The RACGP has been working with medical defence organisations and with vendors who provide clinical information system software, to achieve clinical systems that are consistent and safe in the way they record, use and share information.
GPs need to be able to work safely with any clinical information system and improving common functions in clinical information systems will help to improve the safety, quality and efficiency of care.
The RACGP Standards for general practices (4th edition) (the Standards) require general practices to have a ‘rigorous’ follow up system. This is to ensure the appropriate follow up of tests and results. Follow up systems are also important to deliver preventative healthcare.
Follow up systems in general practice rely heavily on system-generated ‘recalls’ and ‘reminders’. An RACGP review of some widely-used clinical information systems identified that ‘recalls’ and ‘reminders’ are handled differently.
Each clinical information system has built in functions to generate a ‘recall’ or ‘reminder’. However; there is a significant variation between the processes and use of terminology. There are also multiple places where recalls and reminders may sit in each clinical information system.
The variation and inconsistency in the ways these terms are used in clinical information systems is, in part, a consequence and reflection of the inconsistent way in which ‘follow up’ terminology appears in the Standards.
Consistency in the way that information is handled by different clinical information systems together with a standards based approach will improve the manner in which information is collected, managed and stored, improving efficiency and assisting in reducing clinical risk.
These guiding principles aim to support clinical information system software vendors and general practices achieve this consistency.
Additionally, we make recommendations for the consistent use of follow up terminology in the next edition of the Standards.