Bundaberg GP Patrick Byrnes is gearing up to launch his new Patient Assistance Tool (PAT) for chronic disease management in July.
PAT, which Dr Byrnes has developed with software engineers from Bundaberg-based clinical software company Best Practice, has been designed to generate general practice management plans (GPMPs) and to provide ongoing education to both patients and doctors, particularly registrars.
PAT is a step by step approach to chronic disease management and contains a number of “clinics” covering the most common chronic diseases such as asthma, arthritis, atrial fibrillation, coronary heart disease, cerebrovascular disease, COPD, diabetes, chronic heart failure, chronic kidney disease, hypertension, osteoporosis and peripheral vascular disease.
PAT is installed on the practice server and on any client workstation, including on touchscreen tablet PCs, Dr Byrnes said. “The touchscreen is ideal for patients to use in the waiting room. The long-term plan is that we can tell motivated patients that they are due for a clinic but if you want to save yourself time, log on and do your patient section at home.”
The 'Nurse' section is the first step in the tool and is a checklist approach for measurements and ECGs, which then leads into a ‘coaching’ role to start the patient using the tablet. The 'Patient' section allows questions normally asked by the nurse to be completed by the patient, with the questions triggering appropriate educational information.
The process then continues in the consulting room where the 'Doctor' section of PAT is installed on the doctor's desktop, with a click option instead of touch. The doctor goes through a series of screens to input further data, and at the end PAT automatically generates a general practice management plan specifically determined by the patient's and the doctor's answers.
Dr Byrnes said he had taken a different approach from other chronic disease management tools such as cdmNet, which starts with computer extraction of data into a provisional GPMP which has to be edited. PAT, on the other hand, uses a gradual, build up approach for the GPMP.
Dr Byrnes said his team had devised a number of interviewing wizards for the tool based on a mixture of cognitive behavioural therapy and motivational interviewing. The tool interviews the patient about their smoking or exercise habits, for example, before they even see the doctor. This information is summarised in the GPMP as well.
“It is called Patient Assistance Tool because it actually starts with the patient,” Dr Byrnes said. “The patient is personally involved. cdmNet does the patient education after the GPMP is edited with your patient education online. PAT does the patient education in small bites on each screen before they see the doctor.
“As well, there are extra education and interviewing screens at the end of the patient section that will be triggered if required. So if they don't need education on diet they won't get it. If they do need education on diet they get that before they come to the doctor.
“The clinics are exportable and importable in XML because we have a blank template option so you can design your own clinic, for example men’s health, and export it to other interested practices. We have designed it so you can extract data for your optional performance indicators.”
PAT allows multiple clinics to run at the same time with multiple patients, the only limit being the number of touchscreens, a technology that is particularly useful for elderly people. Dr Byrnes actually got the idea when he was waiting at an airport and noticed elderly people who seemed quite content to check in using touchscreens, and for those who were unsure there were designated assistants to help them.
“Some of the American literature shows that many older people cope well with touchscreens if they are coached, and [with PAT] the nurse coaches them through the first five screens. We say, 'this is how it goes, it is actually pretty simple technology and if you feel confident you can now carry on'.
“You are going to get 10 or 15 per cent of people who can't do it because of health literacy problems but all you have to do is read the screens to them. It is designed to reduce the repetitive load on nurses in chronic disease management and to conserve labour costs for CDM.”
While patient-friendliness is important, the actual driving force behind the development of the tool is Dr Byrnes' years of educating new doctors. He is a full-time GP, a senior lecturer at the University of Queensland's rural clinical school, and has for many years trained registrars. He estimates he is currently training his 35th registrar in his Bundaberg practice.
“Every six months we get a new registrar, so I am constantly reminded of how difficult it is for new doctors to approach a complex area like chronic disease management. My background is heavily in educating the next generation of doctors and that is really where this program comes from. It comes from sound educational principles and is designed upwards rather than just being a theory that this should work.”
He said other applications such as cdmNet can prove a bit daunting for young doctors, who can often get overwhelmed by chronic disease. “What my program does is it takes the doctor one step at a time. For example, for blood pressure, it gives you the National Heart Foundation levels, and then there is a quote from a recent study which says 'if you see people and escalate treatment you will get control'. So it tells the doctors what they should be doing, they can say yes or no, and then that goes into the GP management plan.
“Then the next screen will be cholesterol and then the next perhaps calculate their absolute cardiovascular disease risk – it is just one simple task after another that has just enough information on that screen for them to deal with. They are building up the GPMP in layers.
“The PAT GPMP is generated because they have actually done all of the checking, they have gone through it step by step, and anything that is within normal limits, PAT will just leave it out of the GPMP. Because really, there is no point in telling patients to exercise and eat correctly if they are already doing that.”
PAT also provides an audit trail in case Medicare asks questions about the GPMP, he said. “Every single question has a unique number and it keeps a record of every single question you have asked and what the response was. So if you get an audit from the health department you can show them the patient did 35 questions and I did 45. I might have created a GP management plan with only five things in it but I have actually checked all of these.”
The program is Windows-based and has been designed to be integrated with common GP clinical software. It has been trialled with Best Practice users because of the close links between Dr Byrnes and Best Practice's founder Frank Pyefinch, but all were keen to ensure it could easily be used with a wide range of products such as Medical Director and practiX.
“We have built it to interface with any Windows-based SQL program. It has a very simple connection – just the right person, date of birth, Medicare number. Then you just alt-tab the screens between PAT and the clinical package you are running. Some modern computers have two screens and that's the ideal way to do it. You have a PAT checklist screen on one side and you are entering the data in your main program.”
The PAT might also make using the PCEHR simpler as it contains an optional patient consent screen at the end of the patient section which asks “Do you want this practice to be the practice responsible for uploading your PCEHR summary?”
“Then the very first doctor's screen says, 'Clean your data, look at their past history, look at all of their current medical problems, check their medication',” Dr Byrnes said. “You have to do this to be able to complete the PAT doctor section correctly anyway, so you end up with an uploadable health summary. It is future-proofed that way.”
PAT will be officially launched in July this year with Best Practice marketing it as a separate product under licence from Dr Byrnes’s company Ageana, which owns PAT.