Professor Liaw is Profesor of General Practice at the University of New South Wales, Australia, and Director, Academic General Practice Unit, South West Sydney Local Health Network. He is also a Honorary Professorial Fellow, Univerity of Melbourne, Australia.
Abstract: The Australian National Medicines Policy embodies four tenets: availability, quality, safety and efficacy of medicines; timely access to affordable medicines; quality use of medicines (QUM); and a responsible and viable medicines industry. The promotion of QUM requires a multidisciplinary approach, including contributions from government, the pharmaceutical industry, health professionals, consumers and academia. However, there are significant tensions and unintended effects associated with the multidisciplinary approach, especially with the relationships between prescribers and dispensers of medicines. The general practitioner and the pharmacist share a common ancestor - the apothecary. The separation of dispensing from prescribing, which began in medieval Europe and 19th century England, reframed and confined the patient-doctor relationship to one of diagnosis, prescription and non-drug management. The role of pharmacists was limited to dispensing, though the present trend is for their responsibilities to be widened. Historical antecedents, the contribution of an increasing number of actors to the costs of health care, universal health insurance and an evolving regulatory framework, are among the factors influencing doctor-pharmacist relations. The prescribing and dispensing of medicines must be guided by an ethical clinical governance structure encompassing health professionals, regulators, the pharmaceutical industry and consumers. There must be close monitoring of safety and effectiveness, and promotion of quality use of medicines and improved patient outcomes. Ongoing training and professional development, within and across professional boundaries, is essential to support harmonious and cost-effective inter-professional practice. The approach must be "apothecarial" with complementary roles and responsibilities for the prescriber and dispenser within the patient-clinician therapeutic relationship, and not adversarial. Aust Health Rev 2009: 33(2): 268-278
Abstract: BACKGROUND:A cluster randomised trial was conducted to determine the effectiveness of locally adapted practice guidelines and education about paediatric asthma management, delivered to general practitioners (GPs) in small group interactive workshops.METHODS:Twenty-nine practices were randomly allocated to one of three study arms. Australian asthma management guidelines were adapted to accommodate characteristics of the local area. GPs in the intervention arm (Group 1, n = 18 GPs) participated in a small group based education program and were provided with the adapted guidelines. One control arm (Group 2, n = 18 GPs) received only the adapted guidelines, while the other control arm (Group 3, n = 15 GPs) received an unrelated education intervention. GPs' knowledge, attitudes and management of paediatric asthma was assessed.RESULTS:Post intervention, intervention arm GPs were no more likely to provide a written asthma action plan, but were better able to assess the severity of asthma attack (Group 1vs Group 2 p = 0.05 and Group 1 vs Group 3 p = 0.01), better able to identify patients at high risk of severe attack (Group 1vs Group 3 p = 0.06), and tended to score higher on the asthma knowledge questionnaire (Group 1 vs Group 2 p = 0.06 and Group 1 vs Group 3 p = 0.2). Most intervention arm GPs felt more confident than control GPs to manage acute asthma attack and ongoing management of infrequent episodic asthma.CONCLUSION:Using interactive small group workshops to disseminate locally adapted guidelines was associated with improvement in GP's knowledge and confidence to manage asthma, but did not change GP's self-reported provision of written action plans.
Abstract: The iterative development of the Falls Risk Assessment and Management System (FRAMS) drew upon research evidence and early consumer and clinician input through focus groups, interviews, direct observations, and an online questionnaire. Clinical vignettes were used to validate the clinical model and program logic, input, and output. The information model was developed within the Australian General Practice Data Model (GPDM) framework. The online FRAMS implementation used available Internet (TCP/IP), messaging (HL7, XML), knowledge representation (Arden Syntax), and classification (ICD10-AM, ICPC2) standards. Although it could accommodate most of the falls prevention information elements, the GPDM required extension for prevention and prescribing risk management. Existing classifications could not classify all falls prevention concepts. The lack of explicit rules for terminology and data definitions allowed multiple concept representations across the terminology-architecture interface. Patients were more enthusiastic than clinicians. A usable standards-based online-distributed decision support system for falls prevention can be implemented within the GPDM, but a comprehensive terminology is required. The conceptual interface between terminology and architecture requires standardization, preferably within a reference information model. Developments in electronic decision support must be guided by evidence-based clinical and information models and knowledge ontologies. The safety and quality of knowledge-based decision support systems must be monitored. Further examination of falls and other clinical domains within the GPDM is needed.
Abstract: Objective: To examine doctors' perceptions and attitudes to prescribing within the Authority Prescribing System (APS). Design and setting: Questionnaire survey of Australian doctors' responses to a number of statements and factorial vignettes, conducted between 1 May and 30 June 2001. Participants: A national random sample of 1200 doctors, stratified according to specialist/generalist, rural/urban and high/low prescriber: 669 (56%) responded. Main outcome measures: Self-reported perceptions of the APS and attitudes to prescribing within the APS. Results: 72% of doctors agreed that the APS makes effective medications available to the socioeconomically disadvantaged members of the Australian public and 50% agreed that it compromises patient privacy. Fewer agreed that authority indicators were based on the highest quality of evidence quality (40%) or medication safety (12%). Doctors placed more emphasis on the doctor-patient relationship than on the criteria for authority prescribing in their decisions about prescribing APS medications. Doctors who used computers to prescribe were more likely to agree that computers can improve the authority prescribing process. Conclusions: This study suggests that authority-required prescribing is not achieving the stated aims of the National Medicines Policy in reducing variability in prescribing. Strategies to improve the quality of prescribing must consider the professional and ethical conundrum associated with prescribing outside of PBS/APS approved use for clinical and patient-centred reasons.
Abstract: Objective To develop and evaluate a strategy to teach skills and issues associated with computers in the consultation. Intervention An overview lecture plus a workshop before and a workshop after practice placements, during the 10-week general practice (GP) term in the 5th year of the University of Melbourne medical course. Design Pre- and post-intervention study using a mix of qualitative and quantitative methods within a strategic evaluation framework. Outcome measures Self-reported attitudes and skills with clinical applications before, during and after the intervention. Results Most students had significant general computer experience but little in the medical area. They found the workshops relevant, interesting and easy to follow. The role-play approach facilitated students' learning of relevant communication and consulting skills and an appreciation of issues associated with using the information technology tools in simulated clinical situations to augment and complement their consulting skills. The workshops and exposure to GP systems were associated with an increase in the use of clinical software, more realistic expectations of existing clinical and medical record software and an understanding of the barriers to the use of computers in the consultation. Conclusions The educational intervention assisted students to develop and express an understanding of the importance of consulting and communication skills in teaching and learning about medical informatics tools, hardware and software design, workplace issues and the impact of clinical computer systems on the consultation and patient care.
Abstract: Objective. This study aimed to examine if providing feedback to the doctor can improve patient-doctor concordance (PDC) on health problems and treatments. Method. The study was carried out in a hospital-based primary care service in a lower socioeconomic status (SES) region of metropolitan Melbourne, Australia. A summary of the existing patient-doctor concordance on health problems and treatments was presented to doctors along with a questionnaire seeking their perceptions of and suggestions on how to act on the findings. In a pre- and post-intervention study, data were collected from consecutive new patients who completed a pre- and post-consultation questionnaire seeking information on the presenting complaint, patient-reported health problem, doctor-recorded health problem, treatments received, and patient expectations of and satisfaction with care. Diagnostic data were classified into body systems. Descriptive statistics were obtained and PDC measured. Following the intervention, data collection was repeated to detect any changes in PDC and patient satisfaction. Results. The pre-intervention sample (n = 197) was young (mean age 33 years), evenly divided into English-speaking (48%) and non-English-speaking (52%), and low SES (66%). The post-intervention samples (n = 95) was similar except for a lower proportion of persons from a low SES (27%). Main body systems reported were musculoskeletal, skin, respiratory, digestive, urological and gynaecological. Post-intervention, PDC on health problems improved significantly from 31% to 63% at the problem level (P = 0.001) and from 65% to 79% at the body system level (P = 0.02). PDC on treatments received also improved significantly from 5.5 to 6 out of 7 treatment options (P = 0.003). There were no significant differences due to gender, SES and non-English-speaking background status. Conclusion. PDC is a practical, useful and relevant indicator of effective patient-doctor communication. A well-presented summary of existing levels of PDC is an effective intervention to improve PDC and, by inference, patient-doctor communication on health problems and treatments. PDC should also be examined and reported in prevalence and incidence studies based on patient's reports and doctor's records.
Abstract: The objectives of this study were to describe how GPs in South Australia manage and use office and clinical information, as well as their plans for the future. The study was set in a primary medical care centre in South Australia, and used a cross-sectional study with a mail questionnaire. Utilization of and satisfaction with office and clinical information management systems, with a focus on the use of patient summaries were outcome measures. A random sample was obtained from a register of GPs in South Australia that had been stratified into geographic regions based on socioeconomic indicators. Sixty-eight per cent of GPs approached responded (n = 315). There was no significant difference in response rate from each region. The use of computer applications was comparable to that in the general population. Half the GPs used index cards and 5% used computer-based records. Users of RACGP problem-oriented A4 folders were most (92%) and index card users least (65%) satisfied. The use of patient summaries could be improved. GPs planned to change to computer-based billing, more comprehensive paper-based records and computer-based patient records. Perceived reasons for and obstacles to change were documented. Factors that influenced the use of different forms of office and clinical information management were type and place of practice, staff employed, gender, a diploma in obstetrics, age, year of graduation, type of record used and satisfaction with it, vocational registration, FRACGP and FMP training. Given the pattern of utilization, generally low satisfaction and planned changes, there is an unmet need for useful office and clinical information management systems in general practice.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: OBJECTIVE: To examine the management and use of patient records as well as plans for future information management. SETTING: General practice in South Australia (68% response, n = 315). METHODS: Descriptive and analytical cross-sectional study using a mail questionnaire. RESULTS: The sample was representative by age, gender and postcode location of practice. Half the GPs used index cards and 5% computer-based records. Users of the RACGP folder were most (92%) and index card users least (65%) satisfied. The use of patient summaries could be improved. GPs planned to change to computer-based billing, more comprehensive paper-based records, and computer-based patient records. Perceived reasons for and obstacles to change were documented. Factors that influenced the use of different forms of patient records were type and place of practice, staff employed, gender, a Diploma in Obstetrics, age, year of graduation, type of record used and satisfaction with it, vocational registration, FRACGP, and FMP training. CONCLUSION: Given the high use of index cards, a variable but generally low satisfaction and planned changes, there is an unmet need for useful patient record systems in general practice. The effect of affluence of suburb and vocational registration warrants further study.
Abstract: The objectives of this study were to describe how GPs in South Australia manage and use office and clinical information, as well as their plans for the future. The study was set in a primary medical care centre in South Australia, and used a cross-sectional study with a mail questionnaire. Utilization of and satisfaction with off ice and clinical information management systems, with a focus on the use of patient summaries were outcome measures. A random sample was obtained from a register of GPs in South Australia that had been stratified into geographic regions based on socioeconomic indicators. Sixty-eight per cent of GPs approached responded (n = 315). There was no significant difference in response rate from each region. The use of computer applications was comparable to that in the general population. Half the GPs used index cards and 5% used computer-based records. Users of RACGP problem-oriented A4 folders were most (92%) and index card users least (65%) satisfied. The use of patient summaries could be improved. GPs planned to change to computer-based billing, more comprehensive paper-based records and computer-based patient records. Perceived reasons for and obstacles to change were documented. Factors that influenced the use of different forms of office and clinical information management were type and place of practice, staff employed, gender, a diploma in obstetrics, age, year of graduation, type of record used and satisfaction with it, vocational registration, FRACGP and FMP training. Given the pattern of utilization, generally low satisfaction and planned changes, there is an unmet need for useful office and clinical information management systems in general practice. There were significant sociodemographic, educational and practice management indicators of use of patient summaries and computers. Structural and demographic factors that encouraged or discouraged changes to information management were also reported. The effects of affluence of suburb and vocational registration warrant further study.
Abstract: The objective of this study was to describe the attitudes of general practitioners (GPs) and their patients to patient-held health records (PHR). The study was set in a general practice in South Australia. It consisted of a descriptive study using a mail questionnaire. A stratified random sample, based on socioeconomic indicators for areas in South Australia, of GPs (n = 315) and their patients (n = 500) was used. The indices for contents, problems and benefits of the PHR showed adequate internal consistency and reliability. Patients mostly perceived the PHR as a personal document for reference while GPs perceived it as a management and communication tool. The solo GP who scored high on the 'PHR benefits' and low on the 'PHR problems' indices, and doubted that GPs were influential in changing patient behaviour would let patients keep full copies of their records. The younger female rural GP who scored high on the 'PHR benefits' and low on the 'PHR problems' indices favoured a patient summary. The more entrepreneurial GPs who scored high on both the 'PHR benefits' and 'PHR problems' indices favoured a 'censored summary'. Awareness of smart cards was high and opinions on their use guarded. It was concluded that patients and doctors have different attitudes to and expectations of PHRs. Significant sociodemographic, educational and attitude correlations with PHRs were found. The 'PHR benefits' and 'PHR problems' indices were consistent, useful and may have a wider applicability in quantifying the opinion of patients and providers before implementing PHR programmes.
Abstract: The objective of this study was to describe the attitudes of general practitioners (GPs) and their patients to patient-held health records (PHR). The study was set in a general practice in South Australia. It consisted of a descriptive study using a mail questionnaire. A stratified random sample, based on socioeconomic indicators for areas in South Australia, of GPs (n = 315) and their patients (n = 500) was used. The indices for contents, problems and benefits of the PHR showed adequate internal consistency and reliability. Patients mostly perceived the PHR as a personal document for reference while GPs perceived it as a management and communication tool. The solo GP who scored high on the 'PHR benefits' and low on the 'PHR problems' indices, and doubted that GPs were influential in changing patient behaviour would let patients keep full copies of their records. The younger female rural GP who scored high on the 'PHR benefits' and low on the 'PHR problems' indices favoured a patient summary. The more entrepreneurial GPs who scored high on both the 'PHR benefits' and 'PHR problems' indices favoured a 'censored summary'. Awareness of smart cards was high and opinions on their use guarded. It was concluded that patients and doctors have different attitudes to and expectations of PHRs. Significant sociodemographic, educational and attitude correlations with PHRs were found. The 'PHR benefits' and 'PHR problems' indices were consistent, useful and may have a wider applicability in quantifying the opinion of patients and providers before implementing PHR programmes.
Abstract: Some educational, training and politico-economic reasons for the decline in GP obstetrics in Adelaide, South Australia, are described. It is recommended that similar studies be done in other centres in Australia to evaluate the general nature of the findings.
Abstract: OBJECTIVE: To describe the reasons for encounter (RFE) at the casualty department of a small rural hospital and to highlight the value of the hospital to the community, and to health care workers, medical educators, and policy makers. SETTING: A small South Australian rural town with a population of about 4500 served by a 50-bed hospital that provides a 24 hour casualty service manned by the local three-person general practice on a fee-for-service basis. METHODS: Using an integrated computerised health information management system, data on all the RFE at the casualty department were accumulated over 9 months, coded with ICHPPC-2-Defined, analysed and transferred to a spreadsheet for presentation. RESULTS: There were sex variations in the various age groups with males presenting more commonly with accidents and injuries. The main reasons for encounter were injuries (35%), respiratory system problems (13%), ear problems (10%), infections (5%), ill-defined problems (5%), supplementary classification (5%). CONCLUSIONS: There is sufficient 'clinical material' for undergraduate and graduate training in the management of trauma and orthopaedic problems but insufficient for obstetric and abdominal surgical emergencies in small rural hospitals. Small rural hospitals must be supported and used effectively by educators and policy-makers to help rural doctors meet the needs of the 30% of the Australian population who do not live on the coastal fringe.
Abstract: This study aimed to assess perceptions of continuity of care by patients from different socioeconomic areas using focus group interviews augmented by postal replies. Patients were randomly selected from two contrasting primary medical care locations: a middle class suburb and a less affluent suburb in Adelaide, South Australia. The Ethnograph was used to analyse the content of the interviews and postal responses. Analysis used the framework described by Curtis and Rogers in the USA and Freeman in the UK. The response rate was much lower from the lower socioeconomic group (5% focus group; 20% when postal replies included). They emphasized access factors and importance of records, and alleged situations where they were taken too casually and their problems were not dealt with. Those from the middle class area (response rate 25%) emphasized interpersonal ('art of care') factors and were more likely to use their presenting problem as a criterion to decide whether they needed to postpone the problem to a time when they could see their personal doctor. Focus groups can be useful evaluation tools in general practice, but oversampling of lower socioeconomic groups is needed. Continuity of care should be considered as an aid to consistent quality of care, rather than its essence. Well controlled intervention-outcome studies in different types of practice organization in differing socioeconomic situations will increase our understanding of continuity of care.
Abstract: The use of a problem and episode oriented computerised medical record in general practice for self-audit, some methodological constraints and the profile produced are discussed in this article. The profile was produced specifically for comparison with the results of the 1987 Australian Morbidity Study and with other Australian studies in the diagnostic content of general practice.
Abstract: This paper describes the establishment of a consortium to advance health and medical informatics in general/family practice in the Asia Pacific Region. The objectives, current activities currently taking place in the region and key activities planned will be outlined.
Notes: 9th World Congress on Medical Informatics: Global Health Networking - A Vision for the Next Millennium (MEDINFO 98) xD;1998 xD;Seoul, south korea
Abstract: This thesis aimed to examine how continuity of care is appreciated, how it can be facilitated by continuity of information and how modern information technology can serve that continuity. A multi-dimensional framework and a qualitative approach was used to examine patient perceptions of continuity of care. Then patient-doctor concordance on health status, health problems and medications was studied in an elderly population. It was found that provider continuity may not be perceived as vital in health care, continuity of information may be an acceptable alternative/backup to provider continuity, and Patient-Doctor Concordance (PDC) may be due to biased reporting or ineffective information sharing. xD;Two subsequent cross-sectional studies examined patient and doctor perceptions of information management and patient-held health records (PHRs). The sampling frame for these two studies included general practices, community health centres, Child, Adolescent and Family Health Services clinics, paediatric outpatients and accident & emergency department of a teaching hospital, and the primary health care department of a suburban hospital. It was found that: xD;1. x9;Patient record keeping was mostly paper-based & little active use was being made of patient summaries. xD;2. x9;Significant variations exist between socioeconomic groups in information management, perceptions of PHRs and the utilisation of the South Australian parent-held personal health record (Blue Book). xD;3. x9;Significant lack of concordance between patients and doctors in the utilisation of the Blue Book and expectations for PHRs. xD;4. x9;GPs foresaw changes to and were apprehensive about information management in the near future. xD;5. x9;A third of the GPs were willing to evaluate a computer-generated PHR in their practices. xD;A pilot intervention study, which sought to test methods and develop hypotheses, was conducted to examine the impact and utilisation of a computer-generated PHR. This used both quantitative and qualitative approaches within a randomised trial design and incorporated a post-test only (PTO) group. It was found that: xD;1. x9;A wide range of health care providers from primary and secondary levels of care used the PHR and found it useful. xD;2. x9;Patients were generally very positive about using a PHR, reporting a sense of increased involvement in and responsibility for their own health. This was confirmed by the GPs' reports. The use of the PHR may result in a more critically aware patient. xD;3. The interesting effects of socioeconomic factors and practice management as well as variations in attitudes, perceptions, functional status and blood pressure among the patient groups warrant further study. xD;4. x9;The methodology and the computer-based patient record system fulfilled most of the technical objectives of the study. xD;These studies demonstrated the practicability of intervention studies using computer-generated PHRs. A model to evaluate PHRs was developed which could guide future development in this area. The future of computer-generated PHRs is promising with the development of sophisticated and robust "read-write" optical cards and increasingly positive attitudes to information technology and health information networks. In summary, this thesis adds to the foundation of existing work and knowledge on PHRs and offers some future strategies for use of information technology in the improvement of health care and health.
Abstract: AIM: To describe the patients attending a hospital-based primary care clinic (HBPCC), focusing on the main medical and non-medical reasons for seeking health care in the clinic, and expectations of and satisfaction with care xD;SETTING: A HBPCC in the northern region of metropolitan Melbourne, Australia. xD;METHODS: Bilingual interviewers assisted consecutive new patients to complete a pre- and post-consultation questionnaire seeking information on the presenting complaint, patient-reported reason for encounter (RFE), doctor-recorded health problem, treatments received, and patient expectations of and satisfaction with care. xD;RESULTS: The sample (n=197) was young (mean age 33 years), mostly low socioeconomic status (68%), and showed a higher than expected proportion of NESB (Non-English-Speaking-Background) Australians (53%). Three-quarters had a regular GP elsewhere. Accessibility and familiarity, being part of a hospital, ease of obtaining radiological examinations, and the quality of the doctors were important reasons for choosing this service. The most common health problem was trauma-related (14-16%). The main body systems involved were locomotor, skin, digestive, respiratory, pregnancy-related and non-specific. Patients were mostly satisfied with their care; those with ill-defined problems were more likely to report that their expectations were not completely met. No significant demographic and ethnic variations in the outcome variables were found. xD;CONCLUSION: HBPCCs can complement the regular GP’s ongoing relationship with patients from NESB and lower socioeconomic groups to improve the continuity and coordination of health care. Experienced and culturally sensitive GPs, good communications, and an effective and comprehensive interpreter service are necessary to facilitate this care coordination to benefit the patient and GP. One strategy is a hospital-based Department of General Practice linking academic GPs and a local Divisional network of GPs to provide this clinical service and undertake teaching and research in the areas highlighted by this study.
