Tuesday, July 28, 2015

The SA Coroner Is Now Saying Snail Mail Is Really Not Good Enough. Secure Electronic Communication Is Becoming The Standard Of Care.

This appeared a little while ago.

Delayed hospital letter to GP led to patient death

20 July, 2015 Paul Smith
A leading cardiologist has been criticised for using 'snail mail' to inform a GP that he had prescribed warfarin to an elderly patient, with the letter arriving four days after the patient died.
Marjorie Aston suffered a fatal subdural haematoma when she fell and hit her head at her Adelaide home on 4 January 2013.
She had originally been prescribed warfarin for chronic atrial fibrillation two weeks earlier by Professor John Horowitz, (pictured) the director of cardiology at the Queen Elizabeth Hospital.
Professor Horowitz told the 86-year-old that she would need monitoring and should make an appointment to see her GP, Dr Fong Liew.
After the consultation, Professor Horowitz dictated a letter to the GP informing him that he had "arbitrarily” started Mrs Aston on a daily dose of 5mg of warfarin.
The letter also made it clear that she would need monitoring “until the dose is right”, the implication being that Dr Liew should take on the responsibility for the job.
However, although Dr Liew’s practice and the hospital was “separated by a carpark” — a distance of about 100m — the letter took two weeks to arrive, by which time Mrs Aston had already died.
In a inquest that concluded last week, the SA Coroners Court was told that although Professor Horowitz had referred Mrs Aston for an urgent INR test following his consultation —  a test that was carried out — he had made no provision for Dr Liew to be copied in on the results. 
Professor Horowitz told the court that it was common practice for a specialist such as himself to communicate with a GP by sending a letter by ordinary post.
However, deputy state coroner Anthony Schapel was dismissive. 
…..
 “Consideration should be given to the issue as to whether the general practitioner, on the advice of the specialist, should both initiate and manage the patient’s warfarin therapy,” he wrote in his findings.
The coroner added: “[Where] the specialist initiates warfarin therapy but does not intend to manage that therapy, the specialist should immediately advise the patient’s general practitioner, by the most efficient method of communication available, that warfarin therapy has been initiated and that the general practitioner is expected to manage that therapy.
“In this regard, the practice of communicating with general practitioners by way of ordinary post should be curtailed and be replaced by a means of communication that would include email and/or facsimile transmission.” 
More information: 
The full article is here:
The Coroner is right about a move to e-mail - but it would have been much better had he suggested a compulsory move to secure clinical messaging - rather than the now virtually obsolete facsimile or insecure e-mail. A little more specificity would have been very good indeed!
He also should have been suggesting that the time has well and truly come for specialists to adopt secure messaging!
David.

3 comments:

Bernard Robertson-Dunn said...

“Consideration should be given to the issue as to whether the general practitioner, on the advice of the specialist, should both initiate and manage the patient’s warfarin therapy,” he wrote in his findings.

In other words, all care (although in this case, not much) no responsibility.

No amount of technology is going to make up for the lack of proper business practices that put patient care front and centre.

I've had recent first hand experience of this lack of patient centric care. I had an incident late January from which I am still suffering because everybody I have consulted with has given me advice that was either specialist and narrowly focused and did not take into account all my problems or so general that it wasn't much help. And a lot of the advice was just plain wrong.

Six months of pain and incapacity focuses the mind. The conclusions I've come to are that:

* an eHealth record would not have made a blind bit of difference.

* improving health care has got very little to do with technology, although technology is likely to play a part in any improvements.

* health care workers themselves don't know what they should be doing differently - there are no obvious answers. It's going to take a lot of trial and error involving many disparate stakeholders until better practices evolve. Only then will technology make a difference. Starting with the technology is dumb.

And to be clear, I'm talking about health information systems that support decision making, not health IT involving sensors, devices etc.

Anonymous said...

"And a lot of the advice was just plain wrong"

Bernard, I have long had a concern that a shared national e-health record is a real threat to individual health because it may inhibit the ability to seek a second (and third) opinion.

Will doctors offer a fresh eye, a clean slate approach, if you will, when they are confronted with a record of previous inadequate, narrowly focused and just plain wrong diagnoses/courses of treatment suggested by colleagues, peers and superiors?

Or will the patient's view that something is not right and further investigation is required be even more firmly set aside as crackpot or malingering?

My son is extremely longsighted and I knew there was a problem with his vision from around 12 months as he ran into walls, couldn't follow a story book, was extremely frustrated and distressed by daily vision-related accidents. From first appointment with paediatric specialist at 15 months, at which we were informed there was no problem, it took until a nurse/orthoptist realised that this kid really couldn't see some four years later - I stuck him in front of her during an appointment for my daughter at the eye clinic led by a renowned specialist at a leading children's hospital.

Said expert was not happy - and certainly not apologetic - for his failure to diagnose the problem during the three previous occasions he'd examined the child.

Instead I was admonished for my persistence. In the first year of school, teachers realised there were significant vision-related learning problems, and son (by now wearing coke bottle strength glasses) qualified for classroom assistance from the excellent then-Royal Blind Society program.

Three years later, during routine review, opinion was sought from his "specialist", who opined that I was an annoying, over-servicing-seeking neurotic mother who had somehow gotten support son was not entitled to. The RBS people were shocked, as they were well acquainted with depth of vision problems. And so it is them that I credit with son's progress and adaptation, not the "illustrious" head of dept who scorned a mother's best efforts to get help.

And so, I have real concerns that doctors and others will be influenced and perhaps biased by the opinions of others - although it will no longer be possible for doctors to write disparaging personal comments about a demanding patient/carer in a shared record, it might take a brave practitioner to revisit previous medical decisions.

Bernard Robertson-Dunn said...

"Will doctors offer a fresh eye, a clean slate approach, if you will, when they are confronted with a record of previous inadequate, narrowly focused and just plain wrong diagnoses/courses of treatment suggested by colleagues, peers and superiors?"

Good question.

Here's another. How will they know if it is "inadequate, narrowly focused and just plain wrong"? Or, to put it another way - can they trust it?

Well, considering that the Department itself says that the PCEHR is not a replacement for other eHealth systems, the conclusion is that it should not be trusted.