Thursday, July 28, 2011

The Clinical Document That Can Really Make A Difference - We Need To Be Sharing Them Electronically More Often!

This is a draft article for a magazine - comments and suggestions welcome!


At its core e-Health is, as most will agree, trying to use technology in a way that best facilitates the flow of information between the various actors in the Health System, be they consumers, care providers or information sources such as pathology labs etc.

It is often said that a key goal of e-Health is to get the right information to the right person at the right time in the hope that the decisions made when in possession of all the facts will be the best possible. Good provider systems and secure clinical messaging can achieve this outcome.

For practical reasons, and maybe a lack of imagination, most e-health services and applications aim to replicate, to a greater or lesser degree, the presentation of information to the practitioner in the familiar way of looking in as many ways as possible like the paper records that they are replacing. To this end we have electronic replications of all sorts of documents such as referrals, prescriptions, clinical results and so on.

At its simplest level e-Health undertakes the pretty basic tasks of preparing, managing, organising storing and communicating these clinical documents. In this basic context I want to suggest that there is one document which we see not enough sharing of and which to my mind is greatly undervalued. That document is the specialist letter the specialist writes back to the referring GP when the patient has been seen, assessed, investigated and treatment initiated or updated.

Before discussing why I think the specialist letter is so important it is necessary to point out that I in no way minimise the difficulties that may arise in having successful sharing of detailed clinical information, however I would point out that of all the shareable documents the specialist letter may be the simplest to share successfully, being essentially just a header and a test file typically.

The reasons I especially highlight the importance of the specialist letter are as follows.

First, such correspondence is created in a calm, unhurried and focussed environment where there is time to give careful thought to what is being planned and said. Inevitably this maximises the quality, value and trustworthiness of the document.

Second, especially if created by a consulting physician, it will typically have a very clear statement of the patient’s clinical history, previous major health issues, present therapy and so on as well as the reason for the present review and the associated conclusions and recommendations.

Third these days the document will virtually always be created in electronic form making it very straightforward for it to be provided in a very accessible form to a clinical messaging client that can then provide the appropriate security and encryption prior to the letter going directly to the referring clinician.

Fourth, from my experience in both Critical Care and Emergency Care situations, I found these letters to be the single most useful paper document contained in a record and always made a practice of looking for such documents before beginning work assessing the other more detailed components of the record. Indeed, a recent well considered specialist letter was often able greatly speed up the assessment and treatment process in the emergent situation.

A single caveat I would put on all this is that, as the communication back to the GP is critically important so is the effort put in by the GP in developing a referral that explains clearly what is needed from the consultant and provides as much current relevant information as possible.

The National E-Health Strategy, developed for the Council of Australian Governments in 2008 and agreed that same year by COAG, laid out a range of priorities of National E-Health initiatives. The highest priorities were to improve the quality and usage of the IT systems used by providers and to improve clinician to clinician communications via secure messaging. It was also felt that these steps and the creation of appropriate e-health infrastructure (terminologies, health identifiers etc.) offered the best platform from which to then evolve into more advanced e-Health applications such as shared Electronic Health Records.

In both these two top areas there has been steady progress with a range of GP system providers gradually improving the quality and usability of their offerings and the emergence of a number of secure clinical messaging providers who now have very considerable geographic reach and are able to facilitate effective document exchange. Interestingly, very little of this progress can be attributed, at least so far, to NEHTA or the Commonwealth Department of Health who, despite claims to the contrary, have not funded the National Strategy and have proceeded to commence work on the Personally Controlled Electronic Health Record (PCEHR) and telehealth initiatives (involving a total expenditure of close to a billion dollars) which were not mentioned as top priorities in the Strategy. Additionally, while NEHTA has done considerable work on developing e-referral specifications, there is little apparent emphasis on ‘closing the loop’ with the return specialist letter.

The specialist clinical letter is, in my view, a much undervalued document where electronic clinical exchange could be quickly enhanced using services already in existence and at very low cost. I know many GPs are already getting such a service from many specialists but a concerted push to improve the level of penetration would be a very good thing - and would allow for incremental improvements in care while we all await the delivery of some useful e-Health applications from NEHTA and DoHA.

Adopting this suggestion can make a real difference, real soon!




Anonymous said...

Dr David More MB PhD FACHI said...

Thanks. Good to see the idea is now getting some official recognition.

It is hard to see why the back channel was not always a major part of the e-referral work.

It is a bit silly not to link the referral and the response pretty tightly.


Jason Trethowan said...

Hi David

I'm presenting at the AGPN E-Health Conference on Monday regarding this very topic. Specialist letters received securely to GPs has been a big winner in Geelong. A more immediate challenge is supporting the change process for Specialists to receive the initial GP referral electronically. Coupled with that is tipping the balance where the majority of Specialists want to receive referrals electronically. This way, a Referring GP does not have to think if sending electronically to a particular Specialist is an exception. We are getting there but it is all part of closing the loop as you say.