Reports from the frontline indicate that well-intentioned GPs are drowning in a sea of double handling and mismatched records when it comes to providing medical care to residents of aged care facilities. Many GPs working in this space feel the system is broken and not conducive to providing the best care. Research confirms their concerns, with an Australian study lead by Sydney GP Professor Meredith Makeham, revealing that in more than 95% of cases the details of medications listed in GP practice records don't match those in patients' nursing home medication lists.
The accuracy of medical records becomes even more pertinent when dealing with vulnerable patients, such as those in aged care. The research also demonstrates that some of these medication discrepancies have the potential to cause harmful effects highlighting additional risk to patient safety.
When the left and the right hand can’t talk to each other
Despite their clients being vulnerable, “GPs tend to be an afterthought at aged care facilities,” says Northbridge-based general practitioner, Dr Brian Morton. He goes on to explain that there is a lack of preparation and organisation for visiting medical practitioners, who often struggle to have a private space to examine patients.
However, the biggest struggle is the strain created by the distinct lack of integration between multiple systems.
The charts used in aged-care facilities are designed to last for months and focus on documenting dispensing. While this may be appropriate in hospitals where patients, doctors, nurses and pharmacists are co-located and can use the same chart, it does not work effectively in residential aged-care facilities. The varied locations of these health professionals’ result in notes needing to be copied or shared electronically in order to provide a comprehensive and accurate picture of a patient’s care.
“You physically write in the patient’s notes for the nursing home, which is a separate file. Some nursing homes have electronic software and you write in a shared electronic file what you’ve done and what you’ve prescribed, but there’s no automation or connection between the nursing home’s software and the records management system in the GP’s practice,” says Dr Morton.
The result, he says, is the mismatched records uncovered by the Makeham study. This lack of connectivity has created a wieldy, burdensome system producing inconsistent records and immense duplication. As GPs can see 10 or more patients in an aged care facility per day, they are then left to make their own notes after each consult, before transferring those notes into their own practice records when they return to the office.
A single source of truth
When a medical record does not reflect the true patient status or provide an accurate picture of their medications, patients experience the impact firsthand.
This lack of a single source of truth in medical records for aged care residents undeniably results in poor continuity of care. An emergency department, for example, needs a full picture in order to come to a correct diagnosis. The outcomes for the patient are infinitely better if you can add a more detailed history, says Dr Morton.
“A classic example is a patient who recently started trialling psychotropic medication after being violent to other patients and staff. If they are transferred to hospital without this information, hospital staff are at risk. The patient also often returns with a discharge letter indicating they have Parkinsonian symptoms, when these were potentially a side effect of their psychotropic medication and the underlying issue has in fact been missed.”
Conceivably, patients from residential aged care facilities may not also be able to provide accurate information on what medications they are currently taking due to age, dementia or serious illness. “I have found that the impact of this can be minimised if their doctor directly requests that the aged care facility sends an accurate copy of the medication chart directly to the hospital,” says Dr Morton.
The longer-term issue
While patient safety and continuity of care are at the centre of short-term concerns, Dr Morton remains concerned about the lack of medical support for aged care facility residents in the longer term.
“The lack of integration between the systems and the need to duplicate records is impacting GPs in such a way that fewer and fewer doctors are visiting, despite a greater and greater need for medical support,” says Dr Morton.
While acknowledging sharing notes with residential aged care facilities is challenging, communication between the GP and facility is vital to patient safety. Ideally, GPs should have remote access to their practice’s electronic health record to allow them to write notes at the facility directly after they have seen the patient, though at present this is extremely uncommon.
As a practitioner who visits several aged care facilities, Dr Morton recommends the following actions to promote patient safety:
- When you are advised of a patient transfer to hospital and you are not present or when you refer a patient to a specialist, ensure you request that the aged care facility sends a copy of the most recent medication chart to the next practitioner. Include a note in your referral letter that the patient’s medication chart should come with them from the aged care facility.
- If you’re at the aged care facility at the time of transfer, write the referral letter immediately and fax your letter and the medication chart to the hospital simultaneously.
- Make a copy of any referral letters and the patient’s medication chart yourself so you can add it to the patient’s record back at the surgery.
- Be professionally correct when communicating with the next doctor to protect continuity of care, especially when your history is different to that of the nursing staff.