose problems to sell more drugs.

The Australian Pharmacy Guild wants to change this. They prefer pharmacists to do health checks, give advice and perform interventions such as vaccinations – while at the same time selling the solution to the problems they identify.

The Guild’s strategy is marketed as providing better access to patient care, and is apparently based on overwhelming international evidence. Indeed, in some countries pharmacists offer a wider range of services.

I’m not sure it’s always better overseas. One New Zealand doctor seemed very unhappy about pharmacists managing medical problems (and I have heard similar stories from other countries):

“I practise in New Zealand where pharmacists are allowed to treat ‘easy’ diagnoses like urinary tract infection [UTI]. Last week I consulted with a young lady who had had two diagnoses of UTI and two courses of trimethoprim [an antibiotic]. When I examined her she had a significant UTI, thrush and the possibility of a chlamydia infection, results awaited. Nothing is ‘easy’ in medicine!

The Pharmacy Guild may be a politically clever bunch, but they should have suggested a multidisciplinary solution here. Their strategy will create a backlash. In the end nobody will be better off.

Where to from here?

The signs are on the wall. Dispensing medications is not sustainable for pharmacies. Just like video rental shops had to change their business model because people started downloading movies and using automated DVD rental kiosks, this particular part of the pharmacist’s job may soon be history. The authors of an article in the British Pharmaceutical Journal ‘Dispensing: it’s time to let it go’ said: “If the aspirations of pharmacy fulfilling a clinical role integral to public healthcare is ever to be realised, community pharmacists must shift their focus away from dispensing and towards NHS service provision.”

The key here is integration. According to the authors medications could be provided in-house by health care organisations or delivered by mail, and the focus of pharmacists should be on providing integrated services like medication reviews and drug utilisation reviews. This would indeed employ the skills of pharmacists and at the same time ad value to patient care provided by other health professionals.

Or maybe pharmacists should be made responsible for quality control of over-the-counter medicines and help to stamp out misleading claims made by the domestic complementary medicines industry.

We need honest medication advice. “(…) It comes as a shock to walk into some pharmacies to see them urging products on customers where there is no evidence base of effectiveness,” said NHMRC boss Professor Warwick Anderson recently. “If you’re providing advice and care to patients, you should be clear about the evidence for the treatment.”

The pharmacy industry is comfortably protected by their community pharmacy agreement with the Federal Government, and state laws stipulate only pharmacists can own a pharmacy. A new pharmacy cannot set up shop close to an existing pharmacy. Other professions, like doctors and lawyers, don’t have this competition protection.

The service expansion drift of pharmacy-owners will eventually provoke a response from the AMA and RACGP and other medical organisations. The idea of the pharmacist in general practice has been floating around for a while. Doctors may demand dispensing rights and lobby for an end to the pharmacy cartel.

A study in the Medical Journal of Australia showed that dispensing doctors issued fewer PBS scripts than non-dispensing doctors. This is one argument for dispensaries in GP surgeries; other arguments are evidence-based medication advice and consumer convenience. Think about it: What’s easier than, after having seen the doctor, walking to the dispensing machine in the hallway, scanning your script and receiving your medications? Robotic dispensing reduces medication errors (see video below) and nobody is suggesting multivitamins, supplements or probiotics at the same time.

But just because a service is more convenient, doesn’t mean that it is a good solution. Doctors should not do the pharmacist’s job, just like pharmacists would do well to stay away from medical services.

There is still time

Pharmacy-owners face reduced profits because the Government has set lower prices for generic medications under the price disclosure arrangements. Although it is understandable they are looking for other income streams, this is a dead-end. The last thing we need is a war between pharmacists and doctors.

Needless to say it’s not in the interest of health consumers. It will create confusion, duplication, false reassurance, frustration, missed screening opportunities, fragmentation of care and higher costs.

Doctors have to accept change too. If people feel they cannot access a GP when they need to, we should improve this. One solution would be to fund nurse-lead walk-in vaccination services within the safe, clinical environment of the GP surgery. The pharmacist can play a role as part of the multidisciplinary team.

The current community pharmacy agreement expires in June 2015. There is still time.

Follow me on Twitter: @EdwinKruys

Doctor, do I have to stay on these medications?

This is the first article in the ‘Blogging on Demand’ series. If you have a topic you want me to blog about, feel free to send an email, contact me via social media or leave a comment below. Jen Morris picked the topic of this post. She tweeted me saying: “I’d love a GP view on polypharmacy, deprescribing & importance of reviewing and stopping treatment, not just continuing indefinitely.”

I really like this topic. I’ll explain why. It’s fair to say I have a love-hate relationship with medications. They can do a lot of good, but also cause misery. Prescribing drugs is a bit like cooking, and getting the balance of the different ingredients right an art: Use too little and your dinner guests are unimpressed, use too much and it becomes unpalatable.

There are many guidelines in medicine informing us when to use which ingredients, but unlike cooking books, they never tell when a dish should be taken out of the oven, or, in other words, when to stop treatment. This is odd, especially as patients often rightly ask: “Doctor, do I have to stay on these medications for the rest of my life?”

Here is a summary of the why, when and how to stop long-term medications – based on the limited amount of evidence available. For more information I refer to the sources mentioned below.

#1: Why stop medications?

Research shows that elderly people often feel better after their medication is discontinued. One study found that only 2% of the medications had to be restarted because the original symptoms reoccurred. This suggests that many people take medications unnecessarily.

It is estimated that up to 30% of hospital admissions for elderly patients are related to the medications they take. Reviewing the medication list periodically is therefore important, for example after the annual home medication review by the pharmacist.

#2: When to consider stopping

There may be good reasons why, after review, it is better to continue long-term medications. But there are 5 circumstances when stopping should be considered:

  1. A patient is taking multiple (more than 4) drugs
  2. An adverse drug reaction is suspected
  3. The drug doesn’t work (anymore)
  4. A patient experiences falls or cognitive decline
  5. The condition of the patient improves or worsens dramatically.

 #3: How to stop

Deprescribing can be done safely, but is not without risks. Withdrawal symptoms, rebound syndromes and reappearance of the original symptoms may occur. Medication withdrawal should be undertaken in consultation with a doctor.

The literature suggests different methods, but I particularly like the following simple 5-step approach:

  1. Prepare: Always consider the option of deprescribing at the start of a therapy, in case it is required later on.
  2. Recognise the need to stop: are any of the above mentioned 5 circumstances applicable?
  3. Prioritise one drug at a time to stop.
  4. Wean, especially benzodiazepines, opioids, beta blockers, corticosteroids, and levodopa.
  5. Monitor: Look out for withdrawal symptoms, discontinuation and rebound syndromes, reoccurrence of illness, falls, and changes in cognition and quality of life.

Research into deprescribing has mainly been done in elderly people taking multiple drugs. I believe it is not unreasonable to apply the same principles to younger people, even if they are on a smaller amount of long-term medications.

I always find it extremely satisfying if we manage to cut the number or dose of someone’s medications – and most patients seem to be equally pleased. Less is sometimes more.

Thanks to Jen Morris for the topic suggestion.