INTEGRATION PROJECT
Paper No. 2
August 1999

Minimum Requirements for the Transfer of Information between hospitals and GPs

The purpose of this paper is to establish a set of minimum requirements for the transfer of admission and discharge notification between hospitals and GPs. The requirements were initially developed after consultation with Divisions and hospitals throughout Victoria. The consultation formed part of the statewide audit of current practice that included 31 Divisions and 36 hospitals. (See Integration Project paper No 1).  Input to the first version was also received from the Integration Project Reference Group that met on 24 March 1999. (A list of members is attached in Appendix 1). The first version was then circulated in April to 31 divisions throughout Victoria for comment by their members. Many comments were received from divisions. The Reference Group discussed divisions’ comments on 16 June 1999 and made suggestions for the final minimum requirements.  The paper in its present form is the result of this extensive consultation.

The aim of developing minimum requirements is to encourage practices and procedures that will provide for the effective and efficient transfer of patient information.  The patient is seen as the ultimate beneficiary of improved communication.

Requirement 1. Participation by GPs

GPs through Divisions participate in the planning and implementation of admission and discharge notification specifications in hospitals.

This requirement relates to the participation of GPs in the design of notification specifications in hospitals. Currently, GPs participate in hospitals in a number of different ways. For example, Mornington Peninsula (Frankston Hospital) has a high level of participation by GPs with a hospital department known as the Division of General Practice. 35 GPs with admitting rights participate in teaching, supervision, clinical rounds, and have resident staff allocated to them. GPs also have a strong presence in West Gippsland Hospital where they manage Hospital in the Home and pre-admission and are represented on a number of hospital committees. Several other hospitals include GPs on their medical staff meetings, quality committees and/or unit meetings. Some, like Latrobe Regional Hospital, have minimal participation by GPs at present although plans are afoot to increase participation.

Each hospital is unique in the services it provides. Hospitals provide different services to different populations and depending on the hospital’s services, the information transferred to GPs changes. Also, hospitals and GPs have different capacities for the transmission and receipt of information. Hospitals need to find out from GPs the type of information they require and the most appropriate method of transferring the information according to each hospital. This process is often facilitated when GPs participate in other facets of hospital operations.

Each Division’s support of participation by GPs is important. If Divisions assist hospitals by nominating GPs with an interest in hospital liaison, Divisions become the first point of contact for hospitals and are able to provide continuity. The GPs participating in hospital liaison then become representative of other GPs rather than operating as individuals.

Requirement 2. Timeliness of information transfer

Admission and/or discharge notification is sent by hospitals on the day of admission or the day of discharge. If the transmission of information is impossible on weekends due to the closure of GPs’ practices, then the information is sent on the next working day.

The timeliness of the transfer of information affects its value to GPs. For example, the Mercy Hospital provides a computer generated discharge summary but the GPs’ copy is sent with the patient, so the GP receives the information when the patient presents for her next appointment. GPs report that they would prefer to receive the information prior to the patient’s visit. Ballarat Hospital manually faxes discharge summaries and a copy of the treating doctor’s notes to GPs. This system provides the GP with timely and accurate information. (Legibility of information is addressed as a separate item in Requirement 6).

In order for patients to benefit from admission and discharge notification and for hospitals to provide continuity of care, notification should be sent either on the day of admission or the day of discharge.

It should be noted that, in some cases, weekend transmission of information occasionally presents a problem for GPs. The Reference Group discussed the option of the Division providing weekend backup if faxes were not able to be delivered at weekends due to the GP’s fax machine being turned off. The suggestion was that direct communication between the GP and the hospital was preferable and that hospitals should send information on the next working day if the fax was not delivered.

Requirement 3. Criterion for notification

Hospitals notify all admissions, discharges and deaths. Same day procedures are notified by either admission or discharge except on-going routine procedures such as dialysis and chemotherapy that are notified at the start of the course of treatment.

Hospitals differ in their policy relating to when they notify admission and discharge. The Northern Hospital notifies admission and discharge for all patients who stay longer than 1 day. Other hospitals send discharge notification for patients who stay longer than 3 days. However, these practices are not suited to all hospitals. For example, the Eye and Ear Hospital has an average length of stay of just over one day. Guided by the clinical requirements of patients, the hospital provides discharge summaries for all patients including same day procedure patients and the majority of outpatients. Most hospitals notify either admissions or discharges rather than both. Southern Healthcare Network notifies admissions, transfers and deaths. GPs would prefer to receive notification of both admissions and discharges except same day procedures where either admission or discharge notification is sufficient.

There was discussion at the Reference Group about the merit of admission and discharge notification being determined by the clinical status of patients rather than the length of stay. The Reference Group was concerned that hospitals may be deterred from notifying GPs if the criteria were too complicated. On the other hand, routine notification of all patients’ admissions and/or discharges including procedures such as dialysis and chemotherapy becomes a burden for GPs. Instead of notification of each routine treatment, GPs would like hospitals to indicate the course of treatment that is planned for the patient.

Requirement 4. Content of notification

The admission and discharge notification contains information as listed below:

The inability to provide all the information listed above should not prevent notification from proceeding.

Currently, hospitals provide different amounts of information. The combinations include admission, discharge, transfers and death, as well as discharge summaries, notification of outpatient’s attendance, emergency department attendance and pathology results. Southern Healthcare Network notifies admission, deaths and transfers. The Austin and Repatriation Medical Centre (ARMC) is conducting a trial of the electronic notification of discharge summaries for renal patients with information collected from pathology, radiology, operating theatres, admissions and the wards. Other hospitals, such as Frankston, notify admission, discharge, transfers and deaths.

Another inclusion is investigations. Pathology results are an area of rapid change for GPs. Some GPs with computerised practices receive pathology results electronically and forward these results to specialists with their letter of referral. Some hospitals such as ARMC are trialing the email of pathology results to GPs with discharge summaries and other hospitals are investigating GP access to electronic patient records to view pathology results on a web browser. Peter MacCallum is currently conducting a trial of electronic patient records with a small number of GP practices from Central Bayside and Mornington Divisions.

This requirement provides the content of notification of admission or discharge as determined by divisions and the Integration Reference Group. It should be noted that the inability on the part of hospitals to provide all the information should not deter them from proceeding with routine notification.

Requirement 5. Method of transfer of information

The method of transfer of admission and discharge notification is chosen according to the GP’s capacity to receive information and according to the urgency of the patient’s needs.

The variety of methods for the transfer of information between hospitals and GPs are e-mail, automatic faxing, manual faxing, mail delivery, patient delivery, pigeonhole and telephone. Telephone contact is usually only used in cases of urgency. The other methods have varying degrees of reliability and usefulness. In rural hospitals where GPs are the admitting officers and visit the hospital every day, patient notification delivered to a pigeon hole located in the hospital proves to be a reliable method. In metropolitan hospitals, trials of notification have involved e-mail delivery and automatic faxing. These methods have provided timely notification. Tertiary hospitals that have trialed and/or implemented automated notification include Alfred, Austin Repatriation Medical Centre, Southern Healthcare Network, Geelong, Peter MacCallum, St Vincent’s and Western.

It is important that both GPs and hospitals are flexible about the method of transfer of information. For example, in cases where GPs need to be informed of a medical emergency, hospitals will often telephone GPs. In other cases, hospitals will select the most appropriate method of notification according to the hospital and GP’s capacity: either e-mail, fax, pigeon hole or mail delivery.

Requirement 6. Legibility of notification

Hospitals provide information that is legible.

Many hospitals send GPs the third copy of a handwritten discharge summary. GPs have commented on the illegibility of the copy. Either computer generated or type written notification is preferable.

Requirement 7. Privacy and confidentiality

The patient information transferred from GP to hospital and vice versa complies with the AS 4400 – 1995 Personal Privacy Protection in Health Care Information Systems standards.

There are a number of considerations in the transfer, storage and use of confidential information from hospital to GP and vice versa. One consideration is protection against unauthorised access to electronic information while gathered, stored, transmitted and used. Southern Healthcare Network implemented a protection mechanism against unauthorised access when it faxed all GPs on its database to verify fax numbers.

Australian standards that relate to the transfer of health information are the AS 4400 – 1995 Personal Privacy Protection in Health Care Information Systems. These standards relate to all aspects of information gathering, storage, disclosure, use, verification and correction. A copy of the standards is available from Australian Standards, phone 9693 3500.

To provide the necessary safeguards, GP practices may also wish to draw up and implement an information policy for their practice. The Royal Australian College of General Practitioners has published a Code of Practice for the management of health information . It includes procedures for gathering and storing personal health information and securing against loss or alteration of data.

Another consideration is the implementation of some form of notation of patient consent to disclosure of personal health information and any restrictions to this consent.

Requirement 8. Patient’s consent

Patient’s consent for the transfer of information is obtained at each admission by the hospital prior to transfer of information proceeding.

Hospitals employ different methods to obtain consent to transfer information from hospital to GP. Some provide the patient with a consent form to sign; others make verbal requests for consent. The onus rests with the hospital to ensure that the patient consents to the GP being informed.

It is important that hospitals obtain clear consent for the transfer of information and that consent is obtained for every patient admission.

The suggested format for hospitals in obtaining consent from patients is to ask the patient ‘Which GP would you like to be notified regarding this admission?’ The GP’s name is then selected from the database and is recorded on the patient record.

Requirement 9. Obtaining details of the patient’s GP

Hospitals ensure that GP contact details are obtained from the patient in a manner that is least disruptive to the patient and according to hospital procedures.

The usual method of obtaining details of the patient’s GP is by asking the patient directly. With many hospitals providing pre-admission planning for elective surgery, this can occur prior to the admission. With emergency patients, the emergency department clerk is often responsible for obtaining GP contact details.

Western Division of General Practice employs a different approach and provides GPs with a card for patients’ use that includes details of the patient’s nominated GP for use when the patient is admitted to hospital. It is reported that this system works well with the division’s GPs. It is not a system recommended for hospitals with a statewide catchment due to the need for accuracy and currency for routine notification. Divisions would need to provide new business cards each time a GP changed his/her address.

APPENDIX 1

Integration Project Reference Group