Identification of features of electronic prescribing systems to support quality and safety in primary care using a modified Delphi process.

BACKGROUND: Electronic prescribing is increasingly being used in primary care and in hospitals. Studies on the effects of e-prescribing systems have found evidence for both benefit and harm. The aim of this study was to identify features of e-prescribing software systems that support patient safety and quality of care and that are useful to the clinician and the patient, with a focus on improving the quality use of medicines. METHODS: Software features were identified by a literature review, key informants and an expert group. A modified Delphi process was used with a 12-member multidisciplinary expert group to reach consensus on the expected impact of the features in four domains: patient safety, quality of care, usefulness to the clinician and usefulness to the patient. The setting was electronic prescribing in general practice in Australia. RESULTS: A list of 114 software features was developed. Most of the features relate to the recording and use of patient data, the medication selection process, prescribing decision support, monitoring drug therapy and clinical reports. The expert group rated 78 of the features (68%) as likely to have a high positive impact in at least one domain, 36 features (32%) as medium impact, and none as low or negative impact. Twenty seven features were rated as high positive impact across 3 or 4 domains including patient safety and quality of care. Ten features were considered "aspirational" because of a lack of agreed standards and/or suitable knowledge bases. CONCLUSIONS: This study defines features of e-prescribing software systems that are expected to support safety and quality, especially in relation to prescribing and use of medicines in general practice. The features could be used to develop software standards, and could be adapted if necessary for use in other settings and countries.

Developing the guidelines for preventive care - two decades of experience.

BACKGROUND: The Royal Australian College of General Practitioners Guidelines for preventive activities in general practice (the 'red book') are now more than 20 years old. Therefore it is an important juncture to reflect on their appropriateness and implementation, and how they can be improved in future editions. OBJECTIVE: This review analyses the guidelines and their development against criteria identified by the AGREE collaboration to ensure the quality and applicability for use in Australian general practice. DISCUSSION: The 'red book' is widely accepted as supporting the provision of preventive care and is now a key element of the quality system in Australian general practice. This independent guideline has rigor, relevance and applicability to general practice. However, its impact on practice could be improved by broader consultation and by using a wider range of means for dissemination and implementation. This needs to be informed by more rigorous evaluation of its implementation and impact on practice.

Health inequalities, physician citizens and professional medical associations: an Australian case study.

BACKGROUND: As socioeconomic health inequalities persist and widen, the health effects of adversity are a constant presence in the daily work of physicians. Gruen and colleagues suggest that, in responding to important population health issues such as this, defining those areas of professional obligation in contrast to professional aspiration should be on the basis of evidence and feasibility. Drawing this line between obligation and aspiration is a part of the work of professional medical colleges and associations, and in doing so they must respond to members as well as a range of other interest groups. Our aim was to explore the usefulness of Gruen's model of physician responsibility in defining how professional medical colleges and associations should lead the profession in responding to socioeconomic health inequalities. METHODS: We report a case study of how the Royal Australian College of General Practitioners is responding to the issue of health inequalities through its work. We undertook a consultation (80 interviews with stakeholders internal and external to the College and two focus groups with general practitioners) and program and policy review of core programs of College interest and responsibility: general practitioner training and setting of practice standards, as well as its work in public advocacy. RESULTS: Some strategies within each of these College program areas were seen as legitimate professional obligations in responding to socioeconomic health inequality. However, other strategies, while potentially professional obligations within Gruen's model, were nevertheless contested. The key difference between these lay in different moral orientations. Actions where agreement existed were based on an ethos of care and compassion. Actions that were contested were based on an ethos of justice and human rights. CONCLUSION: Colleges and professional medical associations have a role in explicitly leading a debate about values, engaging both external stakeholder and practicing member constituencies. This is an important and necessary step in defining an agreed role for the profession in addressing health inequalities.

The educational needs of nurses working in Australian general practices.

OBJECTIVE: To describe the educational needs of nurses working in general medical practice in Australia. DESIGN: Survey research combining qualitative and quantitative data collected via telephone interview. SUBJECTS: 222 enrolled (RN Division 2 in Victoria) and registered nurses (RN Division 1 in Victoria) working in general practice in rural and urban areas of Australia. RESULTS: Nurses identified a number of educational areas of high importance including communication skills (94.1%); infection control (93.7%); confidentiality and national privacy legislation (93.7%); legal and ethical issues (91.9%); first aid and CPR (91.4%); wound (91.0%); care cold chain monitoring (90.0%); sterilisation (90.0%); and triage (90%). Barriers to education were identified including lack of time due to work (21.9%); costs of courses (17.3%); distance to education (13.9%); and lack of time due to family commitments (13.1%). More rural/remote nurses identified distance as a barrier (20.5%) than urban nurses (3.6%). DISCUSSION: cussion: The education areas that were rated as important by a high number of the nurses appeared to relate directly to the activities nurses currently undertake in Australian general practice. Barriers to education may reflect the workforce characteristics of general practice nurses and/or the capacity of general practices to finance training for employees. CONCLUSIONS: As a growing specialty of nursing in Australia, general practice nursing should be supported by a solid foundation of ongoing education and training that is tailored to the current needs of nursing in general practices and reflects appropriate delivery options to overcome barriers to training.

A quality framework for Australian general practice.

BACKGROUND: Quality improvement in health care is a priority. After more than a decade of strategic change in Australian general practice, The Royal Australian College of General Practitioners has developed a conceptual framework for quality improvement. OBJECTIVE: This article provides details of the process that led to the forming of the Quality Framework for Australian General Practice. DISCUSSION: Quality has dimensions of acceptability, accessibility, appropriateness, effectiveness, efficiency and safety. Domains of professionalism, competence, patient focus, capacity, knowledge and information management, and financing merit consideration at the level of the individual consultation, within the setting of care, and at regional and national levels when designing quality improvement efforts. A quality framework can be used to plan or evaluate quality initiatives, map the current scene, clarify roles and responsibilities and to stimulate broader thinking about quality in general practice.

Capacity and the quality framework.

BACKGROUND: The quality framework developed by The Royal Australian College of General Practitioners is described by Booth in this issue of Australian Family Physician. This article applies the framework to the 'capacity' domain. OBJECTIVE: ThIS article considers both individual and systems approaches to capacity. It focuses on practice capacity and lessons that emerge from general practitioners working with complex and marginalised patient groups. DISCUSSION: The framework provides a mechanism for assessing policy and implementation initiatives in an Australian context that takes account of the realities of clinical practice.

General practice nursing education in Australia.

The quality of care delivered by nurses working in Australian general practices rests on a strong foundation of nursing educatlon and training. A national study of nurses working in general practice was conducted using qualitative and quantitative research techniques to explore their role and educational needs. Results from this research suggest that education for general practice nurses is seen by nurses and General Practitioners to be largely non-formal in nature and is seen by GPs and nurses to be tailored towards general practice nursing needs. Such education is often available locally through general practice support organisations; is strongly focused on National Health Priority Areas and clinical care; and is more appropriate for registered rather than enrolled nurses. The educational opportunities currently available to support nursing in general practice are largely ad hoc and vary in relation to quality, appropriateness and accessibility. Nurses working in general practices in Australia need a system of ongoing training and education to support their responsibilities and foster the development of the position as a viable career option for nurses.

The changing face of nurses in Australian general practice.

OBJECTIVE: To describe the workforce characteristics and current responsibilities of nurses working in Australian general practice settings. DESIGN: Survey research combining qualitative and quantitative data collected through telephone interview. SUBJECTS: 222 enrolled (RN Division 2 in Victoria) and registered nurses (RN Division 1 in Victoria) working in general practice in rural and urban areas of Australia. RESULTS: General practice nurses in Australia are likely to be RNs (84.7%) who work on a part-time basis (75.3%) in a medium to large practice (93.7%). Often the nurse has worked less than five full time equivalent years (52.3%) in a general practice environment and is likely to work in a practice where at least one other nurse works (64.4%). The nurse is likely to have some post-basic formal education (65.9%), and to have participated in professional development in the past two years (94.9%). The nurse performs a diverse range of activities within the general practice. No substantial differences were found in the workforce characteristics or role of urban and rural general practice nurses. CONCLUSION: It appears that nurses working in general practice are no longer the 'handmaiden' to the doctor but are professionals who perform a vast range of clinical, administrative and organisational responsibilities within the general practice primary health care setting.