Managing patient information to support preventive care

An example of an internal register that practices may want to establish is one related to high-risk familial cancer. Family history tends to be under-recorded and underused in general practice.

When asking about family history of cancer, it is important to identify the number of family members affected, their age when the cancer was identified and their connection to the patient. The latter is best depicted in a genogram. A number of brief screening tools can help the GP identify family history of cancer more efficiently and comprehensively. The RACGP family history screening questionnaire can assist with this.

^{– Assoc Prof John Litt, Green Book Editorial Committee}

Three areas where registers are important, particularly for medico-legal reasons, are for patients:

• on some form of anticoagulant (eg warfarin or novel oral anticoagulants)
• at high risk of cancer because of their family history
• with diabetes.

^{– Assoc Prof John Litt, Green Book Editorial Committee}

It’s also important to identify within the practice's record software particular groups of patients who might need special preventive interventions. This may include Aboriginal and Torres Strait Islander peoples, refugees and vulnerable population groups (eg with developmental disability). This may require an adaption of the field within the records so that these patients can be readily identified for individual care and clinical audit.

This will also enable creation of a registry of each of these groups if a practice decides to use these for recall (eg for health assessments).

^{–  Prof Mark Harris, Green Book Editorial Committee}

Letter to 49-year-olds to encourage bowel screening

General practices can send a letter to their 49-year-old patients to encourage them to complete the National Bowel Cancer Screening Program (NBCSP) test when they receive it in the mail around their 50th birthday. There is strong evidence that a letter signed by a person’s GP endorsing the faecal occult blood test (FOBT) is an effective method to increase participation in bowel cancer screening. The NBCSP has developed a template letter that GPs can use to recommend screening to patients outside regular consultations.

^{– Alice Creelman, Cancer and Palliative Care Branch, Population Health and Sport Division, Department of Health}

Mismatch between patients with colonoscopy as coded diagnosis versus patients with recalls: Case study

Activity

My PN colleague was looking at our practice recall system and how we might streamline lists and make sure that coding was correct, in order that we could easily manage mail merge recalls and put action notification in patient files. While doing this exercise, I noted that there were very few recalls in the system for colonoscopies.

We then looked at how many patients had been coded as having a colonoscopy performed versus how many had recalls.
We also looked at how many patients had family history of bowel cancer coded. From some files of people who had had colonoscopies, we noted that there was a family history noted in free text in a patient profile but not coded in a searchable way.

Action

We checked the files of all patients who had coded colonoscopies and read the colonoscopy reports and specialist recommendations for follow-up. We coded all those with family history of bowel cancer so that we could easily search for those patients and ensure this would appear in their medical history.

I needed to carry out some backend adjustments of the recall lists via the maintenance function in the recall system used at our Leichhardt practice, especially where the doctors had free text in the ‘reason for recall’ section or there were multiple names for the same condition.

We put recalls for surveillance on all those that were indicated as needing follow-up surveillance – whether at three years or five years.

We presented the activity at the combined staff meeting to let all staff know this was happening and to engage the team.

We put the action list in all the patient files so that any health professional opening the patient file would see the action and follow-up regarding bowel cancer testing/colonoscopy. With our clinical information system, once you have put an alert in the 'action' list, this will be the first screen to open in the patient file and you cannot navigate the file until you close the box (hopefully having read, noted and actioned the alert where necessary).

We looked at the patient registration form. This had previously been amended to include family history questions for several conditions (eg diabetes, breast and bowel cancer), but these were not always being added at the new patient visit. This process was also discussed with the team to ensure that these risks were recorded and coded in a searchable way.

Outcomes

Invitations were sent to all patients who required screening due to family history and risk of bowel cancer to visit their GP and discuss the issue.

Recalls were sent for those who had not been added to the initial recall but who required ongoing surveillance and were due for screening.

Recalls were added for those who required future follow-up.

Although the GPs were used to adding the coding for a procedure, they were more aware of adding recalls at the time of reviewing a specialist report.

There were other patients picked up in this exercise, where family history was not an issue but specialist- recommended recalls for follow-up had not been added.

Our senior registrar was conducting a population health project on bowel screening, and because we had a system in place where family history was coded and recalls were in place, measuring the practice’s starting point became far easier.

^{– Ms Karen Booth, Green Book Editorial Committee}

Using your data to improve your practice

Below is an example of how we used our practice computer system to improve our patient care while also improving our income.

With the Australian Government program to fund the shingles vaccine for all patients aged 70–79 years, our nurses have used our database to target these patients with telephone calls advising them this is available and arrange appointments for this at the same time, if they were willing.

With dedicated work, since inception of the program in November 2016, we have reached all of our patients in this age group who have not had shingles in the last year and are not on an immunosuppressant (these are contraindications) and offered them the vaccination. Our nurses performed a simple search in our practice software. With more sophisticated searches, we plan to use an extraction tool to extract data.

We started with those patients who were aged 79 years and about to turn 80 (and who then would no longer qualify under this program) and worked backwards to age 70 years. We have called everyone in this cohort and have successfully vaccinated over 70% of them, which we are informed is more than double the average for other practices Australia-wide.

Having accurate data has made things much easier. Calling these people also gave us an opportunity to tidy up our database by removing (inactivating) those patients who no longer attend. Fortunately, because we pay strict attention to inactivating deceased patients when we learn of their passing, we did not have any embarrassing calls asking if dead people wanted a vaccination!

^{– Dr Rob Hosking, Bacchus Marsh GP (adapted from his blog entry, posted on 21 November 2017)}

Recording demographic data

Since we started routinely asking all patients if they identify as Aboriginal or Torres Strait Islander, the number registered has gone from one to 300 (over a four-year period). Recording this in the practice software demographic section enables our PNs to optimise the uptake of the Indigenous Chronic Disease Package.

^{– Dr Michael Fasher, GP and Adjunct Associate Professor, University of Sydney}