Hervey Lau

Using the My Health Record system to screen for non-adherence to prescribed asthma therapies.

Lay summary

The Medicines Preview of the My Health Record provides an easy and effective way to screen for non-adherence to prescribed asthma medications. By noting their prescription refill rates, possible non-adherence to prescribed therapies can be readily identified.

Objective

Adherence to prescribed therapies is an important ‘treatable trait’ in the management of patients with severe asthma. Improving adherence results in improved asthma control and asthma-related quality of life. In the following case studies, we seek to use the Medicines Preview of the My Health Record to find out a patient’s adherence to prescribed asthma medications. In particular, we will screen for non-adherence by reviewing their prescription refill rates.

Benefits and considerations

Example 1

A 33-year-old lady was referred to us by the Endocrinology team for management of her severe allergic asthma.  Due to chronic, high-dose prednisolone use for frequent exacerbations, she developed tertiary adrenal insufficiency necessitating hydrocortisone replacement. In the context of her poorly controlled allergic asthma and repeated exacerbations, the option of using a biologic therapy was raised.

Based on the data obtained from her My Health Record, non-adherence to her preventer medications was strongly suspected as a factor in her poor asthma control. From the records, it can be seen that her last preventer prescription was filled 3 months ago. Additionally, over an 18-month period, we can see that the medication was only dispensed 8 times. This information was subsequently brought to the patient for discussion. Accordingly, instead of proceeding with her biologic application, we redirected our efforts to improving her understanding of and adherence to her asthma preventer.

Example 2

A 72-year-old gentleman with severe eosinophilic asthma continued to struggle with poor symptom control despite the use of optimised asthma therapy. As a result, he too was referred to the Severe Asthma Multidisciplinary Team meeting for consideration of starting a biologic therapy.

On review of his My Health Record, the meeting was satisfied that the patient met the Pharmaceutical Benefits Scheme (PBS) criteria for a biologic application: the patient demonstrated adherence to maximal inhaled therapy, including the use of a high-dose inhaled corticosteroid and long-acting beta-2 agonist for at least 12 months.

Conclusion

The My Health Record system serves as an effective screening tool for non-adherence to prescribed asthma therapies. In clinical practice, this information should be discussed openly with the patient – in a collaborative manner – to optimise treatment adherence. It is important to remember that the My Health Record does not provide a complete record of all prescriptions; refills of private (that is, non-PBS) scripts or refills obtained on discharge from hospital will not be recorded.

Using the My Health Record system to identify inhaler device polypharmacy

Lay summary

The Medicines Preview page of the My Health Record allows for the rapid detection of inhaler device polypharmacy. By reviewing their prescriptions and dispense claims, the use of 3 or more inhaler devices can be readily identified. Additionally, the use of conflicting medication dosages and brands can also be uncovered.

Objective

Inhaler device polypharmacy results in increased treatment regimen complexity and costs leading to reduced treatment adherence and excess future exacerbations. Through our case vignettes, we aim to highlight the role of the My Health Record system in identifying inhaler device polypharmacy.

Benefits and considerations

Example 1

A 33-year-old lady with difficult-to-treat allergic asthma was reviewed in the outpatient clinic. After a detailed assessment, non-adherence to her preventer medications was identified as being a contributor to her poor asthma control. In order to improve her adherence, we undertook a review of her prescribed asthma therapies.

On review of the data, inhalation device polypharmacy was readily identified and posited as being a contributor to her treatment non-adherence. Even when the same medicine was being prescribed, the records revealed the use of three different devices across conflicting brands and dosages. Accordingly, rather than prescribing a new medication or device for her asthma, we performed asthma medications education with the patient with a focus on using her rapihaler device through a spacer.

Example 2

A 52-year-old retired shoemaker was admitted to the hospital with an exacerbation of difficult-to-treat asthma COPD overlap. Non-adherence to prescribed medications and inhalation device polypharmacy were once again implicated in the patient’s poor disease control: the patient was unable to name or describe any of his usual asthma medications to the team.

In order to obtain this information, a review of his My Health Record was undertaken:

Overlapping prescriptions of multiple inhalers from the same medication classes were evident on review of his My Health Record. In order to optimise his adherence, rationalisation of his asthma medications was performed alongside intensive asthma medications education.

Conclusion

Through our case vignettes, the ease and effectiveness of the My Health Record system in identifying inhaler device polypharmacy is demonstrated. Additionally, the My Health Record system has utility in both the inpatient and outpatient settings.

Jayasri Srinivasan

Electronic prescribing and transfer of care

Lay Summary

Patient B is a boy, almost 2 years old, with a history of developmental delay and was admitted for seizures to a tertiary hospital. He was admitted to ICU where he was ventilated and also commenced on various medications including opioid and sedative infusions. On day 6 of the admission, the patient's clinical state improved with no further seizures and he was transferred to the ward. Just prior to transfer, the infusions were ceased and the patient was commenced on an oral opioid medication to use as required in case of worsening pain, with the plan for it to be reviewed within a few days. A week later, the patient had a further episode of seizure-like movements overnight and became unsettled. The oral opioid (still charted) was administered, possibly contributing to some respiratory depression. Following this event, the primary medical team discovered that the patient was still charted the oral opioid, and this was fully rectified and full disclosure was given to the family. The patient improved and was eventually discharged home.

Objective

The objective of this case study is illustrate that the introduction of electronic prescribing means that there are additional areas to review when patients are handed over between medical teams.

Benefits and considerations

The implementation of electronic prescribing has been largely beneficial. The ease of electronic prescribing has made it easier for prescribing medications when multiple medical teams are involved.

However, this case study illustrates that extra diligence is required by the medical team accepting care to ensure that all the aspects of electronic orders are reviewed on a regular basis, especially following transfer of care.

Additional Advice and Comments

Essentially, this case study highlights that electronic prescribing doesn’t replace a thorough medical handover and frequent review of the patient’s chart.

Acknowledgements

Thank you to Dr Ai-Lynn Wong for providing information pertinent to this case report.

The benefits of electronic prescribing

Lay Summary

A 14-year-old boy who was run over by a truck (60 kmph) whilst crossing the road had an initial GCS of 5 (E1V1M3) and was intubated at the scene. He sustained a traumatic brain injury, fractured zygoma, and a ligamentous injury of the cervical spine. Clinically, the patient had a severe traumatic brain injury, and imaging revealed findings consistent with a subarachnoid haemorrhage and diffuse axonal injury. Agitation and aggression were a feature of the patient’s prolonged inpatient stay. Management included a low stimulus environment, 1:1 care with psychology nurse specials, removing hazards within the single room, and medications. The patient was prescribed a variety of regular medications at different times for behaviour management during his inpatient stay, including Aripiprazole, Methylphenidate, Risperidone, Propranolol, Clobazam, Clonidine, and Olanzapine. Prescribers included various doctors from the inpatient home team but also subspecialty doctors providing consultations. There was a period of elevated liver function tests following the introduction of particular medications, and this eventually resolved spontaneously. The patient’s problematic behaviour was finally managed with a combination of Aripiprazole and Propranolol.

Case objective

The objective of this case study is to illustrate the importance of easier chart access that electronic prescribing can offer when multiple prescribers are involved, and the adverse events emerge.

Benefits and considerations

Electronic prescribing has revolutionised medical practice, and charting medication has never been easier. Gone are the days of searching for the hard copy medication chart, which was usually never where you expected it to be during ward rounds.

This case study illustrates the ease of prescribing for a complex patent when multiple providers are involved. In addition, when an adverse event attributed to a medication occurs, there is easier access to an extensive chart review of prior medications, and the ability to document these adverse effects.

Additional advice and comments

Electronic prescribing benefits involve more than simply charting a drug; review of prior medications, drug interactions, and other events can be accessed much more easily.

Acknowledgements 

Thank you to Dr Ai-Lynn Wong for providing information pertinent to this case report.

Umbreen Hafeez

Inpatient care for oncology patients can be delivered efficiently and safely with the implementation of an electronic medical record system (EMR)

Lay summary

Since June 2018, all inpatient episodes of care at Olivia Newton-John Cancer Wellness & Research Centre at Austin Health are recorded electronically by treating and consulting team doctors, nurses and allied health staff. This also includes completing mandatory assessments, recording patient observations, prescription and administration of medications. All these tasks were historically being completed using paper. Once a patient is discharged from the hospital, a discharge summary is delivered electronically to other health care providers in a timely manner. Discharge summaries, discharge medications, pathology and imaging results are also uploaded on my health record. This information can be accessed by patients and other health care providers, depending on the patient’s preferences in My Health Record.

Objective

In June 2018, oncology department was the first department at Austin hospital to go paperless. This case study shows that inpatient care for complex oncology patients can be delivered efficiently and safely after being transitioned from a paper-based to a paperless model of an electronic medical record.

Benefits and considerations

• Improved documentation of episodes of care; this is essential for efficient communication between health professionals to enhance clinical outcomes. An audit conducted at Olivia Newton-John Cancer Wellness & Research Centre, one year after EMR implementation showed that 98% of nurses use template assists when recording information about their patients. In the same study, 92% of nurses stated that the system template helped them to critically evaluate the care they provided to patients throughout a shift.
• Improved legibility of medication prescriptions; this is vital to decrease medication Data from incident reporting system at Austin Health indicated a reduction in all categories of medication errors.
• Increase in the documentation of allergies due to system prompts; penicillin allergy audit at Austin Health showed a reduction in patients without documented allergies fell from 8.0% to 2.6%.
• After EMR implementation there was 8% reduction in the time spent by junior doctors on administrative patient activities which is equivalent to 38 minutes a
• Improved cancer staging data due to system This enables standardised data sets to be analysed for research.
• EMR system enables users to remotely access patients’ record, which has been vital for health care providers during COVID-19.

Considerations

• Pathology and radiology investigations carried out at other health care providers are not retrieved electronically. Lack of integration with other health care providers can result in loss of vital information.
• Safety of electronic medical records from malicious cyber-attacks needs to be considered.

Acknowledgements

Ms Lynne Keith and Dr Richard Khor

Electronic chemotherapy prescription system at the Olivia Newton-John Cancer Wellness & Research Centre

Lay summary

Chemotherapy prescription, validation and administration is a complex process which requires meticulous attention at each step. Historically chemotherapy has been prescribed on paper medication charts at Olivia Newton-John Cancer Wellness & Research Centre at Austin Health. After the implementation of electronic medical record (EMR) in June 2018, chemotherapy prescriptions are now carried out electronically. For patients starting intravenous chemotherapy, a treatment management plan is created in Cerner® oncology by treating doctor. Patient flow coordinator then schedules time for chemotherapy administration via OSIRIS® scheduler. Appointments are then generated by a support officer in Track care® and Cerner® oncology. At present, nearly 50% of intravenous chemotherapy protocols are live on Cerner® oncology. Once intravenous chemotherapy is prescribed by oncology doctors at chemotherapy unit, oncology pharmacists do routine checks and verify chemotherapy dosage electronically. The system is integrated with pharmacy dispensing system, reducing manual entry. Variations required in a chemotherapy regimen are also communicated electronically via a communicate form to chemotherapy unit staff and pharmacists. There is a plan for remaining chemotherapy regimens to go live in the near future.

Objective

Chemotherapy prescription and administration is a complex process, and medication errors can be life-threatening given the narrow therapeutic window of these drugs. This example demonstrated that a complex process like chemotherapy prescription could be safely completed electronically.

Benefits and considerations

• Improved clinical satisfaction, 75% of clinicians reported improved satisfaction when measured in a survey at Austin Health.
• Improved legibility of medication prescriptions. An audit conducted at Austin Health showed that after implementation of EMR, the number of times nurses contacted medical staff to clarify prescribed orders reduced by 14%.Chemotherapy drugs doses are now calculated electronically, which reduces the chance of error and improve patients’
• There is improved accountability for variations made to chemotherapy
• Electronic tracking board implementation has streamlined the workflow in the chemotherapy unit which ultimately will reduce chemotherapy unit waiting
• EMR can be accessed from a computer on-site or remotely, and patient results can be reviewed remotely before prescribing This provides clinicians accurate, real-time clinical information at the point of care enabling more informed clinical decision making.

• While there is significant support for the implementation of EMR and the positive impact this would have on clinician satisfaction, the current-state system, which is not fully implemented, creates additional challenges and risks in using a hybrid and incomplete
• Currently, at ONJCRI, four electronic systems are used, i.e. Cerner® oncology, Track care® , OSIRIS® scheduler and MOSAIC® . Lack of integration between all systems and manually copying information from one system to other does increase the chance of

Additional advice and comments

Staff training for system updates is resource intensive. This requires careful consideration primarily when temporary staff is employed to cover staff shortages.

Acknowledgements

Dr Geoff Chong

Ms Jadwiga Debska Ms Lynne Keith

Mr Jim Siderov

Dr Imogen Walpole

Phillipa Wormald

My Health Record can be valuable when providing care for a critically unwell child of non-English speaking background

Lay summary

This is a paediatric case study about a 5-year-old boy who presented unwell to a regional hospital emergency department late in the evening with headache, vomiting and dizziness. He and his family had extremely limited English language, therefore no past medical history, including immunisation status, was available. An appropriate language phone interpreter was not available, despite multiple attempts (rare language).

He deteriorated with a decreasing level of consciousness and there was concern about the possibility of meningitis for which treatment was initiated. Reassessment revealed abnormal eye movements and stiffness of one arm, indicating that this boy was in fact have a seizure. Treatment with anti-seizure medication (midazolam) terminated his seizure and he recovered quickly.

While this boy was in the emergency department, the medical team was able to access to his My Health Record (MHR), providing pertinent information, not otherwise available due to the language barrier. He was admitted to the paediatric ward for further observation, and an appropriate language interpreter was sort to discuss his progress.

Objective

This paediatric case study highlights the benefit of access to a patient’s My Health Record (MHR) in the emergency department when a patient is acutely unwell, especially in the scenario where there is an insolvable language barrier. When information about a patient’s previous medical care is available and can be accessed in a timely fashion through MHR, improvements in clinical care can be achieved.

Benefits and considerations

Being able to access information through the MHR can be valuable in providing information about a patient that can be utilised to optimise assessment and management of that patient in acute paediatric scenarios. As in this case, ability to access immunisation history, outpatient provider information, and recently dispensed medication can contribute to patient care, especially if there are communication difficulties. While there were no clinical documents available in this patient’s MHR, the information in the Medicare Overview section of his MHR was quite useful.

For this patient, being able to confirm his immunisation status lead to less concern about the likelihood of meningitis, and therefore fewer invasive investigations. From his MHR, the medical team looking after him were able to contact the paediatrician who has previously cared for the child, who was able to provide more information about the child’s previous medical care. It was also clear from his MHR that he was not on any regular medications such as anticonvulsants, which could have changed the acute management for this child. This was all information the mother was unable to provide to the medical team due to a language barrier and the lack of availability of an interpreter. Having this information, after hours, with a child with an acute deterioration of his neurological status, was valuable.

It was disappointing however to note that discharge summaries produced at this regional hospital are not uploaded to the MHR, and this is a significant limitation for access to information. If these discharge summaries were uploaded, information about the patient’s recent hospital stay, including diagnoses and discharge medications, would be available for other clinicians. This may be useful for the family due to their communication language barrier, both for routine follow up and if he happened to present to a different hospital with an acute illness.

Another significant limitation to accessing the MHR at this regional hospital is that the link to open the MHR through the hospitals electronic medical record system (BOSSnet) is not obvious. Many medical staff only become aware of this link when someone else specifically teaches them about it, and this was not in the hospital’s orientation.

Additional Advice and Comments

This case study highlighted the importance of checking for information in a patient’s MHR when they present to the emergency department. This can be especially useful if there is a language barrier.

Encouraging patients to allow information to be uploaded to their MHR, especially if they have chronic medical illness, or communication difficulties, can lead to improved care, regardless of where they present for care.

Improving the hospital’s electronic medical record systems interaction with MHR would make it easier to access routinely and would allow more information to be uploaded and available to the MHR.

Electronic prescribing for acute asthma management in a paediatric patient

Lay summary

A 4-year-old boy, Sam, presented the emergency department of a general metropolitan hospital with breathing difficulties. He had a history of asthma, and this presentation was consistent with a severe acute exacerbation of asthma. Sam had been unwell for a few days with rhinorrhoea, fever and a cough. He had been reviewed by his GP and started treatment with salbutamol. He continued to get worse and presented to the emergency department. He had significant respiratory distress when he arrived and was triage category 2. He received standard initial treatment with salbutamol ‘burst’ therapy (6 puffs via spacer every 20 minutes for an hour) as well as an oral steroid medication, prednisolone. He did not improve as expected so treatment was escalated following the SCHN Asthma guidelines (1) to include ipratropium bromide and ongoing frequent salbutamol. Sam also required supplementary oxygen via nasal prongs. He then required treatment with intravenous magnesium sulphate and intravenous steroids. He was also treated with intravenous antibiotics for possible secondary bacterial pneumonia after a chest X-ray shows some areas of lung collapse. COVID testing was negative. Over the first few hours in hospital Sam then showed some improvement and was transferred to the paediatric ward for ongoing care. Over a 3-day admission he continued to improve. His supplementary oxygen was discontinued, salbutamol dosing interval stretched to third hourly, steroids and antibiotics changed to the oral route. He was discharged home with a continuing treatment plan (salbutamol/prednisolone/azithromycin) and follow up with his General Paediatrician was organised.

Objective

The metropolitan hospital where Sam presented has a complete electronic medical record (EMR) including electronic observation charts and electronic prescribing. Sam received multiple doses of multiple medications during the first four hours of his admission (administration of approximately 20 doses of at least 8 different medications). These were prescribed electronically however keeping track of all of these medications in the hospitals EMR was quite confusing. In this case there were no errors or delays in medication delivery, however it is easy to predict how errors could occur, and these may lead to significant clinical consequences for an acutely unwell child with asthma. The objective of this case study is to highlight the benefits and pitfalls of using prescribing and other aspects of the hospital’s EMR in the management of a child with asthma throughout their journey from ED presentation to the paediatric ward, then home.

Benefits and considerations 

Wheezing illnesses such as asthma are common in children, affecting up to 11% of the Australian population (2). Asthma is a frequent cause of presentations to the emergency department and admission to the paediatric ward, with an admission rate of 363 admissions per 100 000 children 0-14y old in 2018 (2). Electronic medical records (EMR) and e-prescribing brings both benefits and pitfalls in the management of these children in both the emergency department and the paediatric ward. As a paediatric registrar responsible for patients in multiple locations across the hospital (paediatric ward, special care nursery, delivery suite, emergency department, outpatient clinics), ability to access the observation chart and medication information through the electronic medical record can enhance patient care and assist with the doctor’s workload. The ability to remotely prescribe medications, especially in consultation with the nurse caring for the patient, expedites patient care. There is also the possibility of the consultant paediatrician on call the ability to access the EMR remotely to monitor the patient’s management.

Electronic observation charts detailing the patient’s heart rate, respiratory rate, temperature and oxygen saturation levels are extremely valuable, allowing clinicians the ability to keep track of their patient’s progress, as well as alerting staff when observations are outside the accepted normal range for age. It is easy to look at trends in the observations, and one can change the time intervals to view a few hours or a few days of observations, allowing the clinician to monitor for response to treatment.

Electronic prescribing and dispensing of medications have many benefits in the hospital. Firstly, the prescriptions are legible, and follow a set format. For many paediatric medications there is suggested per kilogram dosing information built into the prescription sentence, and the prescribing software contains an automatic weight-based calculator for drugs. This software could be optimised further to include appropriate rounding of medication doses and a ceiling for maximum appropriate (or adult) dosing.

For some medications though, and in some situations, the current electronic prescribing and dispensing system can be confusing and lead to misunderstandings about when a medication was last given or is next due; and this could lead to sub-optimal care for patients. This is particularly true for children with acute severe asthma requiring many doses and potentially multiple medications. This patient received over 20 doses of a combination of oral, inhaled, and intravenous medications and fluids during his first few hours in the emergency department. Salbutamol therapy is the mainstay of management of acute severe asthma, with dosing interval from 20 minutes to fourth hourly, and dosing route as inhaled via spacer, or nebuliser, and sometimes intravenous. The dosing interval can change frequently in correspondence with the patient’s clinical status, and the electronic prescribing system does not allow for this. For Sam, during the early part of his hospital admission, the salbutamol was prescribed in 4 separate prescriptions, both on the regular chart and the PRN chart. A clinician reviewing his salbutamol treatment needs to scroll through multiple screens to work out when and how frequently salbutamol was given. In the EMR, a new prescription added to the regular chart has a notification stating ‘not given in the past 5 days’ despite a dose of the same medication having been dispensed only 15 minutes earlier via different prescription, adding to the confusion about what medication is due when.

Magnesium sulphate, a potent bronchodilator, given intravenously to this patient, is another example of problematic charting in the EMR system. It is prescribed as an intravenous fluid, and therefore is in a separate part of the EMR and can be easily overlooked when reviewing the patient. It is prescribed as an additive to normal saline – so at first glance in the EMR is looks like a fluid order for normal saline and has the magnesium sulphate (the active drug) in the comments section.

Additional advice and comments

Implementation of electronic prescribing has many benefits across the hospital system, however it needs to be closely monitored in consultation with users, to ensure that systems are upgraded and improved taking into consideration practicalities of specific clinical situations, to optimise patient safety. This case study demonstrates specific problems identified in prescribing both inhaled and intravenous medications in the acute care setting managing asthma. Clinicians need to be able to work with software providers to improve the way some of these specialised medications are prescribed and displayed in the EMR.

References

1. Sydney Children’s Hospitals Network (2019). Asthma – Acute Management Practice Guideline. (Guideline No: 2007-8358 v9). Accessed October 2020 at https://www.schn.health.nsw.gov.au/_policies/pdf/2007-8358.pdf
2. Australian Institute of Health and Welfare 2020. Asthma. Cat. no. ACM 33. Canberra: AIHW. Accessed October 2020, https://www.aihw.gov.au/reports/chronic-respiratory conditions/asthma

My Health Record: A useful link between tertiary and regional hospitals in the care of paediatric patients

Lay summary

A 7-month-old boy with complex medical problems including chronic renal impairment presented to the regional hospital emergency department close to his home with persistent vomiting and mild dehydration in the absence of fever or signs of infection. He required admission to hospital for further investigation of his symptoms, including blood tests and an x-ray, as well as fluid management, the consideration of antibiotics and monitoring to determine if he needed escalation of treatment which may include transfer to the tertiary paediatric hospital 350 km away. On this occasion he was able to be managed locally with regular input from his specialist renal team.

At the time of his admission, his hospital electronic medical record (EMR) was accessed and in the correspondence section there was a letter from his local paediatrician highlighting his medical history, and a copy of his discharge summary from the tertiary hospital several months ago. These provided a good overview of his past medical history. There was not however any recent information from the renal team, specifically there was no correspondence/discharge summary following his recent 3 admissions to that tertiary hospital. Accessing this patient’s My Health Record (MHR) showed discharge summaries from the previous months 2 admissions to the tertiary hospital, detailing the management that had taken place, and confirming the current medication doses.

Objective

Paediatric patients with complex medical illnesses who reside in regional areas receive medical care from both local and specialist tertiary paediatric services. This case study demonstrates the utility of MHR for a 7 month old boy with chronic renal impairment who lives in a regional area and who has been frequently transferred to a tertiary paediatric centre for specialist management. When he is acutely unwell, he presents to the regional hospital for assessment and initiation of medical care, then is stabilised in consultation with the specialist team, or transferred to the tertiary centre. On the occasion described in this case study access to information in his MHR helped to bridge the gap between the local team, the information the mother could provide, and the specialist team.

Benefits and considerations

Accurate information about patients with chronic medical problems is necessary to ensure they receive optimal care when they present to the hospital. Sharing information between care providers at different sites is essential for providing high level care to patients.

For a paediatric unit at a regional centre, the MHR can be very useful to allow access to discharge summaries for complex patients who have had recent admissions to the tertiary paediatric centre. These discharge summaries do not always make their way into the patients EMR record at the hospital.

Being able to find discharge summaries from a different hospital in the patients MHR improves continuity of care for the patient and improves communication between the peripheral hospital dealing with an acute management issue for the patient, and their usual tertiary specialist team. This is especially pertinent for presentations that occur at night. Access to a recent discharge summary for this patient allowed his medications to be charted correctly and allowed for clarification around his recent care at the tertiary hospital. This also facilitated succinct conversations with the on-call renal specialist at the tertiary hospital about the new presentation.

When information is available in the patients MHR, it can be very useful. It is however exceedingly frustrating when this information is incomplete. For example, in reviewing this patient’s MHR, it was noticed that only the most recent two admissions to the tertiary centre have discharge summaries available. Discharge summaries for earlier admissions have not been uploaded. On this occasion it is unlikely this missing data would have made a difference for the patients care, but there are certainly situations where the inconsistent availability of the information may have had adverse effects on patient care.

It was also noticed that discharge summaries from our regional hospital do not get uploaded to MHR and this is certainly an area for improvement. Further improvements in the use MHR may include uploading of specialist letters, and real time medication lists.

Janakan Selvarajah

Advanced Care Directives/Resuscitation forms for nursing home resident

Lay Summary

Currently My Health Record contains health summaries, medication dispense histories and some external hospital investigations.

While these are valuable to the immediate management of the patient, the medium-term management goals require discussion around goals of treatment. Many elderly nursing home residents come in with dementia and confusion and will not be able to meaningfully discuss resuscitation goals like CPR and ICU. Furthermore, an advanced care directive may exist, but the nursing home often will not send this with the patient.

A resuscitation form may already exist from another hospital, but it is not available to the current admitting hospital.

Objective

Advanced care directives and resuscitation forms are crucial to the admitting registrar especially for nursing home patients. Initiation and outcome of MET calls, CODE BLUE are all contingent on resuscitation forms. On many instances, the resuscitation goals may have to be discussed with next of kin or medical power of attorney at night which can be distressing for them and sometimes not possible to get hold of the individual.

Increasingly more patients are having advance care directives being completed but the document is left at the nursing home. Furthermore, patients are also using more than one hospital which means there is duplication of tasks when a new admitting hospital receives the patient.

Benefits and considerations

By having resuscitation forms from other hospitals and any advance care directives done with the GP or at a nursing home uploaded onto MyHR, a clear goal of treatment can be established early which can prioritize the wishes of the patient.

Seeing completed resuscitation forms or advance care directives will help the admitting registrar form an appropriate management plan.

Furthermore, in cases where the advanced care directive is clear about the patient's wishes such as not wanting to come into hospital, the Emergency doctor can perform acute assessment and initiate palliative care back at the nursing home avoiding unnecessary inpatient admissions.

Medications history in My Health Record

Lay summary

Currently MyHR medications are recorded in chronological order of being dispensed and the prescriber. However this list can sometimes be misleading as scripts dispensed 4 weeks ago can be no longer used by the patient. Furthermore patients will get repeats for some medications, while older medications still in use may be registered as 6 month old scripts.

While it is important for the medical team in hospital to have a complete record of all the medications prescribed over last 12-24 months, it is more important to have record of current active medications.

The admitting medical registrar usually needs to wait for the pharmacist to do a medication reconciliation to get the correct medications. This can take up to 48hr and several medication omission or errors can occur on admission.

Objective

In elderly patients, MyHR will have a very long list of all the prescriptions for last 12 to 24 months but the admitting registrar is unable to determine which medications are currently being taken. Often the patient is unable to recall names, let alone doses. Not all have webster packs. Many patients do not bring in their medications or webster pack on presentation. Furthermore, webster packs do not contain inhalers or insulin doses.

There is significant clinical risk borne by the admitting registrar, especially overnight, if seizure medications, insulin doses, opioids are missed or if incorrect/old doses are prescribed.

Benefits and considerations

My Health Record has given much needed medication history for the admitting medical registrar as well as for the morning consultant ward rounds. Having a complete prescription history is very useful to have before starting new medications.

However, this benefit can be improved with simple changes. When a patient gets a renewal of prescription by the pharmacist or GP, a reconciliation should be done in the community to confirm which are active medications.

For instance, if a patient comes for a repeat script of Metoprolol with the GP, the GP should confirm which other medications are being taken by the patient and tick them as "CURRENT" or "ACTIVE".

If one month later the patient presents to hospital we can be confident which medications were active or current one month ago.

Either the pharmacist or GP can confirm all the current medications in the community.

Specialist letters and correspondence in My Health Record

Lay Summary

My Health Record has discharge summaries from hospitals and GP health summaries which provide vital information on past medical history and outcomes of recent admissions.

However, a significant gap in the patient's treatment history and recent medication changes are contained in private specialist letters.

It can take several days sometimes to source specialist clinic letters.

This includes specialist clinic letters in private rooms of specialist physicians and public outpatients’ clinic.

Objective

Patients with chronic diseases such as diabetes will have multiple specialists involved. These specialists may make changes to medications and prescribe new doses sometimes with new scripts or verbal recommendation to patients.

This communication will not be reflected in My Health Record and patients may not see GP soon after specialist appointments.

For instance, a diabetic patient may have insulin dose adjustments with Endocrinologist in May and then get admitted to hospital in June. The insulin adjustments will not be known to the hospital and the medical assessment in May is also unavailable to the admitting hospital medical registrar.

Other vital information in clinic letters include oncology appointments in which specialists will outline any progression of cancer and the rationale for cancer treatment changes.

Benefits and considerations

My Health Record has given valuable information from hospitals and GPs with regard to past, static medical history.

However, specialist letters in private rooms and public hospital outpatient clinics provide current and dynamic information regarding the progress of chronic conditions and medication changes in specialized therapy.

Having access to specialist letters on My Health Record will significantly improve the quality of care provided to patients and reduce the risk of medication errors on admission and throughout their inpatient stay.

For instance, knowing recent changes in insulin doses or Parkinson medications will be important to know to avoid medication errors as these may not be captured on the medication dispensed list on My Health Record. Often a specialist may say "take a half a dose of drug X from tomorrow" and no new script is dispensed.

If letters from clinics are available on My Health Record, the admitting hospital can ensure the right dose is given, otherwise the old incorrect doses will be prescribed based on static history.

Elizabeth Thompson

Co-design feedback from people with intellectual disability when using My Health record

Lay summary

Three people with intellectual disability (ID) chatted to a doctor about the My Health Record ‘Personal Health Summary’ section.

People with ID are often not included in medical research yet have higher rates of health needs than the general population.

Case study

ID refers to a deficit in cognitive ability and functional performance due to an intelligence quota of 70 or below on psychometric testing. The deficit is present before 18 years of age. People with ID experience higher rates of:

• co-morbid diagnoses
• trauma and sexual abuse
• physical impairments limiting service access or appropriateness
• behaviours of concern
• environmental sensitivities
• routinely have fragmented care provision

A person with ID, like any healthcare consumer, should have a role in planning their care.  They may be constrained by limited capacity in certain domains buttheir ‘voice’ needs to be heard. General public health measures can paradoxically widen inequalities in health care provisions for people with ID because of their different health profiles and patterns of disease.

This case study of 3 participants with ID) was purposefully designed to engage the My Health Record end-user and capture their feedback. Co-design principles were utilised. The information gained is shared below with the intent that there may be future collaboration on similar projects aimed specifically at improving health literacy, fostering self-determination, and promoting user confidence in healthcare settings.

Implementation science techniques were used to evaluate how the My Health Records Personal Health Summary section was received and if the interviewees would feel comfortable using the portal. An Easy Read booklet was created and given to the participants prior to the session, to enhance their understanding, knowledge and engagement in the focus group.

Focus groups are a recognised beneficial data collection method for people with ID, a semi- structured approach allows the person to be active participants; and encourages those who may otherwise have believed they have little to contribute to instead participate. With respect to how heterogeneous the intellectual disability community is, three participants with intellectual disability of varying backgrounds with differing biopsychosocial and health literacy abilities were invited to participate.

Discussion began by talking about participant comfort levels with doctors; who might view their My Health Record; when it might be used and how they might complete it.

When discussing their relationships with primary health care professionals, all participants felt that having a strong connection and relationship with their General Practitioner was important. They identified that being listened to made them feel heard and respected; “he was aware I had an intellectual disability, but he didn’t judge”, “she listens to me, she asks me lots of questions”.

If the person with ID was able to include or chose support people to be present (during medical interactions), the participants felt this was anopportunity to enhance consumer comfort “he asked my mum so that he didn’t touch me anywhere that might hurt me”.

The My Health Record was unanimously seen as a helpful opportunity in communicating the participant’s health knowledge, particularly if unable to communicate in an emergency situation, like being in a hospital emergency department. One participant was aware of the excellent health documentation “passports” already available and others that are under development. This participant thought that having a My Health Record would be helpful if they were to forget their hard copy of a hospital passport documentation given the My Health Records online presence.

People with ID have difficulty accessing and interacting with primary health care services due to the service’s delivery design. The environmental design, staffing and accessibility to quality resources for people with ID are often inadequate in mainstream healthcare delivery models.

People with an ID are hospitalised at 6 times the rate of those without an ID. Due to communication difficulties and fragmented care provisions, people with ID present for medical review later and with higher rates of complications. Dismissal of overt ill-health can occur due to attribution of symptoms to the person’s comorbid intellectual disability.

Completion of the My Health Record independently was considered a goal but that support people may need to assist, “I wouldn’t be able to do it on my own”. One participant noted they’d prefer to ask a family member with a health background to assist them to ensure accurate information was entered, another noted that they felt able to complete it independently as “mine would be simple and boring so yes”.

When designing programs to enhance the delivery of care to people with ID, it is imperative to include them and their care support network in the dialogue. “Empower” was a word, identified by all 3 participants, of importance during interactions with health professionals.

Participatory action research aims to empower the user by utilising their reflections on the intervention. As the rest of our healthcare ethos shifts from paternalism to co-design and autonomy, so too should the dialogue for people with an ID, their support networks and hospital workers. Collaborating with end-users in the review of the My Health Record allows a glimpse of the benefits and considerations required when working with People with ID and the My Health Record.

Additional Advice and Comments

The difficulty in supporting self-determination and autonomy whilst enabling general disability and a universal level of service delivery needs to be acknowledged.

Those participating were compensated (financially) for their time.

Formal ethics approval was determined to be unnecessary according to The Local Health District’s Research Ethics and Governance office.

Out of respect to those interviewed, their feedback is captured verbatim. Identifying details have been anonymised.

Acknowledgements

Thank you to Jen Cush of Community Disability Alliance Hunter for her assistance.

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