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Seamless exchange of information between aged care and general practice


Position

The patient medical record systems used in residential aged care facilities (RACFs) are not compatible with those used in general practice. The RACGP believes that the Federal Government’s aged care and digital reform agendas should prioritise the need for these healthcare settings to seamlessly share clinical information in real time, creating a ‘single source of truth’ medical record that is accessible to all clinicians involved in an older person’s care.

RACFs’ patient medical record systems should be digitised and made interoperable with the clinical information systems (CISs) used in general practice.

The implementation of new, interoperable digital systems is associated with considerable financial costs and impost to end users (such as time taken to train in the use of those systems). Implementation of these systems will require a significant funding program and transition plan. General practitioners (GPs) and RACF staff must be supported with adequate training to transition to new technologies, as well as support to manage the requisite organisational or workforce changes.

Due to its limitations, My Health Record should not be considered a complete solution to the issue of interoperability and should instead be used in complement to an interoperable CIS.

Definitions

For the purposes of this position statement, the term ‘patient medical record system’ refers to any system or product, whether paper-based or electronic (computer- or cloud-based), that is used to collate a patient’s medical data, such as clinical notes, medication history, laboratory results or reports, and clinical images.

The term ‘clinical information system’ (CIS) refers to an electronic system or product that provides immediate access to current patient medical data.1 A GP CIS should also include other functions such as medication management and facilities to request pathology and imaging.

‘Interoperability’ refers to the ability of an information system or product to exchange information – in this instance, information pertaining to an individual’s healthcare – within or between systems or products, without special effort on the part of the user.2

‘Single source of truth’ is a term used in this statement to describe a medical record that is synchronised across healthcare settings (in particular, across general practices and RACFs).


Background

The case for interoperability

GPs play a critical role as clinicians and care coordinators within the aged care system, seeing over 90 per cent of permanent aged care residents.3 Those residents see their GP twice a month on average, with this increasing to five times as they near the end of their life.3

GPs provide an in-depth understanding of the whole patient through their longstanding relationships with patients and their families. The GP’s continued involvement in providing person-centred care is paramount in achieving optimal health and wellbeing outcomes, including end of life care, for older people in RACFs. Many GPs continue to see their patients who have moved from independent, community based care into a RACF.

Patient medical record systems used in RACFs differ wildly between facilities. Many RACFs still rely on paper-based systems for information exchange, relying on outmoded technologies such as the telephone, fax, and hand-written entry,4 though anecdotally this is less common since the COVID-19 pandemic. In RACFs that use a CIS, that system is not interoperable with those used in general practice or other branches of the healthcare sector: that is, the various IT systems are unable to exchange vital medical information about a particular patient.

Accessing pathology results is a particular problem for those GPs working in RACFs. At present, this is a very time-consuming and complicated process, which has the potential to make prescribing, diagnosis, and medication monitoring dangerous.

Although many GP CIS can be accessed remotely for the purposes of writing notes, accessing medication lists, and prescribing, RACFs do not generally provide GPs with a dedicated computer on site for this purpose. Remote access can also be limited in its functionality. Though some RACFs might allow GPs to access their CISs remotely, this is not always the case and is usually allowed by special arrangement only.

Noting the challenge of sharing medical information between a general practice and an RACF, the RACGP’s aged care clinical guide (Silver Book) recommends that notes be copied and pasted from the GP CIS into the RACF’s system after a visit.5 Other solutions include printing a hard copy of the patient’s medical notes from the GP CIS for inclusion in the RACF’s patient medical record system, or transcribing a second, truncated version of the notes into that system.5 Obviously, these methods are inefficient and fraught with the risk of a communication breakdown between one healthcare professional and another, which could impact patient safety. Also, these options ignore the updating of medication lists in GP CISs, which is a separate process to any of the above recommendations.

The poor state of IT systems in RACFs is a major deterrent for GPs when considering whether to work in these settings. Over half of GP respondents to the RACGP’s General Practice Health of the Nation 2021 survey indicated that improved IT infrastructure, including interoperability with their practice software, would make them more likely to work in aged care.6

The 2021 Royal Commission into Aged Care Safety and Quality (the Royal Commission)7 revealed deep, systemic problems with the technological infrastructure within the aged care sector. The RACGP broadly supports the Royal Commission’s recommendations relating to digital health. One such recommendation is that by July 2022, every approved provider of aged care should use a digital care management system, including an electronic medication management system, that meets a standard set by the Australian Digital Health Agency.7 The Royal Commission goes on to recommend that significant investments be made to develop a new service-wide client relationship management system with standardised systems and tools to improve the user experience and that will progressively move to real-time, automated reporting.7

The RACGP would go further to recommend that any standardised, service-wide system be interoperable with those used in general practice, to create a single source of truth record. Ideally, a patient’s medical record would be completely uploaded from the general practice to the RACF’s system, and the record would synchronise automatically and in real time across settings when updated. This is the best way to ensure that the key healthcare providers involved in an older person’s care have access to complete, accurate, and up-to-date data.


Delivery of the right information to the right people

GPs are required to collaborate with an older patient’s broader multidisciplinary healthcare team, including the resident’s family, RACF staff, carers, nurses, other specialist medical practitioners, and allied health professionals. In the case of older people, GPs often perform a transitional care role, supporting the patient as they are cared for at home, and then into low-needs RACF care and/or high-needs RACF dependency as required. Across these stages, the patient’s medical information must be readily available to all their healthcare providers, across all care sites. This is a requirement of modern healthcare provision.

Safe and efficient healthcare requires the timely electronic transfer of information between care teams, across disciplines and between care sites. This transfer must be enabled by technology that consistently and readily communicates not only diagnosis and management of clinical conditions, but also the patient’s unique medical, family, social and environmental history and circumstances.

As outlined in the RACGP’s Position statement ‘Supporting sustainable GP-led care for older people’, interoperable CISs will allow the clinicians involved in the delivery of an RACF patient’s medical care to access and exchange information at the point of care.


Reducing the risk of harm

A complete picture of a patient’s health is crucial to ensure clinical decisions are based on the right information, at the right time.

Fragmented and duplicated patient records can result in detrimental or even fatal outcomes. On transition into RACF, the way in which patient data are inconsistently integrated to RACF records may present a safety concern. Problems might also arise when a patient living in a RACF sees an external healthcare provider such as a GP or is transferred to another institution for medical care. Manual transfer of data from the healthcare provider’s patient medical record system to the RACF’s system can lead to transcription errors or legibility issues that endanger patient safety. Transitions between hospital and RACF present a flashpoint for safety issues, as data for acute care are easily lost.

Management of multiple medicines is a particularly fraught issue for healthcare providers caring for patients in RACFs. The healthcare needs of residents in RACFs are significant and often complex, involving the management of multiple chronic health conditions with an associated increase in polypharmacy. One recent Australian study showed that 94.6 per cent of RACF residents had one or more discrepancies between their RACF and GP medication lists.8 Nearly half of those residents had a discrepancy which has the potential to result in moderate harm, and almost 10 per cent had a discrepancy that could result in severe harm.8

Interoperable IT systems eliminate the need for duplicate data entry to transfer information, thereby reducing the risk of transcription errors, legibility issues, and medication discrepancies. One patient medical record could be used across providers and facilities.


Reducing the administrative burden

Most RACFs continue to require information be provided via paper-based or stand-alone online forms that are unique to each facility. Many GPs work across more than one RACF. Familiarising oneself with the unique processes of each RACF is in and of itself a time-consuming process for GPs that is unlikely to be accounted for in billing structures.

Upon seeing a patient, GPs must manually transfer the information from their own clinical and administrative IT systems to the relevant RACF’s records by scanning and uploading the information, entering details into an online form, hand-writing details into a paper-based chart, faxing, posting, or sending it via email. These are inefficient and burdensome tasks, and the time they take is time that may not be billed, again resulting in a loss of income for GPs.

This administrative burden falls to RACF staff as well. One study showed that during the course of a shift, a nursing staff member in an Australian RACF will spend an average of 30 minutes transferring information from paper to a computer system, make on average 1.5 calls to GPs and two calls to pharmacies, and send 1.5 faxes to GPs and two to pharmacies.4

The implementation of interoperable systems would facilitate a ‘one-touch’ approach that allows GPs (and RACF staff) to devote less time to information documentation and more to the provision of face-to-face care. Integral to the development of new interoperable systems for RACFs is that they are user-friendly, that is, they can be used effectively by time-poor staff. With rollout, there must be initiatives to support individuals with a low level of digital literacy.


Supporting health strategy and quality improvement across the sector

A further recommendation of the Royal Commission was for the Australian Institute of Health and Welfare to curate and manage a National Aged Care Data Asset which would include demographics, clinical characteristics and care needs of residents.7

At present, a lack of standardised coding and terminology within GP and RACF CISs hampers the use of big data for research, clinical decision support, quality improvement and public health policy. Without systems that use a common language, it is difficult to collect systematised data that would greatly assist in big data projects to improve the standard of care in RACFs.

Any CISs implemented in RACFs should use nationally agreed-upon rules for coding, terminology and information transfer that are consistent with those CISs used in general practice. These should be enshrined in national standards for RACF CISs.

Facilitating the identification of key patient groups

The numbers of Aboriginal and Torres Strait Islander clients within RACFs are low compared to other communities for a number of factors, including the social determinants of health inequities which contribute to a gap in life expectancy from non-Indigenous Australians.9

Technologies must be interoperable between RACFs and GPs to support cultural safety and play an important role in facilitating the identification of Aboriginal and Torres Strait Islander clients.


Minimum requirements for CISs

In 2018, the RACGP developed a set of ‘minimum requirements’ for GP CISs in discussions with GPs, the Australian Digital Health Agency, and software developers.9 These minimum requirements, designed to help ensure CISs meet the needs of end users and improve useability and functionality, would be useful in setting a benchmark for RACF patient medical record systems.

For example, at minimum, a CIS should:10

  • Facilitate the input of high-quality data by users
  • Display core clinical information in a way that is easy for users to view and update if required
  • Support the use of standardised terminology, nationally recognised coding systems and medical vocabularies
  • Restrict free text to narrative sections of the record
  • Ensure structured data entry is usable and does not disrupt clinical workflows
  • Seamlessly populate data from external sources into the record after they are reviewed
  • Incorporate identity management and access control frameworks that are consistent with industry best practice
  • Have mechanisms to ensure software currency
  • Ensure recalls and reminders are clearly visible, easily actioned, can be prioritised based on urgency and clinical importance, and are linked to an audit log that shows what action was taken and who took the action
  • Support the consistent capture and recording of ethnicity, sex, gender, and Aboriginal and Torres Strait Islander status in all relevant fields.

Standards for RACF CIS should be developed through a collaboration between end users such as GPs and RACF staff, experts in clinical informatics, and CIS software vendors.


Issues

Workforce challenges

RACFs will need significant support to undertake the organisational and workforce changes required to utilise new interoperable CIS. A substantial boost in funding will be required to incentivise RACFs to upgrade their existing patient medical record systems and upskill staff in their use.

GPs, too, will require funding and assistance to undertake relevant training and upgrade their own systems as required. The implementation of any new IT system in healthcare should also be considered alongside existing business models and how the two will work in concert.

It is imperative that GPs be consulted in developing and implementing new digital systems and the RACGP welcomes the opportunity to be involved in this process in consultation with its membership.


My Health Record not a complete solution

Information sharing between GPs and RACFs is in some cases facilitated by the national electronic health record, My Health Record, which is an online repository for documents and data. Various healthcare provider organisations can upload and access patient information in My Health Record.

The Final Report of the Royal Commission recommends that RACF systems be made interoperable with My Health Record for case management and monitoring.7

While the RACGP encourages the use of My Health Record in RACFs, as it does in other healthcare settings, My Health Record is not a complete patient medical record and should not be relied upon as such. Individuals are free to choose whether to have a My Health Record; its use is not mandatory. Further, information in an individual’s My Health Record might not be up to date, and the individual can choose to remove documents from view or restrict access to their record. For these reasons, information in a My Health Record should be verified using other sources, such as the GP CIS.11 The RACGP recommends that My Health Record be used in conjunction with an interoperable CIS.


References

  1. Islam MM, Poly TN, Li YC. Recent advancement of clinical information systems: opportunities and challenges. Yearb Med Inform. 2018 Aug;27(01):83-90.
  2. Global Digital Health Partnership. Interoperability .
  3. Australian Institute of Health and Welfare. Interfaces between the aged care and health systems in Australia— GP use by people living in permanent residential aged care 2012–13 to 2016–17 [Internet]. Canberra: AIHW; accessed 2022 April 7. 
  4. Gaskin S, Georgiou A, Barton D, Westbrook J. Examining the role of information exchange in residential aged care work practices – a survey of residential aged care facilities. BMC Geriatrics. 2012; 12(40).
  5. The Royal Australian College of General Practitioners. Aged care clinical guide 5th edition (Silver Book – Part B). Melbourne: RACGP; 2019.
  6. The Royal Australian College of General Practitioners. General Practice: Health of the Nation 2021. Melbourne: RACGP; 2021.
  7. The Royal Commission into Aged Care Quality and Safety. Final report: Care, dignity and respect. Volume 1: Summary and recommendations. Canberra: Commonwealth of Australia; 2021.
  8. Makeham M, Pont L, Verdult C, Hardie RA, Raban MZ et al. The General Practice and Residential Aged Care Facility Concordance of Medication (GRACEMED) study. Int J Med Inform. 2020 Nov 1;143:104264.
  9. National Aboriginal Community Controlled Health Organisation and The Royal Australian College of General Practitioners. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. 3rd edn. Melbourne: RACGP; 2018.
  10. The Royal Australian College of General Practitioners. Minimum requirements for general practice clinical information systems to improve usability. Melbourne: RACGP; 2018.
  11. The Royal Australian College of General Practitioners. My Health Record: a brief guide for general practice. Melbourne: RACGP; 2018.

 

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