RACGP expands e-health focus in new Standards for general practice
The Royal Australian College of General Practitioners launched their 4th edition Standards for general practice at the GP10 conference in Cairns in early October.
According to the RACGP, the process of developing the 4th edition of the Standards was aided by a separate e-health standards working group that reviewed all the standards and their alignment with national e-health initiatives, such as patient, provider and organisation healthcare identifiers, and electronic health records.
The working group comprised of the RACGP e-health working group members and NEHTA clinical leads, a group of over 50 clinicians engaged by NEHTA to sell the organisation’s vision for e-health to their colleagues and the wider community.
In a statement, NEHTA’s National Clinical Lead Dr Mukesh Haikerwal, said general practice is well positioned to support national e-health initiatives.
“With over 98 percent of GPs using computerised healthcare systems for clinical purposes and, 117.4 million GP consultations provided each year, GPs will be at the forefront of driving e-health in Australia. We know that GPs can provide a GP Health Summary for the vast majority of Australians and this information will form the basis of data for electronic communication between healthcare providers and will be a key component for electronic health records,” said Dr Haikerwal.
In the preface to the Standards, the RACGP highlights criterion 1.7.1 (Patient health records), criterion 1.7.2 (Health summaries), criterion 3.1.4 (Patient identification) as containing e-health related material, however other sections of the document including criterion 1.5.3 (System for follow up of tests and results) and criterion 1.6.2 (Referral documents) make specific references to practice software and electronic referrals.
Criterion 1.7.1 (Patient health records) requires that each patient attending the practice has their own health record, and that practices using both paper and electronic health record systems indicate in each record where clinical notes are recorded to ensure entries are not overlooked. Active patient records need to include multiple pieces of demographic information, including the patient’s full name, date of birth, gender, and contact details. It is understood that the accuracy of such details will be important when the Healthcare Identifier service is usable, as such details will be needed to import patient Healthcare Identifiers into clinical software. Criterion 1.7.1 also encourages practices to record the contact details of the person a patient wishes the practice to contact in the case of an emergency. It also instructs practices to record the details of their patients’ cultural backgrounds.
Criterion 1.7.2 (Health summaries) sets targets for the recording of allergies, adverse drug reactions, current medicines, current health problems, relevant past health history, health risk factors, immunisations, relevant family history and relevant social history including cultural background. This criterion also requires practices to document the “standardised clinical terminology (such as coding) which the practice team uses to enable data collection for review of clinical practice.”
As was the case with the previous edition of the Standards, much of the computer-related technical detail practices need to be mindful of has been omitted from the Standards document. However a separate document, the RACGP Computer security guidelines — itself recently updated — has been released as an accompaniment to the Standards.
Posted in Australian eHealth