Column

Can we deliver high value care with one eye on the clock and the other on the screen?


Edwin Kruys


22/02/2018 3:06:35 PM

Given longer consultations are associated with better health outcomes, the Medicare Benefits Schedule should be restructured to incentivise appropriate consultation time in general practice, Dr Edwin Kruys writes for newsGP.

Dr Kruys believes the inherent time pressures associated with general practice can be distracting and cause cognitive errors.
Dr Kruys believes the inherent time pressures associated with general practice can be distracting and cause cognitive errors.

It is estimated that doctors are making an incorrect diagnosis in up to 20% of cases, and up to 30% of investigations may be unnecessary. It is often thought that medical knowledge and skills are the culprit, but there is another reason for the majority of medial mistakes.
 
Doctors need time to listen and think. General practice’s inherent time pressures of, interruptions and the need to record information on computers can all be distracting and cause cognitive errors. Our thinking process is also influenced by our emotions; for example, as a result of work stress or running late.
 
This is not rocket science and has all been well documented. For example, in his New York Times bestseller, How doctors think, Harvard professor Jerome Groopman described how snap judgments and other cognitive errors by doctors can lead to medical mistakes.
 
In a television interview, Professor Groopman explained how over the years the consultation time gradually had to drop from 30 minutes to about 12 minutes. A doctor can’t think, he said, with one eye on the clock and the other eye on the computer screen.
 
In Australia and New Zealand, chronic conditions account for 85% of the total burden of disease, and a chronic disease is a contributing factor in nine out of 10 deaths. The increasing multimorbidity and complexity of care requires that doctors spend more time with their patients. Managing several medical and psychosocial problems in a 15-minute consultation is increasingly challenging for doctors and many patients.
 
It is not surprising that longer consultations seem to be associated with better patient outcomes. The benefits of extended consultations of 20 minutes or more for certain patient groups have also been explored overseas. More time with patients may lead to higher patient satisfaction, fewer errors and a lower volume of prescriptions, investigations, referrals and hospital presentations.
 
It is time to slow down. At the moment, the Medicare Benefits Schedule (MBS) fails to recognise this growing problem as it encourages throughput. For example, seeing patients in blocks of four 15-minute appointments per hour is valued at $148.20, but two 30-minute consultations per hour is worth a total of $143.40.
 
Is block funding such as proposed in the Federal Government’s Health Care Home model encouraging more time with patients? Probably not. In fact, one could argue that it incentivises less face-to-face time with the GP and more contact with nursing staff and other team members.
 
Our patients deserve our time. The MBS schedule could support our patients with chronic and complex health conditions by better rewarding longer GP consultations.



chronic-disease general-practice-consultations screen-time



Oliver Frank   24/02/2018 8:50:29 AM

Well said, Edwin!


Dr Perera   27/02/2018 7:51:55 AM

Well said! , it's a daunting problem that looms over us since rofever , something should be done .


Steve Hambleton   27/02/2018 10:17:55 AM

It could also be argued that within a health care home practice, having the ability to delegate the elements of routine care to the practice team would allow GPs to spend more face to face time with patients with more complex problems. Additionally the tiered blended payment model, recognises the higher level of need for complex patients compared with the current one size fits all model.


DR J N Parikh   27/02/2018 11:24:12 AM

I think it is even worse than it is discussed I am the victim of more than average levlel C consult necessitating a visit from medicare doctor who was clever enough to understand the complexity of
1 New patient needing more time
2 Drive medical for patients over 75
3 Pap smear now called HPV screen
4 Patient needing interpreter
and many patients taking more than 12 medications etc which need DMMR
I bet we all know the mental state of colleagues going through this
Luckily she understood and did not take any drastic action
Regards


Quick doctors   28/02/2018 11:05:06 PM

I think it is the doctor's problem. We probably need more training on doing things quicker and more efficiently. For example, walk faster to call a patient, know your EMR system well, use shortcuts instead of mouse clicks, better layout rooms, voice recognition software, better printers, faster servers/internet connections and larger computer screens.

Chronic diseases are just patterns. GPMP is there, use it as a framework. If there is a change, update it, you may not need to bill the items.

Refine workflows too. For example, when waiting for PBS authorities, get the BP done. When getting the BP, listen to the chest.

Working efficiently is a skill. It needs to be trained. The RACGP training program has no coverage on it.

My last patient booking is 4:15 pm, I seldom leave after 4:30 pm. Patients' waiting time is normally zero, i.e. they are seen at the time if not before their scheduled time.


Dr. Advocate for Sustainability of General Practice   1/03/2018 2:28:22 PM

Here is an issues that deserves us GPs to stand together and bill for our expertise. If the national average for consultations at an MBS item number 36 is ntionally elevated, the usual fear of auditing is removed. It is all about moving the Bell Curve of the average number of 36s a GP bills to a higher number to reflect the complexities of our "bread and butter" consultations nowdays.
I am not advocating fraudulent claiming but we do need to put our money where our mouths are and act.
I understand the Commonwealth's reasons for bundle payments. It is to cap Primary Care Spending where possible and slowly pull back the reigns to make it substantially more difficult to Practices to hit Chronic Disease targets.


Charlene Chideme (nee Kembo)   1/03/2018 7:49:03 PM

Thank you for this well written and dead accurate article. Balancing time spent and quality of the consultation remain an ever present and daily dilemma for GP's not just in Australia but around the world. It's hard to strike a balance it seems. Medicare has done well by recognising that Mental health consultations need to be billed differently, certainly that should also be applied like you rightly say to patients with chronic and complex co-morbidities. I believe that one day, we shall get the balance right and give our patients the very best care that we yearn to.


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