Populations

1. Populations 3P session 3 – EMIS Version

2. Introduction This session builds on your first two 3P sessions: your home visit where you met your patient, and the Practices session where you explored the demographics of your practice population. The focus of this session is split into two parts. In the first part, you will be looking at guidelines relevant to the management of your patient and their condition or conditions. In the second part, you will review the management of your patient compared to the guidelines you have identified. Each part should take around an hour to complete. There are 24 slides in total. 2

3. Learning Objectives • Know where to find reliable clinical guidelines • Know what makes a good guideline • Understand what some of the problems with clinical guidelines are • Undertake a comprehensive patient review At the bottom of each slide, you can see how far through the tutorial you are in terms of slide numbers, and also the time taken to get to the end of the current slide. 3

4. Part 1: Guidelines Think back to the patient that you visited at home and the conditions that you searched for in the Practices session. Task 1: In pairs, spend 5 minutes discussing where you might go to find more information about the management of your patient’s condition. 4

5. Which Guidelines? Clinical guidelines are systematically developed statements designed to help practitioners and patients make decisions about appropriate health care for specific circumstances. 5

6. Which guidelines Many different organisations produce guidelines: • Some of these are disease or system specific organisations such as the British Heart Foundation or the British Thoracic Society. • Some are produced by organisations which cover a much broader spectrum of conditions such as NICE and SIGN. • Some are international organisations such as the Global Initiative for chronic Lung Disease (GOLD) or the European Society of Hypertension. There are even organisations that make summaries of clinical guidelines such as ‘Guidelines’ (https://www.guidelines.co.uk/) 6

7. Which Guidelines? Many Clinical Commissioning Groups (CCGs) also produce their own local guidelines for clinicians. In the Bristol region these guidelines are on a website called Remedy that also features information about local referral pathways: https://remedy.bnssgccg.nhs.uk/ It is well worth having a look at the above link– it has huge amounts of information that GPs use frequently. 7

8. Searching for Guidelines Task 2: Spend up to 20 minutes searching online for guidelines that are relevant to the patient you visited at home. NICE CKS (https://cks.nice.org.uk/#?char=A) is a good starting point. Create a list of the resources that you find in your workbook. You will find it helpful to keep copies of relevant guidelines that you find open on the desktop. 8

9. Differences between guidelines Hopefully you have found some guidelines that apply to your patient. Some of these may be very lengthy! If you can, try to find a summary version of the guidelines. Task 3: Now spend up to 20 minutes reading through the guidelines. If you’ve identified multiple guidelines, you might want to just pick two to look at. You may want to each look at one guideline separately (for example with one of you using a mobile device). Then compare notes. Are there any differences between the guidelines that you have identified? Jot these down in your workbook. 9

10. What makes a good guideline? As you’ve probably found, some guidelines can be pretty tricky to read. Particularly if you’re trying to access the information within the constraints of a 10 minute consultation. Of the guidelines you’ve looked at, which do you prefer? Why is this? 10

11. What makes a good guideline? Three key components of a useful clinical guideline have been identified as: • Identification of the key decisions and their consequences • Review of the relevant, valid evidence on the benefits, risks, and costs of alternative decisions • Presentation of the evidence required to inform key decisions in a simple, accessible format that is flexible to stakeholder preferences BMJ 1998;317:427 11

12. Part 2: Applying the guidelines to your patient You’re now going to look at applying the guidelines you’ve found to the patient that you visited at home. First off, you need to know how to navigate the patient’s electronic record. If you already know how to do this, you can skip the next few slides. 12

13. 1 2 Firstly, you need to find your patient’s notes. Open EMIS. Click on the EMIS ball (1) in the top left of the screen and then select ‘Find Patient’ (2) 13

14. Enter the patient’s name and then double click on their details to open their record. You might need to check the date of birth if there is more than one patient with the same name. 14

15. To see their notes, click on the EMIS ball again, select ‘Care Record’ Then select ‘Summary’ This screen gives you an overview of the patient’s history. 15

16. You can then navigate between the different pages of the patients record by clicking on the different tabs. For this exercise, the most useful will be ‘Consultations’, ‘Medication’, ‘Investigations’ and ‘Documents’. 16

17. Consultations contains records of the patients consultation in the practice. Medications contains all their current medication. By clicking the Current/past button, you can see their past medication. Click it again to go back to current medication. 17

18. Investigations contains all the test results that have been requested in the practice for the patient. You may be able to view investigations that have happened in secondary care by clicking the ‘Patient report list’ button. 18

19. Documents contains all external documents received relating to this patient including clinic letters and discharge summaries. You might be able to find some useful information relating to your patient’s management in some of these documents. Some practices use separate document management software such as Docman. 19

20. Within each tab you can search for things of interest by clicking on ‘Search View’ and entering your search term. 20

21. Management of your patient Task 4 (45 minutes) : Now it’s time to have a look at how these guidelines apply to your patient. Things to think about include: Have they been reviewed at the recommended time interval? Have they had the recommended investigations? Are they on the recommended treatments? You may feel that you need to ask the patient some questions – write these down to ask at your final visit. If aspects of the guideline aren’t being adhered to, are there any reasons documented in the notes for this? Are there any recommendations you would make about trying to improve the care of this patient based on the guideline you have read? Record these in your workbook. 21

22. Problems with guidelines Having read some guidelines and applied them to your patient, what do you think are some of the problems with guidelines? 22

23. Problems with guidelines Some potential problems with clinical guidelines include: • They are often disease or system specific. Many patients have multiple long-term conditions and there may be conflicting advice between the different guidelines. • Conflicts of interest still occur due to industry sponsorship of individuals or organisations involved in the development of guidelines. • Guidelines don’t take into account the circumstances or medical history of the individual patient. • The values of those creating the guidelines might differ from those of the patient. For example a guideline might value increasing survival whereas the patient may value quality of life and lack of treatment burden. • The guideline is only as good as the evidence on which it is based, and how well that evidence is interpreted. 23

24. And finally… You may well now have some ideas to discuss with your GP tutor about changes that could be made to improve the management of your patient. Before your final home visit, we would like you to discuss these with your GP tutor and the rest of your group. There will be dedicated time for this in the final three workshops. On your final home visit, we hope that, as well as catching up with what’s happened to your patient since you last saw them, you will be able to discuss any changes to the patients management that you have agreed with your GP teacher. 24