Working with IT and the general practitioner

Published on 14/03/2015 by admin

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Chapter 46 Working with IT and the general practitioner

Michael J. Golding

ED AND THE GP

The disciplines of general practice and emergency medicine may be thought of as two ends of the one spectrum of true generalist medical practice. While emergency medicine focuses on the more acute end of the spectrum, the similarities between the specialties are greater than the differences, although the differences are sufficient to mean that working effectively in one field does not predict success in working in the other.

Unfortunately there is often a poor relationship between doctors working in emergency departments and GPs: emergency department staff too often reflect negatively on the work of the GP in the community. GPs generally deal with one patient every 15 minutes; many will work faster than this. (A resident medical officer (RMO) in emergency department is rarely able to deal with more than one patient an hour.) In that time the GP takes a history, performs an examination, formulates a diagnosis and management plan, organises investigations and initiates treatment. The GP must provide feedback to the patient, address immediate concerns of both the patient and family, and document the encounter.

Admission procedure

General practitioners will often try to avoid referral to the public health system. They are aware of the constraints of the system and the lengthy process the patient will be subject to in many emergency departments. However, investigations in the private system may take days, so the GP who suspects an acute illness is required to refer the patient for emergency assessment.

What many admitting officers do not understand is that GPs on the phone are not generally asking if a patient should be referred to the emergency department—they are telling you that there is a patient that requires review or admission. Too often questions from the emergency department’s admitting officer to the GP appear to be an attempt to prevent a referral rather than to facilitate care for the patient. Equally frustrating to an experienced GP, who is aware of the complex medical and social history of a patient, is to refer a patient to the emergency department for admission, only to have the patient assessed by a junior doctor and then sent home. The lack of value in this type of assessment has led to development of ‘third-door’ initiatives by which GPs refer patients directly to inpatient teams if their patients require admission.

Discharge procedure

Patients being discharged from emergency departments are routinely told to follow-up with their GP ‘in the next couple of days’. But, in many areas, patients find it hard to get an appointment with a GP in this time frame, and emergency departments need to recognise the difficulties many people have in organising appropriate GP follow-up. Often, discharging a patient to a GP is equivalent to doing nothing at all, and discharge management plans should not depend on GP review in less than three days without prior agreement with the GP directly.

Patients who die in the emergency department may have had recent contact with their GP; the GP may have been managing the illness prior to their death. The GP should be notified of the death as soon as possible, using dedicated forms or standard work practices. The GP can then contact the family, with whom they may have enjoyed a long-standing relationship. The GP may also be able to help with a death certificate and avoid an unwarranted coroner’s examination. Most importantly, the GP is often able to help the patient’s family and friends through the grieving process and defuse their fears and concerns about the treatment provided in the emergency department.

Communication

The general practitioner can be a useful colleague when dealing with the ‘difficult patient’. Their relationship is often based on trust and multiple interactions over a long period of time. By involving the GP in management decisions the emergency department may have a greater chance of successfully implementing treatment and management plans. The patient who frequently re-presents to the emergency department can often be better managed in cooperation with the GP.

The emergency department registration process should include asking patients if they give permission for their presentation to be discussed with their local medical officer (LMO) as well as updating the LMO contact details. It is usually better, but not essential, to make the phone call in the presence of the patient.

Communication is particularly important when the GP has asked to be notified of the outcome of an emergency department referral. Effective communication is a prized skill of GPs and is strongly emphasised during their training, so any failure of communication (verbal or written) by the emergency department to the GP following a referral to the emergency department (or other hospital department) is an endless source of frustration. Adverse events and complaint rates can be reduced by communicating directly with the GP about the outcome of a consultation. Each emergency department should have a list of local GPs with their phone numbers. Divisions of general practice are usually very well organised and helpful: they can often provide current lists of local GPs and their hours, availability and capacity for bulk billing. (Put copies of this in the waiting room.) Some divisions offer a uniform referral form.

All patients should get a discharge letter for their GP. A copy of this discharge letter should be sent to the GP by fax or email. (Patients will only rarely take their copy of the letter to their GP.)

The discharge letter should include:

• a courteous opening, e.g. ‘Dear Doctor…., Thank you for…’
• the reason the patient presented to emergency department
• the provisional diagnosis
• a list of pending investigations
• the purpose of referring this patient back to the GP
• any changes to medications made during the visit
• any consultations organised for the patient during the emergency department visit or organised for the future
• a management plan for the patient, with clearly-defined responsibilities (For many GPs, this is probably the most important part of the discharge letter.)
• a courteous ending, e.g. ‘Grateful for your further management and care, With thanks and regards,…’
• a legible name and designation below the signature.

Emergency departments who employ GPs part-time will be enriched by the knowledge and practicality of experienced decision makers. This interaction also enables GPs to experience the complexity and difficulties of working in a modern emergency department. Two-way communication can be an effective tool for breaking down professional barriers, improving patient care and developing mutual respect and professional courtesy.

Most of all, remember this: if the GP system fails, their patients will be found waiting in line at your emergency department.

Pitfalls

• Sending home a patient referred by a GP who has not been reviewed by a senior doctor within emergency department. (There will usually be a good reason for the GP’s referral.)
• Writing a discharge letter to a GP that does not include a clear management plan.
• Expecting a GP to follow up an investigation through a discharge letter: written letters rarely find their way to the patient’s GP.

Pearls

• GP divisions are generally well-organised and effective at communicating with local GPs.
• GPs working short shifts on weekend evenings can help with surge capacity of the emergency department.

IT IN THE ED

Few emergency departments in Australia or New Zealand have realised the futuristic vision of intelligent, voice-recognising, mobile computers capable of automatically uploading patient information, communicating with other emergency department staff, inpatient teams and GPs. There is, however, general agreement about what the ideal IT support tool would be able to achieve in emergency department practice:

• Improve patient flow and work efficiency.
• Assist in patient flow, providing real-time patient electronic tracking with departmental mapping to show the beds and bays.
• Record patient information and key performance indicators so highly prized by health administrators (arrival time, status of consults, triage information, discharge status).
• Provide results and orders without separate log on.
• Facilitate use of protocols, guidelines and best clinical practice for individual patients.
• Facilitate communication between emergency department and other service providers.
• Support intelligent prescribing practices.
• Seamlessly interact with inpatient systems.
• Allow for paperless electronic medical recording (EMR) using voice recognition technology.
• Generate a useful patient discharge letter with distribution to relevant medical providers listing outstanding results, changes to medications and management plan.
• Incorporate links to medical calculators and medical reference materials.
• Take advantage of wireless technology to free the clinician from the chains of the desk.
• Offer online education and quality assurance programs.

The development of the Patient Archiving and Communication System (PACS) for radiology is an example of the efficiencies which can be obtained using IT in the emergency department workplace. However, in other respects, most emergency departments have a long way to go. Many existing IT patient management systems are unable to uniquely identify a patient; many continue to generate discharge letters that start with ‘To Dr Other’ and are signed by ‘Dr LocLoc’ (locum); and, worst of all, many emergency departments rely on an out-of-date, ragged, but much-loved drug reference book, despite the widely available personal digital assistant-friendly electronic versions.

Medical reference information

IT is really useful for storage and transmission of data. Medical reference information, departmental policies, guidelines and protocols can be centrally managed but viewed on all departmental computers, allowing these to be easily updated and responsive to departmental activities. (A departmental intranet website can also replace the departmental communication book and offer a forum for departmental discussion.)

These are some of the many different providers of electronic medical reference information useful in emergency department practice:

• Uptodate: www.uptodate.com—a subscription service that offers excellent practical advice regarding general medical and paediatric conditions; expensive but effective
• eMedicine: www.emedicine.com—a free service offering streamed emergency medicine information in a standardised format
• Toxicology: www.toxinz.com; www.hypertox.com—(cheap) subscription services with excellent emergency department perspective
• MD Consult: www.mdconsult.com—(expensive) subscription service offering an excellent search engine for medical queries and extensive online journals and clinics
• Australian Medicines Handbook: www.amh.net.au—(cheap) subscription service for prescribing information
• Paediatrics: most children’s hospitals have websites with open access complete with drug protocols, patient information sheets, drug calculators and asthma plan generators
• Therapeutic Guidelines: www.tg.com.au—provides updated treatment protocols for a variety of sub-specialties, including the iconic Antibiotic Guidelines.

While protocols and procedures are ideally suited to an IT network, there appears to be no effective electronic replacement for the illustrated anatomy book; nor is there an electronic orthopaedic reference text suitable for emergency department practice. So, in addition to electronic medical reference books and journals, many emergency departments continue to stock a small library.

IT promises clinicians efficiencies that will translate to better patient care, but the costs must be fully evaluated and allowed for:

• Hardware: initial cost, followed by maintenance and replacement as required.
• Software: whether custom-made or off-the-shelf, all software will require updates and modifications; these are generally expensive and slow to be implemented. Allow plenty of lead time and ensure there is a budget.
• Security: an electronic medical record (EMR) is vulnerable to unauthorised retrieval or corruption, and finding the happy balance between being able to track all interactions with patient data and death by a thousand mouse clicks has not been easy.
• Downtime: IT systems rarely fail, but when they do it is rarely during business hours. It does not take long for the old paper system that has been displaced by IT to fall into disrepair. Ensuring a workable backup plan is time-consuming and is rarely a high priority for busy departments. However, a loss of IT capability can result in an internal disaster, and backup paper-based systems are an essential part of emergency department risk management.
• Maintenance: the pressure to centralise IT support to a HELP desk has proved overwhelming for most health organisations. The result can be a loss of engagement of IT staff in the clinical management of the department. A dedicated emergency department data manager is one way of maintaining continuity between the department and the supporting IT department.

The very poor functionality of present emergency department systems contrasts with the remarkable usability of IT systems developed for general practice. These routinely use EMRs, interface seamlessly with other providers, electronically order and review investigation results, contain clinical guidelines and patient information sheets and have intelligent prescribing capability. The success of GP systems is proof that developing a system for an emergency department is possible and offers a framework for development of emergency department systems.

Pitfalls

• Failing to survey and develop the IT skills of the workforce before introducing a new IT system. (How many of the department workforce can touch-type?)
• Depending on a remote HELP service when the printer fails on Sunday evening.

Pearls

• PACS is terrific: make sure the computer is supplied with headphones.
• Doctors’ handwriting is generally abysmal; anything that can be done to reduce the requirement for handwritten notes has the potential for improved clinical practice.
• A departmental intranet can be an extremely effective way of communicating with the staff.

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