Clinical reviewABC of health informaticsReferral or follow-up?Frank Sullivan, Jeremy C WyattWhen patients ask their doctor...
Clinical reviewstage between the decision to refer and its realisation, evenwhen an appointment is available.             ...
Clinical reviewClinical governance                                                         UK general practice contract qu...
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Referral or follow up

  1. 1. Clinical reviewABC of health informaticsReferral or follow-up?Frank Sullivan, Jeremy C WyattWhen patients ask their doctors if a preventable problem could This is the eighth in a series of 12 articleshave been avoided by earlier investigation or referral, the A glossary of terms is available at can be in an unenviable position. Given the information content/full/331/7516/566/DC1available at the time, the response will often be a qualified, “yes.”It must be a qualified response because the aspects of theproblem considered during earlier encounters with patients are Ms Smith is a 58 year old florist with a 15 year history ofoften unknown. The matter is further complicated by issues of renal impairment caused by childhood, professional ethics, and the law. She has hypercalcaemia. She remembers being told in the This article discusses information flows that may have past that she had “a slight kidney problem,” and asks her renal physician whether anything could have been donereduced the risk of Ms Smith (see box opposite) developing then to prevent the current problem developingsymptomatic renal impairment. The risk could have beenreduced at three different points.x If her underlying vesicoureteric reflux had been diagnosedand fully investigated in childhoodx When her chronic pyelonephritis was discoveredx During the intervening period when no follow-up wasarranged.Early detection of underlying problemsChildren aged ≤ 7 years with urinary symptoms, fever, orseveral non-specific symptoms and signs should be tested forurinary infections because, in some circumstances, prophylaxiscan prevent recurrence. Guidelines are available, but theresearch that underpins the advice was published too late forMs Smith. Were Ms Smith a young girl today, any primary careor emergency clinician who saw her would probably have accessto this evidence base as part of their clinical software, orthrough access to guidelines on the internet. PRODIGY (Prescribing RatiOnally with Decision Support) guideline on Undergraduate education, postgraduate training, and investigation of urinary tract infection in childrencontinuing professional development are more traditionalroutes of knowledge transfer. Unfortunately, traditional sourcesof knowledge are relatively inefficient: our stores of knowledge Incoming Learning/feedback loop informationdecay over time, and our brain’s working memory may become Perceptual filter Working memory Store Long termoverloaded. Prompts and reminders at the point of care are History Undergraduate Interpretation memoryuseful adjuncts to an overworked human brain for certain tasks. studies Rearrangement BranchedSome doctors worry that use of such electronic aids may reduce Other experience Comparison or scriptspatient trust, but the evidence is to the contrary. Examination Scientific evidence Storage Wider literature Preparation RetrieveEnsuring appropriate investigation Proposed actionsFifteen years ago, when Ms Smith’s chronic pyelonephritis wasdiagnosed, her investigation would probably have been directed A model of human clinical information processingby a consultant whose experience would have ensured theappropriate level of expertise was achieved. In the informatics Steps in the NHS process for non-urgent referralage, some of this expertise can be represented in protocols. If x During a consultation the general practitioner (GP) considers ifthe protocols are followed, investigation in primary care may referral is appropriateavoid referral or identify the nature of the problem quickly and x Decision is negotiated, to a greater or lesser extent, with patientclearly. In some health systems, referring clinicians may be given x Decision and relevant clinical information is communicated toshorter waiting lists if the referrals have been preceded by consultant or other secondary care provider, usually by letterappropriate first line investigation. x Letter is posted or faxed to hospital x Consultant prioritises referralArranging referral x Outpatient administrator allocates an appointment depending on the level of priority and the availability of appointmentsHealth maintenance organisations in the United States, which x Appointment is communicated to patient, usually by letterprovide integrated primary and secondary care, can book x Patient attends outpatient clinic and sees consultant or a memberelectronic appointments routinely. More complex referral of their teamsettings may have difficulty doing this. Delays can occur at any1072 BMJ VOLUME 331 5 NOVEMBER 2005
  2. 2. Clinical reviewstage between the decision to refer and its realisation, evenwhen an appointment is available. 1. Community 2. Health system Resources and policies Organisation of health care 3. Self- 4. Delivery 5. Decision 6. Clinical management system support informationArranging follow-up support design systemsAt the end of a hospital outpatient visit a decision is madeabout whether hospital, a GP, or shared care is mostappropriate for the patient. Unless an arrangement is made the Informed, Prepared, proactive activated patient Productive interactionspatient may have a “collusion of anonymity.” This occurs when practice teampersonnel at the hospital think that staff at the primary carepractice are providing follow-up and vice versa. In reality,neither are doing so. To avoid such errors, healthcare systems Functional and clinical outcomeshave developed ways of integrating multiple service providersand proactive measures (see chronic care model opposite). Overview of the chronic care model. Adapted from Wagner EH. Effective Clin Pract 1998;1:2-4Hospital follow-upWhen a consultant decides that a patient’s problem needshospital resources the flows of information are straightforward,but potential exists for errors and omissions. Often, patients are If follow-up at hospital is needed thenasked to book their next appointment as they leave the clinic. direct booking of the next visit avoidsAlternatively, one of the clinic team may make the arrangement some potential difficultieson the patient’s behalf, and inform them at the time or by post.GP follow-upIf the hospital team decide that the patient requires medicalsupervision, but no other hospital resources, the primary careteam may be asked to resume sole responsibility for care. This isthe simplest option for hospitals because it only needs adischarge letter to be sent. Most practices in the UnitedKingdom and other industrialised countries have thetechnology and systems to support a call-recall system forscreening. Although this can be extended to support GPfollow-up of chronic diseases, few practices are able to harnesssuch systems to long term clinical care. This will probablychange in countries like the United Kingdom, where achievingtargets is increasingly important.Shared careAlthough shared care seems the most complex of the threefollow-up options, done properly, it may be the best for thepatient. An integrated service takes responsibility for all patientswith the problem it is set up to deal with. Specialists ensure thathealthcare services are configured to respond effectively topatients with problems, and to support clinicians working in the Sharing information across health systems. Clinical data (for example, datacommunity. on prescribing or blood pressure) in one part of the health system that have been recorded in primary care can be made available to other users, such as Antenatal care is an example of this approach. Other areas hospital clinicians, on a “need to know” basisof care, such as chronic diseases, are following suit, withexcellent results seen in the care of people with diabetes andcardiovascular disease. Good, but often asynchronous,communication between colleagues with complementary skillsis vital. In some systems, records may be seen by cliniciansirrespective of where they are working.Patient empowerment“Expert patients” have always been with us, but some doctors Many doctors give patients an audiotape of theirwere not aware of it, or would not acknowledge it. No matter consultation, written material about their problem, orwhat arrangement is made for follow-up by the health website addresses that provide further information.professions, patients with chronic illnesses must deal with it Others (hospital consultants, for example), may copyevery day. Better use of information helps, and consultations letters sent to GPs as text messages to the patient’s mobile phone or send the letters to the patient as emailshould be patient centred (to deal with patients’ ideas, concerns, attachmentsand expectations), but also extend beyond the visit.BMJ VOLUME 331 5 NOVEMBER 2005 1073
  3. 3. Clinical reviewClinical governance UK general practice contract quality points for management of hypertensionAs a result of apparent failures to ensure adequate patient care,society has demanded that arrangements for the supervision of Indicator Coverage Pointsclinical services are improved. The days of autonomy and Register of patients Yes/no 9paternalism are being replaced by rigorous inspection Smoking status 25-90% 10procedures and publication of results. Clinical teams need to Smoking advice 25-90% 10show that they are working to the highest standards. This Blood pressure recorded in past 9 months 25-90% 20depends on their access to the best evidence about the criteria Blood pressure ≤ 150/90 mm Hg 25-70% 56of good care and the standards that can be attained. Data, oftenfrom patient records, are then collected to confirm whether Further readingstandards are being met, or if there are any defects to treasure. x Williams GJ, Lee A, Craig JC. Long-term antibiotics for preventingFailure to hit the target (for example, to offer annual blood recurrent urinary tract infection in children. Cochrane Database Systpressure and renal function tests to Ms Smith), is an Rev 2001;4:CD001534opportunity to improve the service. Electronic records make x The diagnosis, treatment, and evaluation of the initial urinary tractmost of the service automatic, provided that patients agree to infection in febrile infants and young children: at least do not refuse) the secondary use of their personal summary/summary.aspx?doc_id = 1838&nbr = 1064&ss = 6data. Clinical teams can concentrate on providing a service, and (accessed 19 October 2005)using the information that has been captured (and processed) x Sullivan FM, MacNaughton RJ. Evidence used in consultations:electronically to improve patient care. In the United Kingdom, interpreted and individualised. Lancet 1996;348:941-3the quality and outcomes framework of the new general x Hunt DL, Haynes B, Hanna SE, Smith K. Effects of computer-basedmedical services contract for GPs relies heavily on the electronic clinical decision support systems on physician performance andprocessing of Read coded data in clinical systems. patient outcomes. A systematic review. JAMA 1998;280:1339-46 x Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clin Pract 1998;1:2-4Summary x NHS Confederation. General Medical Services contractAchieving effective data transfer and electronic continuity of negotiations: (accessed 19 October 2005)care between different parts of a health service is not essentiallya technical challenge, rather it is a cultural and political one. It is x Perlin JB, Kolodner RM, Roswell RH. The Veterans Health Administration: quality, value, accountability, and information aslargely about reconfiguring workflow. In 2004, the Veterans transforming strategies for patient-centered care. Am J Manag CareHealth Administration showed that integrating clinical records 2004;10:828-36across geographically and clinically diverse sites is feasible andvaluable. Linking individual electronic patient records from Frank Sullivan is NHS Tayside professor of research and developmentdifferent locations into a single electronic health record will in general practice and primary care, and Jeremy C Wyatt is professorprobably transform the quality of health services over the next of health informatics, University of Dundee.decade. The series will be published as a book by Blackwell Publishing in spring 2006.BMJ 2005;331:1072–4 Competing interests: None declared. One hundred years ago Superstitions about pregnancy and parturition Dr. Isambert of Tours has collected notes about local to clean bed linen. In the canton of Ligueil in Touraine, the superstitions still prevalent amongst French countrywomen, mother takes the greatest care to collect and soil as much notwithstanding the general distribution of education on modern sheeting as possible when she is nearing term, and after being principles throughout the Republic from Calais to the delivered between dirty sheets the supply of foul linen is Pyrenees.. . . Certain curious customs, based on an idea that the frequently changed during the puerperium. In one case of male has influence on the fetus beyond the date on which he puerperal fever Dr. Isambert had the greatest difficulty in getting begot it—an idea not unknown amongst uncivilized races—still the soiled sheets removed under his own superintendence, and prevail amongst the French peasantry. Dr. Marignan of though his orders were apparently obeyed, he suspects that the Marsillargues attended a woman who put on her husband’s hat to dirty linen was replaced in the patient’s bed directly his back was hasten labour, preferring it to ergot. Dr. Lalanne repeatedly turned, to be temporarily put aside at his visiting hour. In the observed a similar practice in the Landes, the parturient woman Department of the Var dirty linen is always used to clean the turning her husband’s hat inside out and then putting it on her woman after delivery, the washing itself not being undertaken for head. The idea is carried further in remote districts in Lorraine, the husband’s entire clothing being donned as an oxytocic. In the several hours. The belief in which these insanitary practices same districts, and in parts of the country round Toulouse, the originated remains obscure.. . . In conclusion Dr. Isambert marital cotton night-cap, a familiar object on the head of the declares that some of the methods employed to hasten labour in French rustic, is used as a pad tied against the vulva to prevent a humble cots far from the ignoble strife of the madding crowd of threatened abortion. The gravest of all lying-in-room the boulevards are enough to make the modern obstetrician turn superstitions receives much attention from Dr. Isambert, for he pale, yet somehow fine children are born and bred in those parts. dwells on the strange tendencies in certain districts to prefer dirty (BMJ 1905;ii:345)1074 BMJ VOLUME 331 5 NOVEMBER 2005