Tag Archives: Medicine

Ensuring Physicians’ Competence — Is Maintenance of Certification the Answer?

27 Dec

 “Pressed by their leaders, external stakeholders, and a public troubled by lapses in the quality of care and unsustainable cost increases, physicians are facing stiffer challenges in initiatives designed to link more closely the goals of learning with the delivery of better care and measures of greater accountability… ”

So begins Ensuring Physicians’ Competence — Is Maintenance of Certification the Answer? in this week’s issue of NEJM .

While the essay focuses on US system of reaccreditation, the opening remarks could apply to any (Western) healthcare system which desires its doctors to deliver best possible healthcare to citizens with greater accountability for the medical profession.

I want to know how my leaders allowed the demise of self-regulation to occur after several hundred years of autonomy.

Why does the author of the article believe there is no chance the medical profession can return to less fettered self-regulation?

Is it really in the public’s interest for politicians and healthcare payers to control medical profession ever more tightly? Is the cost for such regulation really affordable?

It is my opinion, that the majority of doctors are self-directed learners who perform better under less scrutiny rather than more. Healthcare innovation may well be stifled by the drive to tighten regulations for physician practice.

This is apparently a global phenomenon at least in the rich countries with managed healthcare systems. National medical bodies may need to work together to fight this threat to the effective care of our patients.

The increasing threats to independent practice and the profession of medicine are contrary to the human values in healthcare that is at the heart of what we do.

eLearning Needs in NHS Sept 2012 #mobimooc

13 Sep

Mobimooc 2012 is up and running.  2 webinars have been well attended.  Regrettably the timing is not great for me – but the team has recorded the lectures 

By coincidence two new systems are due to launch in my region of UK.  An electronic prescribing system (EPS) and new telephone triage service (NHS 111)

NHS 111

http://goo.gl/ra2IE points to introduction to the system.  The NHS has also provided online introduction with accompanying slideshow here with direct link to the video Introduction to NHS 111

Here is a great example of mLearning in action but the local NHS managers insisted on practice teams send delegates to a meeting somewhere in my town.  Clearly this was a poor use of time for my practice manager.  With such a good presentation created, it is clear to me that the time taken for many people to get to the meeting would be better spent watching the slide show.  How patronising of our service managers!  There is apparently good evidence that the new system will be good for patients and reduce some of the demand on emergency services from (trivial) emergencies.

It does look like no-one locally is aware of mobile learning project management.  Here is  an excellent opportunity which has passed us by!  Notice there is no system on the website to help visitors assess their learning after reading the transcript while watching the slide show.  Why is the slide show an embedded video rather than posted on Slideshare, Brainshark, or other public cloud service?  How hard would it be to have a feedback form?

Whether the UK really needs another emergency number is a moot point now.  As a GP, this system looks to me a threat for the future primacy of General Practice as the first point of contact for health care questions by UK citizens.  This is sad.  In the not too distant future UK may come to regret the demise of the family doctor as an independent gatekeeper to healthcare services.  That is a discussion for a future post.

Electronic Prescribing System

I wish to share the following from my local medical committee concerning the roll out of the new electronic prescribing service because the rational behind it is described and the questions from my representatives focus us on another opportunity for eLearning.

NHS Bedfordshire and NHS Luton are working for Electronic Prescription Service (EPS) Release 2.  This will mean that the PCTs would then be enabled to allow practices and pharmacies to take part in EPS, if the practices and pharmacies want to.  This is part of a national programme.  We were told that EPS has been available in Hertfordshire for some time and that just under 30 practices are taking part in EPS there.  
We’ve seen documentation from Bedfordshire and Luton about what EPS is; what practices would have to do under EPS; what the criteria would be for selecting patients who could use EPS and what participating practices would need to do to support patients in making their choice; how patients would nominate which pharmacy they want to use for EPS and what the participating practice would need to do to facilitate this.

Beds LMC members recognised the positive objectives of the scheme, e.g.
It is supposed to reduce GP work load ultimately
It may be more convenient to the patient
It may reduce waste
It is understood that EPS will be optional for practices.
But Beds LMC members did have some concerns:
To what extent is it a whole new area of unfunded work in general practice?
Beds LMC members thought that EPS would create the following work:
1. GPs will be expected to identify suitable patients.
2. The GP has to look at all applications for it and make sure they do not have any of the exclusions (large groups of patients such as those on controlled drugs, anticoagulants and some others).
3. The GP or GP staff will be expected to promote and explain the process and follow this up in writing and collect a signature 
4. The practice will be expected to telephone suitable patients and offer it to them.
5. Time will be need to train GP staff.  Nothing about backfill for this.
6. All prescribers will have to use smartcards and be wary of prescribing some formulations or brands of medication which do not have a suitable barcode.  Not all practices use their “smartcards” when consulting because they cause their system to run slow and time out.  So clinicians log in and work offline.
Patients with regular repeat prescriptions tend to be patients on chronic disease registers.
On the rare occasions when patients such as this come in “just for a repeat prescription” it gives the GP an opportunity to pick up on preventative care, QoF items and other aspects of the health and wellbeing agenda.  In other words, the aspects GPs do not always have time for when dealing with acute illness in a 10 minute consultation.  Could the use of EPS actually reduce the level of care available for some patients?
Concerns that the EPS will not be a simple scheme, as some items cannot be included in EPS, so there would have to be two prescribing systems for EPS patients: one for EPS-included medications and one for EPS-excluded medications
Is there any evidence that EPS has saved time for GPs or staff in primary care?
If any Hertfordshire practices who are using EPS would be willing to share any of their experiences or would be able to answer any of the specific concerns listed, it would be very interesting to hear from you?

Here is my response:

Wow! How can such a simple idea as electronic repeat prescribing become so complex?

FIrst thoughts: I want nothing to do with a system with more bureacracy to set up. We have enough to deal with without this additional burden.

Second: The system is doomed unless bandwith of broadband connections is increased to cope with the demand from our desktops (and mobile devices). Currently broadband speed is around 10megabits per second down and 0.5 mb/s up, at least in Watford. Divide this by 8 prescription terminals and you can see the speed drop makes the system inoperable.

Third: Barcodes are not immune from corruption; at least several times a week a popup warns there has been a problem and the barcode should be scratched out. How do you do that with an electronic script?

Fourth: The main benefit of EPS is prescribing from mobile devices. With 4G/LTE imminent this seems practical so long as all prescribers have feature phones with the necessary hardware. I fear the powers that be are focussing on the wrong systems. We need secure login systems for iPhones/iPads and android devices to make EPS useful (e.g. prescribing urgent scripts on home visits, or residential facilities)

FIfth: How are pharmacists supposed to be persuaded to adopt this?

Sixth: Prescribing2U is already available. How does this differ from EPS 2?

Seventh: All HCPs who access clinical system must log in with NHS Smartcard. If there are hardware problems managing this, the IM&T teams across our area must fix these before rolling out EPS.

This system is being imposed on us on the background of a longterm agenda to cut the printed script costs.  There is also an agenda to improve security of prescribing.  Since proposed several years ago, IM&T systems and devices have evolved.  Mobile devices are so much more capable than before.  For example, my smartphone (HTC One X) is more powerful computer than my desktop system 10 years ago!

There is nothing in my local medical committee concerns nor in the NHS EPS background documents to indicate any desire to develop a mLearning project to aid in the implementation of this system.

Conclusion

Two new systems are being implemented shortly with the intention of improving patient care in an NHS region.  Two sophisticated organisations are responsible for the roll out of NHS 111 and EPS.  Neither seems to embrace education technology which, in my opinion, would ease the pain involved in changing behaviour of health care professionals and the public.

There is clearly a very long way to go to embed eLearning into the NHS.  This is a terrible state of affairs for a developed society.  It is ironic that some countries with large health care burdens (e.g. sub-Sahara Africa countries; South America countries) may be receiving superb instruction in mLearning systems.

I would love to see some discussion about the particular systems described above – your experiences of similar systems in your country, ideas on how to improve implementation, or anything else you think would be interesting.

Thank you in advance…

Medscape | Family Practice Notebook

8 Sep

Via Scoop.itOf human kindness
Medscape‘s features allows its users to review the submitted original journal article documents, use a given customized version of MEDLINE database, which is originally used by the National Library of Medicine, get help in …
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Illusions of Autonomy

Where medical ethics and human behaviour meet

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Jim McManus blogs on public health, ethics, books, theology and more