Improving health record quality in general practice

Sally (RACGP staff member):

Today's webinar will be presented by Dr. David Adam. David graduated from the University of Western Australia in 2010 and undertook general practice training at Lockridge Medical Centre. After completing postgraduate training, he returned to Lockridge in 2016. He is particularly interested in Children's Health and Medical Education. David is a member of the Practice Technology and Management RACGP Expert Committee (REC-PTM) and presented workshops as a ‘Digital Champion’ to RACGP members as part of the 2018 My Health Record national education awareness program. Before becoming a GP, David was an IT systems administrator. David, welcome to the webinar.

Dr David Adam: Thanks Sally, glad to be here.

Sally: Thanks. David myself and the RACGP would like to thank everyone today for taking time out of your busy schedules to participate in today's webinar. We look forward to engaging you in today's webinar and while you may feel like you are the only one participating at the moment, you are joined online by a number of your peers, as well as other eHealth experts who will be available at the end of the webinar to assist David to answer your questions.

Before we begin, I would like to make an Acknowledgement to Country.

I would like to acknowledge the traditional owners of the respective lands on which we are meeting today and to pay my respects to Elders past and present. I would also like to acknowledge any Aboriginal and Torres Strait Islander people present.

Dr David Adam: Thanks very much Sally. So really great to see such a diverse mix of people joining us today, as well. We normally feel like we're mostly talking to doctors, but I think it's good to see so many people from a broad range of backgrounds are interested as you know, health record quality affect us all.

Over the course of today, we will try and fulfil their learning outcomes you can see on screen and to do that, I'll run through run through a few things. So on the agenda, which you'll see on the next slide, we're going to talk about health data collection storage in general practice, some of the rationale between why good quality data is needed particularly electronic medical records and some of the issues that can come up. I'd like to take you through the college's resources, we’ve put together called ‘Improving health record quality in general practice’ which looks at the attributes of high-quality data in good health records and also some tips for improving your in your practice, or in the practices’ you support and then we'll have some time for questions and answers.

So I think most of us who are doctors and nurses learned pretty much from the get-go, you know, it was drilled into us that if it wasn't written down it might as well not have happened and really health records are about supporting our clinical decisions and our day-to-day practice. The RACGP Standards for General practices (5^th Edition) contain a number of core standards. And one of them is the content of patient health records Good Records improve patient safety and well-being by supporting clinical decision-making and I'm sure we've all experienced times when a good record has made it easy to access information - things like patients allergies and patient's medical history as well as that the consultation notes and patient health records are a really important part of our risk management. I know several medical defence organisations have identified the failure to follow up matters that patients are previously raised and the significant risk of that composed of to practices and practitioners.

So, the college standards, the 5^th edition, is the most recent version produced – Core Standard 7, which says that ‘Our patient health records contain an accurate and comprehensive record of all the interactions with our patients’. There is significant detail under that standard, and for example Criterion 7.1 explores the content of the patient health records about when they’re updated, about the person making the entry and the legibility of the record – that, I think, is something that we had hoped would really improve electronic medical records. Of course, we've gone from problems such as not being able to read doctors writing, to now not understanding the myriad of abbreviations that we all like to use and certainly some of us are more used to lots typing than others. It's occasionally very interesting to pull the paper records that we still hold in the archives from before we went digital twenty years ago. I think that some things have changed, and some things have stayed very much the same.

The standards explore in detail what needs to be in a medical record and it’s things like the date, the name of the person consulting, the method of communication - whether that's a home visit or phone call, the clinical findings diagnosis you've made, if you have management plans, medicines prescribed, other directions given and the patient consent for things like third parties in the practice.

The standards also talk about coding of diagnosis, which is an area that many people struggle with I think and then explore some of the other information that can be contained within the record. While we're talking about the RACGP standards, I'd also like to call attention to one of the new areas in the 5^th edition.

One of the overarching statements of the standards, is that businesses need to operate successfully to create an environment where quality clinical care can be delivered and to operate a business successfully, strategic thinking and business planning is just as important as financial budgeting and reporting. To assist with this, there’s new quality improvement module in the 5^th Edition standards and the indicators that are contained within their Criterion are displayed on the screen now.

There's also some examples in the standard themselves about how you any practice can plan and set business goals, evaluate your progress and risk management.

Now, the reason we’re bringing this up is that data quality can often be an important part of quality improvement. And in fact, many of the things that we're going to talk about later on in the day, is about how when you improve the quality of your health records, you feed directly into this accreditation quality improvement idea.

So, to summarise from our resource that we're going to look at later - the primary purpose of the clinical health record is to hold the information about a patient that is required for effective care: good patient information supports appropriate clinical decisions.

And we can break that down a little further. The first is, that our records, number one, supports safe clinical decision making. This is both a part of risk minimisation, prevention problems and as well as improving patient safety and meaning that your practice is a meeting accreditation standards. For those of us that work in these practices or who are using various electronic communication tools, a good record makes good communication easy - it saves time and it provide useful information to our colleagues whether they are in our practice or outside of practice.

It facilitates continuity of quality patient care- a good health summary and good background information helps clinicians provide safe and effective care and this helps us reassure our patients as well, so that they feel listened to. Many people have complained that they feel like they tell people the same thing over and over and over and I'm sure we've all had moments where knowing something in the patient's record saved our bacon and helped our relationship with our patients.

And finally on a financial level, on a practice level, a good quality record can really support sustainability in your practice with that through accreditation new eligibility for patient.

So we're going to put a poll together now. Sorry- Sally-

Sally: That’s alright. We just wanted to know how would you rate your practices ability to maintain high quality health record?

Is it excellent and maintained at a consistently high standard? A high standard but could have some minor improvements? Acceptable but requires further improvements? Unacceptable and requires significant improvements? Or not applicable. So I'll just give it a couple of couple more seconds.

And I'll just close that off and share it with you all now.

So we had 0% Excellent, David.

Dr David Adam: Yeah, and I think that reflect the inherent difficulty in doing everything absolutely right all the time, especially within our current environment the kind of software that we use. I think it's also helpful to realise that we could always be doing something a bit better.

I sometimes talk about the amoxicillin index which is a totally unscientific and unpublished idea. But, what you do, is you ask your practice manager or whoever drives the auditing system in your practice to tell you how many patients in your record have a long-term medication of amoxicillin against their record. There are many people, there are always a few people who should be on it long term, but most of the time we find that an entry in the long-term medications list of an antibiotic is a mistake, and I think that can useful guide, just as a broad indicator of how the quality of your health records are. So for example, we've got about 12 or 15 thousand patients on the books and we have about 30 of them have a long-term medicine prescribed of amoxil - some of the most of those were in the late 90s or early 2000s. So there's some good examples of records that clearly haven't been kept up to date.

And that takes me on to our next slide, which is a comment from the paper from the New England Journal of Medicine, which says that the record should not be right only. So, they said that data by itself was useless - and to be useful you have to be able to analyse it, interpret and act upon it and I think that's a good reminder to us that we're not just writing for the sake of writing. We're not interested in just getting it on the paper to get it out of our heads. We need to be able to use that information in the future - whether that's for clinical or risk management or medical legal purposes or for further analysis.

Some of the issues that we have with health records, some of the things that make it challenging to keep your record high quality, really often comes down to a lack of time with busy clinicians and a lack of training but some of the issues that come up include - under reporting and we forget to write it down or it might be missing as in we haven't asked about it, so we can't fill it in. If data is recorded as a free text entry or structured data, that can cause some issues with either being not specific enough or too specific. I certainly remember working in emergency where every diagnosis had to be coded and they just weren't codes for a lot of things. So, there are a number of people in South West Western Australia who are diagnosed with a crocodile bite because that was that was our sort of catch of all terms that didn't fit in the coding system. And so this can certainly did people obviously big data collection.

At the same time, free text doesn't always give you the right answers either. I've seen several patients in our record where the smoking status is recorded ‘stopped several years ago’, but there's no entry -there's no idea for when that entry is made. So there's “Was that 25 years ago?” “Was it when we first spoke to the patient with an electronic medical record?” or was it yesterday with the patient presented?

We will certainly encounter differences in measurements or recording or in the clinical focus. Which you know, is exactly what you're thinking about on the day, when you're typing into the system can make things duplicated or being incorrect. And of course the coding systems that we use can be incomplete or inaccurate. Eg. That crocodile bite example.

The other problem we have in Australia is that just about every major software package in primary care uses a slightly different coding system and that by that I mean what each diagnosis is represented as- so, if I’m using Best Practice, I'll put ‘URTI’ - that might be code A32 that then I go over to MedTech and maybe it’s A05 or whatever and those codes are obviously inconsistent and don't work together.

So, what we're going to put something up on the screen again about what you find the most challenging factor in maintaining high quality records of your practices.

Sally: Yes. Thanks David. So we've got lack of time or training, lack of practice support /Improvement culture, ll of the above, none of the above or unsure or not applicable.

So if everyone could pick an answer, that would be great.

I will just give it a couple more seconds. And share it with you all.

Sally: So we've got lack of time or training.

Dr David Adam: Yep. So lack of time is well and then ‘both’ is a big answer there. That is these barriers that affect us all.

And time is a big problem. When I was first interviewed for my general practice, my supervisor at the time asked me what my greatest weakness was and I didn't really have a prepared answers. I said time management, and as it came out of my mouth, I thought why did I say that? That’s a terrible answer for someone who wants to be a GP- but everyone in the room laughed and they said “No, you think you’re good at time management until you start in general practice and then you realise just how tough it is.” So I think time is a big problem for us all.

Today, we're going to look at some of these ways of managing these issues and how to maintain high quality data going into the practice.

I want to talk briefly about the way general practice health records are changing in the current day and age and this is I guess another reason we're having good quality records can really support us. Many of us will remember the paper record where you had a file or in some cases two or three files with a number of scraps of paper in them. We had our RACGP front sheet at the beginning which we actually kept up-to-date in pencil or a pen, whiteout. Most practices, in fact the overwhelming majority of practices in Australia now use electronic records, but we still have the same problems where from this information is contained in silos. So my practice system doesn't necessarily talk to anyone else’s practice system and they certainly have real difficulty communicating with the hospital systems, with third-party providers and even with patients. So, although there is some limit electronic transfer records, it is still very self-contained and we have more information. I certainly think we collect a lot more information and partly that’s because things are more available but investigation that easier and cheaper and quicker that we - because we've got the typing system and most of us can talk fairly quickly, that it's easier for us to write longer entries and that the culture around what we write in the note is changing.

Twenty-five years ago, it was acceptable to write, you know, “25 year-old male- URTI- reassured” and then the signature. I think in this day and age, you would struggle to defend yourself if that person turned out to actually be sick with the new assessment.

What we are moving towards now though is a shared electronic record and I would say we have limited shared records, with things like the My Heath Record.

Now, since the opt-out changes at the beginning of the year, about 90% of Australians or more have a My Health Record and I think what we've seen in our education around the country, is that it's easy for GPs to participate in the My Health Record system if the data is already good quality in their practices – that we are already keeping good records. It's actually really straightforward- to share data with systems like My Health Record, and certainly the RACGP as a professional body advocates orientation systems and processes, which support things like My Health Record data quality - we minimise the administrative and regulatory burden on general practice. So we would say that, you know to support something like My Health Record. You need to be doing things that support good quality in our own practices.

This is the RACGP has produced a significant resource called ‘Improving health record quality in general practice’. And this is a free document that's available on the RACGP website. The reason that we put this together is to support practices in making and maintaining good quality health records, because of those benefits that we've talked about - appropriate decision making in continuity of care and then especially with the increasing use of shared care models and the introduction of the national health record. Again, Just to reiterate, good quality health records in general practice contributes also to secondary use, so that's data provision for research and quality to education within the practice and kinetic immunity purposes. So the RACGP guide outlines what constitutes a high-quality health record and how practices can put systems in place to ensure that they produce health records that useful and that are fit for purpose. We will send you through a message with a link to it. Your message box and we're now just going to step through it and you'll see what sort of information it contains.

So, the guide focuses on the six attributes of high-quality health records and gives you guidance about how practices can achieve these including how to have a health record system that facilitates the production of high-quality health records, tips and case studies are included throughout to give practical information and the attributes of health records that are presented, align the Medical Board of Australia's code of conduct around how Australian doctors should maintain their records and that section 8.4 the practice that sorry –“The good Medical Practice guide”.

We have tried not to, well in fact, we haven’t imposed new obligations over the current RACGP standards. And in fact, you'll see it linking back several times to the 5th Editions standards with that little flag you can see on the screen here.

Of course, the guide is fairly general in nature – we want it to be applicable to general practice across Australia. And so, you also need to be aware of existing legislation, code of conduct, local & professional standards, clinical guidelines, and existing policies that are relevant to your discipline, organisation within the Primary Healthcare sector. And to give you an example, what needs to be in the record for example, a detention facility or the judicial system may look different to what you need in General practice. In all instances, where the guide refers to the ‘sharing of health information’ - What we're trying to cover is the use of disclosure of information by General practices and includes circumstances where that disclosure is required or authorised by law. So, where you need to just use or disclose information to lessen or prevent serious threat to life or safety. It talks about patient consent - whether that's expressed or implied to the collection and use and disclosure type of information and there's also some information about a patient’s right to access their own health information and includes the circumstances where denying access to that is required or authorised under the law.

So, the quality of health records kept by General practices - as we've already described is critical and this is even more the case as patient health records are increasingly shared with other health practitioners. And so the first part of the guide talks about the rationale and many of these things are already covered about safe decision making, good communication, and good partnerships with patients and making continuity of care easy. I work in a reasonable size practice, where we have a fairly frequent turnover of registrars. But many of our patients have been with us for 35 or 40 years, so they can become a little frustrated when they see a new doctor year on year. If we avoid answering the same questions over again, and if we all have an awareness of the problems that they've had in the past, that helps build rapport with them and make our lives and their lives much easier.

And of course as we said earlier - good records provide evidence of care, so again and again, in many legal cases, if records are complete and demonstrate comprehensive care that is enormously helpful should a complaint be made against you. A number of colonial reports, I've read, had called out the quality or lack of quality in people's recording of decisions across all sectors, whether that that's General Practitioners, hospital doctors ,nurses, pharmacists and others.

We are of course no longer producing health records for the benefit of just ourselves or ourselves in the future.

So Sally’s going to put another poll together about what you found good quality health records to help you with.

Sally: Yes. Thanks David R. So the question is or the statement is “I've used good quality records to” and please answer as many as are relevant to you.

So the options are to avoid unnecessary investigations, Connect to My Health Record easily, Analyse my practice population, Communicate with other practitioners and support patients with a chronic illness.

So, yes select as many as are relevant to you and I'll just give everyone a couple more seconds to vote and I'll just close it off and share it with you all.

Dr David Adam: Yeah, so that's great. So, it's good to see that some people are seeing some benefits from good quality records. I see the lowest number there is against ‘Connected to My Health Record” so less than 50% of people who found that good quality records help them connect to My Health Record. When I do the training with our registrars about how to create things like a Shared Health summary - what we see over and over is that it's actually, it's a really easy process. It takes about 30 seconds - if the person already has a good quality records so that their medical history and classification, they're up to date, their medication list is being maintained and you tidied up their immunisations and their drug allergy list.

All software is different. But ours makes that very straight forward, which is about seven clicks as long as you don't need to amend anything.

All of us have seen referral letters that have been communicating with other health practitioners. All of us have seen the letters that’s missing critical diagnosis or containing information that's irrelevant. And so, I think we've all seen the in the benefit of good quality records in communicating with other practitioners.

So we've talked a lot about the benefits and I think we're all on the same page about why they're important. Let's talk about what makes a good record. And there are six attributes of quality that the guide focuses on you'll see them on your screen now.

 So, data needs to be accurate. And that means it needs to correctly reflect what was said and what was done in the consultation.

29:24

It needs to be complete- it needs to be sufficient for the range of purposes that we need it for. It needs to be consistent, so that we use standardised terminology and recognised coding system to complement the free text narrative. That's important because it helps support many of those participants we talked about. I certainly know in our practice we have for historical reasons, two codes for type 2 diabetes and people always pick the old one first, which is impossible to use as effectively as the new code. So, consistency is really key. It needs to be legible. It needs to be easy to read and understand - if you've imported doctors from example the NHS refugees, but seem to seem to be flooding through on an ongoing basis there may seem to be a whole new set of abbreviations. And I know when I worked with some English doctors, I was constantly going and asking people “What does this mean? What does this mean?”

They have the same problems when they come to Australia - of course, we use abbreviations or you terms of phrase they don't understand. So, it's really important that we are clear- not just that our writing is easy to understand and possibly typos, but that we’re using words that we can understand each other. I don't know that there's many general practices, that’s still doing lots of scanning of handwritten notes - the area we still do that is for home visits, where our doctors do handwritten notes in pen and paper and then it's scanned in later – really, the scanning of third-party information, so information you’ve had had faxed or posted to you, it's really important to ensure that legible. And again, I'm sure we've all seen cases where that's been the problem.

It needs to be accessible. And this is often where your software does the heavy lifting in making information arranged in ways that make it readily retrievable as well as understanding and meaning for other people. And finally, it needs to be up to date these be relevant to what was captured in the consultation at the time.

So, it's not very useful to have a consultation done and then you write the notes six weeks later because obviously things are going to slip through your mind. And people may made decisions in the interim based on incomplete information and that we've got available to them. Again, this is another area that I'm sure we've all experienced. You send the patient to see another doctor and you get to six weeks or even six months later about until you find out what happened to them during their admission to the hospital.

So, we're going to look at each of these attributes in a little bit more detail and how that can be achieved. So, they must be accurate health records are only as good as the quality of the information. They RACGP, in the Standards document and in the guide, suggests a number of attributes for high quality records. So, how you know that your records are high quality, but at the end of the day, they should accurately and comprehensively record information that's captured about patience. Accuracy is critical to patient care. But of course our clinical information is a times uncertain or variably and practitioners reach diagnoses and use variable clinical terms, particularly across disciplines. So, we need to make sure and take time to ensure that our patient records correctly reflect demographic information, the information captured during consultation and information collected funding sources.

So, some useful tips are to regularly check the patient contact details are up to date. That's a really good thing for your front desk to be doing so, printing a prescription and that person saying “Hang on, that's not my address anymore”. So, the practice makes it routine to confirm the details and confirm that each time at the front desk.

 It's important to make sure that only authorised and properly trained team members can access and alter the patient's medical records. When we are conducting consultations, either in person or by phone or by telehealth or other means, it's important that we confirm identities and the way we've got the right record open. I think most of us will have had at least one experience in their life where they start typing and they realise that actually the person is 20 years old and what the record say is that they've had a whole bunch of problems that aren’t on the list. And we’ve actually opened someone else’s with the same name.

It can be helpful as part of your usual clinical risk management to record and review near-misses, regarding incorrectly, inaccurate incorporation of patient information in those records and there are standards for indicators for accuracy in the 5^th editions standards.

Records should be complete. So, there must be a must contain sufficient information to serve a range of purposes. Otherwise, as we’ve discussed already. So, that includes information that's collected by the practice and information from other sources. We need to consider the various different purposes of health records that we’ll be recording during the consultation. And we need to keep in mind that in the current climate, that we should expect to share. The information that is entered into the record, now that may be sharing with the patient who has the right of access to their own record. It may be sharing information with other people.

So, when you entered your diagnosis of ‘systemic heart disease’ or ‘coronary artery bypass grafting’. It's important to think about “Well, what am I going to put in the annotation for that?” Is it relevant to other doctors that they may have had the graph done for their left internal mammary artery? Well, actually it is important to the cardiologist, or that you send them to see them when they're traveling or when their original Cardiologist at the time opens their records. The college standards again, require patient records to contain a number of details and that’s focusing on the ‘Core Standard 7’ and of the RACG standards, which I won’t go through again, although we mentioned some of those things earlier.

Some of the ways you can show your record is complete is by using registration forms, either electronic or paper so that you getting all the information you require about their demographics and their background , that having strong policies and checklists for procedures involved in managing health information - from living the practice and other sources. For example, you might say well if we're going to have a policy that if new patient information forms are returned incomplete, there’s a particular person whose job it is to follow up with the patient or the doctor to complete the form.

Always recording information that you would find helpful- As I said earlier. I think of the other doctors as well, or the locum when you go on holiday who takes over- can they use your records to manage unfamiliar patient to them? And there’s also some information in the guide about managing information that comes from other sources

Consistency. So again, we've mentioned that using recognised medical vocabulary standard terms and abbreviations and being consistent when recording diagnosis and observation procedures. It is essential - what it means is that records are usable by all health professionals who need to refer to a patient's health record and that includes all members of your practice team whether they are GPs, registrars, nurses, pharmacists, health providers.

The other thing that it's useful for, is about searching an analysis of your medical information. Most clinical information systems contain a nationally recognised medical vocabulary and coding system or classification system. We use the ICPC system in our clinic software. I think the Digital Health Agency is desperately trying to get everyone in Australia to move to something called SNOMED CT AU - which they spent lots and lots of money on and lots and lots of doctors and lot of doctor’s time on. We're slowly getting there. But, what that means is that those coding systems allow structured data entry for diagnosis and prescription, pathology. At the same time, it's important for us to compliment that with free text information to provide the narrative or the context from patient's health information. But, of course many systems like that make it difficult to search and unify - if I write DM and you write diabetes mellitus, that can be harder to search for, so we encourage people- it's helpful to educate practice staff about the importance of entering information in a standardised way and provide training in how to take full advantage of the structured data entry that your software provides.

 It could be good to have a standard idea of what you know, the usual terms and acronyms and abbreviations that are generally used by everyone in our and things that we will try and keep to a minimum. The one that often confuses my colleagues is an abbreviation that a former a doctor used in our practice, which was ISQ or “In status quo or ‘everything is stable’ and we've agreed not to, not to write that anymore and what we think is stable or what we can their progress is likely to be - firstly because it's more consistent and more easy to understand and secondly because it supports good clinical decision making.

It can be helpful to set up shortcuts or autocorrects to spell out the common abbreviations. And so, you might write out WNL and that expands out to “Within Normal Limits”. We do encourage people to be careful about using large blocks or copy/pasting information or autofill information, because it's generally very, very obvious that autofill information has been used and it's more difficult to explain should you be required to support why you didn't capture a particular piece of information.

Again, find out what your software can do. Your clinical tools might help you collect consistent information from particular populations. For example, you might have a template for baby checks or screen for postnatal depression or for your diabetes checks. So use your software to do as much of your heavy lifting as you can. If you're not sure how to do that, your software vendors would love to show you how to use it. You know, you're paying them lots of money and they would like you to get value for money out of their software.

So, legibility is the next criteria and that it can be easily read and understood and as we said earlier, it's really important that data is being presented in a way that's meaningful to other people and that includes patients. We know that documenting healthcare records meaningfully can facilitate continuity of care and improve patient outcomes. Now, of course the readability of your health records, you can be influenced by lots of play factors. So, keyboards and typing skills, how familiar you are with the software and the quality of scanning, how forms are laid out - whether you're using paper forms, or electronic forms, using the right fonts, using the right kind of language that you're using. We've mentioned some of these before- so again, avoiding funny abbreviations or shorthand or jargon. Some people who are not strong typists prefer to use voice recognition software and some of those are some of those work really well and some have little a way to go. Certainly, a colleague of mine would we use that fairly effectively, although occasionally be getting halfway through matter and thinking “is this all there?” So, if you are using dictation software it’s important view the output of it.

One thing that’s really helpful to ensure that the whole practice is fulfilling these requirements, is by conducting peer reviews or using your clinical meetings to review people's notes and you'll see a quotation there from one of my colleagues in the RACGP Practice Technology and Management about how they review their records. Certainly, I think some of our more senior doctors struggle a little bit with the typing on the technological side of things and most of our registrar's probably have the opposite problem, where they write 600 lines for a patient who's coming with a sore throat or a runny nose. So, I think there's a balance to be struck.

And finally, sorry not quite finely, but ultimately “Accessible” health information needs to be recorded in ways that make it easily retrievable. Almost all of us are using fully electronic systems and in general, those are the best option for making information easily retrievable. Although, as we've sometimes seen having too much information can make that difficult. One of the criticisms that sometimes levelled against the My Health Record system by some of my colleagues, is that it makes it very easy to capture almost too much information and so without effective filtering and sorting searching capabilities, it can become overwhelming.

And lastly, information should be recorded in patient health records in a timely manner. I think it's fairly obvious to what why that requirement is there. Some of the tips in terms of making sure that this can happen is to set aside time for doctors to maintain patient records and that includes time to review information that needs to be entered from external sources, when they have to catch up spaces for making appointment times long enough to complete notes.

When I was studying for my OSCE’s, one of my supervisors said to me, you know, you should be able to get everything done from a clinical point of view in eight minutes. And the OSCEs are not unreasonable in its time limit. And at that time, in that regard and I said, you know that that's not true. And he said, most important thing is to not touch the computer until you're finished with the patient because typing on your way through, distracts you or writing prescriptions or that kind of thing gets too distracting. He said you can take a history, examine, discuss his/her diagnosis and come up with the management plan in 8 minutes for most people, which then gives you 4 minutes to type in your records, put your prescriptions and write your note and note your X-ray forms. And then another few minutes to have the patient leave the room, take a breather and then call the next patient in. I don't know if that’s possible in all practices, but it's certainly something we're striving for, so time management is important.

It's helpful if your practice systems can help you, so some practices have reminders to review smoking and drinking status, rather than just when you are your first see the patient and then 20 years ago thinking “Well, actually are they still smoking?”

Of course, every practice is a little bit different. Some practices choose to focus on things for monthly. Ie. We're going to review everyone’s smoking status this month.

Another example is on our case study on the next page.

So, this comes from one of my colleagues who helps to run a major Metropolitan after-hours deputising service.

What would happen is that GPs at the beginning to shift were given ten or more patients to triage and then prioritise and then visit and what they found was that doctors were having trouble completing patient records, because they sat down at the end of the shift to do all the records in a row. Now, it might be four five six hours since the patient was actually seen before you sit down to write the notes and there were a number of concerns about the completeness of information recorded this way, as I think you would appreciate.

The service changed its procedure, so that each doctor received no more than three patients that have time to assess and visit and then they were given time to complete their consultation notes before they got more patients. And so that's a fairly small, but systemic change and then they also introduced some audits, so making sure that internally they were looking at the patient records and that they were high quality and what the service found was that there was a significant Improvement and that was a comment from their own staff and also for the external stakeholders.

So, those are the qualities of good records. We're going to run through some more of those ideas about how we can put that quality to practice. And the first thing is making it part practice culture.

A key part of a practices record keeping is of course, the people who use it and so we have to have buy-in from our staff. We need to know that effective record-keeping must be prioritised and it must be routine and it for it to be routine, it's got to be of value. We've got to see that we get something out of it. So really, I really can't ask underestimate how important it is that your team feels like a good record is helpful to them. It requires strong leadership and it requires ongoing education and workplace policies to support that. You might like to think about implementing a feedback process regarding health records to address problems raised by other health care professionals or other services or patients themselves. Or, as we mentioned earlier, it can be really important to keep track of near misses or mistakes in the incorporation of information to identify ways in preventing these from happening again, and you'll see a quote from one of our Practice Manager members talk about their induction process and a really doing a good job of training them in using the system appropriately.

To support that we have systems and management approaches. So, making sure that we have good practice policies and procedures and appropriate support systems. It might be helpful to have a particular team member delegated to manage the strategy and the overview of health records, while the practice management takes that overview of promoting high quality culture. For example, most clinical Information Systems have features that help you order the quality of health records. So, tracking follow-up requests or recalls are reminders that haven't been actioned and you may also be able to get a list of consultations where the diagnosis is not encoded and that can help you to talk to people about how many consultations they have that haven't been coded and also to subsequently into the right information.

There are many policies and procedures that can help manage high quality record management and that includes things about using a health record system risk management. So, ensuring information that contains correct fields around system security. So, some of you will have been to our previous webinar about Information security in general practice. And the college, has again put out a comprehensive document about how you can support that in your practice and about how health record information is handled- so, how it comes into the practice, how it’s managed within the practice and how it’s sent out to others. So whether that to patients or to other clinician.

A good litmus test is how robust your procedure for handling INR management is. Our, is what I suppose is, INR coagulants these days are slowly becoming numbered. But our practice has a really robust system for making sure that when we receive an INR result, that a doctor is notified promptly, that given the result, that the result is followed up and that the decision that's made about it is communicated to the patient - so that touches on all those areas and it's a really good example of the area that leads strong policy procedure behind it.

Education and Training is, as we said at the beginning, is absolutely essential. So, new members of staff, your registrars, new GPs or administrative staff need to understand how to use this. They need to understand your goals with their health record and how important their contribution with you is to it and they also need to know where they can get help so that if they don't know how to enter something on that over how to get something out of it, they need to know who to ask.

Some people provide tip sheets or troubleshooting guides for common problems with the practice clinical information system. But when you're talking to them, you need to really make sure you cover the key areas of the things that we talked about today. They need to understand why it's important to create good records and how to use the system effectively.

So for example, you might want to explore with your GPs what decision support tools are available in your current clinical information system.

As we touched on many times, it's not just the doctor sitting down with the patient who needs to work on good quality clinical records and it's a whole of practice team that needs to be involved. You might like to make the quality of your records a focus of the practice team meeting, as we heard earlier from one of my colleagues, we might like to acknowledge the work of doctors who keep good records, you might like to agree on a standard terminology across disciplines as we mentioned earlier, allocating time, as we said earlier is really important and it's always important to be thinking about you know, what more can you do to help deliver high quality records? Are there checklists you need to be using? Do you need support from your clinical information software vender or from other outside staff? Can Primary Health Networks help? Can software add-ons help? There's a lot of tools that are out there to help with this.

Conduct regular audits - because we want to be making sure that we are doing the right thing rather than just hoping we're doing the right thing and I would hope that if you're auditing, you would have had confidence in the answer that you gave before about how often your record is really good quality.

And then expect to share mindset, we talked about earlier, I think it’s important.

We sometimes see that in our - we’ve got a moderately sized group practice and occasionally get you doctors joining us from solo practices. I think for a lot of the time they've been working, you know, they've been working in practice where they don't have to share that information with anyone else, it's just an aid memoir for them. In our practice, your work together and we understand that has an impact on our record quality.

So just to summarise.

We hope that you've learned a little bit today or reminded a bit today about why we need good clinical records, particularly around safe decision-making, communication and continuity of care. We're giving you some ideas about where and why data quality issues occur, we ran through those attributes of high quality records and some ideas about putting that quality into practice.

A quick word from our sponsors down at the RACGP Practice Technology and Management committee. The division produces a lot of resources that are available to you. So, the one that we talked about today is just part of the picture.

On the screen, you'll see some of the free resources that are available for download that anyone can use and that includes things like the Secondary use of general practice data. So once you've got good quality data, you might be tempted to use it for research or to bring other people in to help you analyse it and some of the secondary use of information you've collected poses significant issues. That document can really help you also see our Information security in general practice which we referred to earlier. There's our information about Privacy about managing health information in general practice. One of the biggest changes in health information that's come up in the last few years is what's called a Notifiable data breaches (NDB) scheme. So, if for whatever reason you lose control of some of the information - What do you do now? What responsibilities and obligations do you have? The fact sheet on Notifiable Data Breaches is your go-to there.

And there's also a document that's been produced from our survey that we run every year (RACGP Technology Survey), so you can find out what GPs experiences are and what do people think about the various technological things that are available to us today.

 The RACGP Expert committee will continue to conduct our eHealth webinar series throughout 2019. And so coming up in July, we've got Technology in general practice and you'll see the other scheduled webinar that on the screen. So, you'll get sent a link through shortly that will have the future webinar series available and certainly encourage you to attend those if that's something you're interested in. So, I hope that's been useful.

We've got about five minutes now, I think for questions, is that right, Sally?

Sally: Yes, thanks for taking us through the information about improving data quality in general practice, David. So, yeah as promised we now have time for Q&A. So, if there's a question you had at all, please send it through.

 We have had a couple of questions come through during the presentation and one of them was “how long do I need to keep patient records for?”

Dr David Adam: Yeah, and I'm going to have to quickly refer to my notes because this is one of those state-based things. In some states, there is legislation around that- so New South Wales, Victoria and the Australian Capital Territory make it very clear the minimum time, which medical records should be kept is until the person is 25.

If you've got it from when they were a child, if you collected information when they were a child, or seven years after the last occasion on which the Health Service was provided to the individual. So, if you don't see someone for seven years, then we would say that probably those records are acceptable to archive. In some cases, you'll see someone and then you won't see them for a three, four, maybe even five years. It's still important to keep those records from you know, when you saw them 25 years ago if they're still attached to it. It's they’re still an active patient of the practice.

Sally: One we've had from the audience. ‘Employees are easier to engage. How do you get contracted GPs to engage in contributing to a high-quality record?”

Dr David Adam: You know, that's a really good question. One thing that we have done and I think it comes back, firstly I should say, to that idea of the practice culture, you know - Are you a team? Or are you just a group of people sharing the building? So, I think once contractors see the benefits of good records and they experience the benefits from other people maintaining good records. I think that helps to create that buy-in. Now, in some cases, some people might need a little bit more of an extra nudge – so, whether that's that you get them to participate in an audit or you ask them to take on a role towards accreditation. Sometimes that involves the financial incentives as well. I know certainly our practice, it gives a small amount of money to whether they're contractors or employees in the practice to those who have helped maintain our My Health Record PIP standards and make sure that our data quality is good.

There’s no one-size-fits-all answer for that, but I really think it comes back to teamwork and when your contractors are interested in being part of a team as well, I think many things will help quality health records improve.

Sally: Okay, so I think we have time for one more question. What about the legal dimension of a good EMR (Electronic Medical Record)?

Dr David Adam: So, we mentioned that a few times on the way through.

 I think there’s a use of ‘records’ in a legal sense is that they can really help you to understand your decision making and to help other people understand that decision making. So, that means that in five or seven or eight years’ time when you're asked a question about a consultation…. I can remember the consultations I did yesterday, last week might be a bit of a struggle, seven years ago is a white out in almost all cases. So, that's where your good record comes in.

I think there’s - I don't know that there's anything particularly that you need to do to make your record good from the legal standpoint that doesn't also apply from a clinical standpoint. I think you can be confident that you know, writing good notes - if you do good medicine, the legal bit will look after itself. If you're making clear records, if you're doing all those other things that we talked about then I think it's unlikely that your records will be called into question, or that your decision making will be difficult to defend. So, good electronic records, make good clinical sense and they also make good legal sense.

Sally: Okay. Well, thanks David. That brings us to the end of today’s webinar. Thanks for a great presentation.

Dr David Adam: All right. Thanks for having me and if you've got anyone that you’d like to send a long running again on Thursday.

Sally: Okay. So we hope you've enjoyed the presentation. If we didn't get to your questions today, please email the eHealth team on eHealth@racgp.org.au and we'll get back to you as soon as we can. Thank you and goodbye.

Webinar ends.