“ E-guidelines and QUALITY reporting templates ” 2009 RNZCGP Quality seminar

1. “E-guidelines and QUALITY reporting templates”2009RNZCGP Quality seminar Dr. Helen Moriarty University of Otago Wellington.

2. Wisdom from this forum to date: • Paradigms have changed – quality is now an expectation. Quality and safety are closely linked. • Other industries do it well and so should we. • Protocols, guidelines and quality reporting underpin quality practice elsewhere. • NZ has indicators, guidelines and information now literally at our fingertips. It should make quality easier. • Besides, there are financial incentives • ..So why are we still missing the opportunities? Dr H J Moriarty, University of Otago Wellington

3. The Evidence-Based Clinical Guideline movement To inform clinical decision making with scientific rigour, and evidence-based guidelines Specialty driven initiatives for GPs to “get it right” Huge expectations, not fully met Don’t accommodate clinical uncertainty well just with scientific evidence Patient-focussed medicine is different to evidence-based medicine

4. Criticisms of Evidence-Based Medicine • Medical evidence is not always what it seems A Flanagin, L Carey, P Fintanarosa et al JAMA 1998; 280: 222-224. • Evidence-based medicine may do more good than harm MGM Hunick. BMJ Oct 30 2004. • Scientific analysis gives different answers if analysed in different ways D Mangin et alBMJ 2007: 335 285-7. Dr H J Moriarty, University of Otago Wellington

5. An applied science Population health importance Takes published peer reviewed scientific literature Grades available evidence Recommends best practice. Used in clinical guidelines, to define competencies, also in clinical protocols. An art of a clinical practitioner Personal health importance Recognises that most clinical decisions are not black and white Integrates quantitative with qualitative evidence, adds critical thinking, applied ethics, cultural and family issues. CDM is individual patient-focussed. EBM vs CDM (clinical decision-making) Dr H J Moriarty, University of Otago Wellington

6. E-guidelines • Should make implementation and monitoring easier: Link to other fields of computerised record Risk calculation algorithms etc Should make clinical practice safer • But: assumes that the guideline is appropriate an added player in the consultation additional clinical skill required*. • (*Moriarty H 2007. Adding reality to clinical skills training: a defining point. FHPE 9:3: 92-94.) Dr H J Moriarty, University of Otago Wellington

7. The e-person interface • A long forgotten thesis * • E-health systems are designed an utilised in differing cognitive environments. • Forces user into a particular behaviour in consultation, windows, storage, language • Use of e-systems changes consultation style • Adaptation is a one-way compromise as Health practitioners have to adapt to e-systems, as they cant change once installed. * E Cornford “Circuits of Power: a study of the development of computer software and its use in general medical practice” MA thesis Massey 2002 Dr H J Moriarty, University of Otago Wellington

8. Example: AOD screening and brief intervention -policy & strategy documents • The New Zealand Health Strategy. Ministry of Health 2000. • Primary Care Strategy. Ministry of Health • National Drug Policy. Ministry of Health 2006 • National Alcohol Strategy. Ministry of Health/ALAC 2001 • Aiming for Excellence. RNZCGP 3rded 2008 Etc. Dr H J Moriarty, University of Otago Wellington

9. Example: AOD screening and brief intervention –practice tools • Guidelines : National Health Committee 1999. Guidelines for recognising, assessing and treating alcohol and cannabis use in Primary Care. NZGG Depression guidelines, Smoking Cessation Guidelines MOH Opioid Substitution treatment, NZ Practice Guidelines • Screening tools: Newer: AUDIT, CUDIT, SACSBI, CUPIT, Older: MAST, CAST, CAGE, etc… Dr H J Moriarty, University of Otago Wellington

10. AOD Research examples • A databank of >170 naturally occurring GP consultations. • ARCH team • Informed consent to use the recordings for clinical interactions research • Videos, accompanying notes, post consultation interviews with the patient and doctor Dr H J Moriarty, University of Otago Wellington

11. AOD discussion –how it really happens GPs seem to sanction, not challenge GPs abruptly halt AOD conversations: • GP: you know sort of half a bottle of gin um //its not as if you going without\ • PT: /well it’s probably\\ i’m exaggerating //( )\ that’s a big night= • GP: /okay\\ • PT: =i might have six seven • GP: okay • PT: corona and lime • GP: yep • PT: (which isn’t) • GP: all right • PT: and then i might have half a dozen doubles of gin or //something\ • GP: /okay\\ so + + you you reckon it was sort of ten minutes or so a couple of days * • PT: ( ) it mightn’t have been that long + ( ) *In the video recording the patient points to his eye and says “back to this again?” Dr H J Moriarty, University of Otago Wellington

12. Another example of how it really happens GP laughs but patient is being serious GP greatly understates seriousness • GP: =your liver’s probably complaining a wee bit maybe from the alcohol //((inhales)) um yeah\ • PT: /oh i’ll (grizzle) any anyway\\ • PT: if it’s er + er (2) if i er ((drawls)) i i must have been a potentially alcoholic ((inhales)) you know i grizzle if i don’t have it and i grizzle //if i do\ • GP: /if you do\\ • GP: ((laughs)) yeah so i think we need to check that out to //make\ sure there’s= • PT: /yes\\ • GP: =no damage going on //there\ and um really just go from there depending on= • PT: /yes yes\\ • GP: =what we find but if you can try and pull that er the old alcohol ((inhales)) back a wee bit maybe you know one or two //a night\ • PT: /oh yeah\\ • PT: i think ((mumbles)) they w- th- the bottle of whiskey ((in a high pitched voice)) where’d i get that anyway somebody //gave it\ • GP: /((laughs)) somebody\\ • GP: gave it to you

13. Further examples of how it happens GP tells patient what answer is acceptable Consult (a). • GP: ((quietly)) mm + + + you’re not having too much ((drawls)) er alcohol at all during the dayyou’re not drinking + much • WF: no just have three little glasses of wine that’s all he //has\ Consult (b). • GP: =know that the higher + certain types of the + cholesterol (that are in) the blood + um the greater the r- long term risk of heart disease + and obviously + that has to be put into the context of whether or not you have other risk factors because all risk factors multiply up + //and\ you're a non smoker += • PT: /yeah\\ Consult (c). GP: you didn’t drink the whole bottle in one night or any//thing no okay\= • PT: /no no\\

14. So what’s going on? • Doctors do know what is expected & they are aware of guidelines and tools • Doctors want to keep patients on side • Both Doctor and Patient seek to avoid offence: “face work”*. • So Doctor and Patient both actively avoid sensitive topics and direct confrontation * “The use of Face Work and Politeness Theory” JA Spiers. Qual Health Res J 1998; * (1) 25-47.

15. My “so what” slide. • E-guidelines and quality templates are all great ideas BUT They assume a systematic problem-solving approach to consultation AND This is not the way most GPs work. • Implementation plan is fundamental, but often overlooked in creating GP “solutions” • Face work underpins polite patient-centred consultation BUT consultation style conflicts with quality tick box paradigm.

16. Moriarty’s QuALITY planning for quality initiatives • Questions: ask the right persons to find the right questions for targeted quality initiatives. • Attribution: entailment and supervenience of causation theory, • Likelihood: clinical uncertainty, shades of grey in CDM, • Implementation: are e-solutions the best/only way to go? • Trouble shooting: risks of e-solutions in a multidisciplinary environment • Yield: costs and hidden consequences