 The magazine of the Melbourne PC User Group Computerised Quackery - General Practice and IT David Ringelblum doodie@melbpc.org.au |
If you have visited your doctor in the past year, chances are that they have
a new piece of medical equipment on their desk - a computer. Through a combination carrot and stick approach
the Federal Government has been pushing the medical profession -which traditionally has been reluctant to
embrace change - into adopting information technology for both clinical and business applications.
The biggest incentive to doctors came last year with a payment of up to $7,500 for doctors to throw away
their script pads and take up computer prescribing. The incentive seems to have worked, for up to 60% of GPs
now use computer generated scripts compared with 5% five years ago. Specialists still lag far behind.
The dominant software package in this quantum shift is an Australian designed program called Medical Director
(MD) which holds over 90% of the market. Medical Director was designed in 1990 by a Queensland GP, Frank
Pyfinch with additional development by a Melbourne GP, Andrew Magennis.
In 1999 MD was bought by Health Communications Network (HCN) which subsequently listed on the Australian
Stock Exchange, and the product remains the cornerstone of that company's drive to be the leader in health
knowledge resources in Australia.
MD comes in two flavours - version 1.84 which is essentially a prescription writing program with extra bells
and whistles, and version 2 which is a fully-fledged clinical records system that replaces all paper based
recording of patient notes, test results, correspondence etc. The script writing module remains the keystone
of the system but many doctors are now tasting the potential of paperless medical records. Product
development of MD 1.84 has now ceased (though it is still supported) and since MD2 incorporates all the
features of the older program, as well as many new ones, it is the version described here.
Program Design
When a patient's record is called up in the program, a multi-tabbed screen appears (see Figure 1). The top
half of the screen provides most of the patients basic demographic data - name, age, address, pension status
and some essential medical information including smoking status, drug allergies and a reminder to the doctor
whether the patient is pregnant, breastfeeding, an elite level athlete and so on.
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The bottom half of the screen consists of a multi-tabbed
document. The first of these is a summary of most of the other pages and displays a few lines of the patients
social history and family medical history; their past problems, current scripts, immunisations and a window
that reminds the doctor which preventative health measures should be considered for this patient. The latter
window is a nagging reminder to the doctor as to when they last measured the patient's height, weight, blood
pressure, performed a Pap smear, gave a flu shot and so on. Some of these also flash up as soon as a
patient's file is opened. Whilst these features can be turned off by the doctor, they are a valuable aid to
optimising a patient's long-term health, by addressing issues which are often put aside in the urgency of
dealing with the presenting problem.
The second tab is the patients current drug list, and in this MD excels over the old paper based summary
where drugs were scratched on and off as medication changed till it became almost impossible to be sure what
the current treatments were.
When a new prescription is written, MD immediately checks to see whether the patient is allergic to that
drug, whether it will interact with any other medication they are on and whether they have any medical
conditions that may respond badly to that medication. For example a patient with an ulcer shouldn't normally
receive aspirin and MD will flag the doctor and ask if they really want to proceed.
Whilst the program has limited capacity to detect all drug-disease interactions, in the area of drug-drug
interactions it excels. Up to 10% of hospital admissions are due to adverse drug effects. When some patients
take up to 15 different medications a day, it is nearly impossible for a GP to be aware of all the potential
interactions, especially with new drugs being released on the market monthly. MD is not foolproof, but most
users will attest to having been given a gentle reminder that they are entering tiger country.
The next tab is the nerve centre of the new MD program and incorporates the progress notes made by the doctor
at each visit. (see Figure 2). The right side has a window detailing a list of previous visits by date with a
one or two word description of each one. The lower right window contains the notes of the visit highlighted
above. A double click brings up all the details. There is also a search function to assist the doctor when a
patient comes in and says "You remember that rash I happened to mention about a year ago".
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The left side of the progress notes screen allows the doctor to
freely type notes on history, examination, diagnosis, treatment and review plan for the current visit.
However to encourage doctors who are not typists to use the program, a series of buttons for each of these
areas brings up a succession of multi-tabbed windows (Figure 3) which allow the doctor to just check-box the
common symptoms and signs associated with the major body systems. Whilst not exhaustive, the options offered
are pretty comprehensive, and a slow typist would only have to add a few extra words of text after having
clicked his or her way through the list. Indeed, most doctors find their medical notes are far more
comprehensive than they used to be when hand written - an important issue in an era when too many lawyers
practice medicine.
To ease things further, most diagnoses can be chosen from a drop down pick list, and the choice of drug
therapy works the same way with every form and strength of drug being given a separate line. A script such as
"Penicillin 500 mg, 4 times a day, with meals, 50 tablets, 1 repeat" can be generated with no typing at all -
just 4 clicks and a mouse drag. Generating repeat scripts for current medications is even quicker - a single
click and press print. This feature more than any other has endeared the package to most doctors who no
longer feel their heart sink when a patient comes in requesting repeats on 7 of their 10 drugs. Within 15
seconds the scripts are done and the consultation can turn to more important issues.
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The subsequent tabs on the main MD window allow the doctor to
examine and add notes to the patients past history, their immunisations, any letters they have written about
the patient, a list of previously written scripts, and for females of the appropriate age a Pap smear
register and obstetric history window. Letters received from specialists can also be scanned into the
program.
MD also allows direct importation of patients pathology and x-ray results.
If the tests are actually ordered through MD itself, it keeps a register of investigations still outstanding
which allows the doctor to chase up patient's who may have neglected to carry out important tests.
MD also boasts a host of other useful features, including detailed drug information available just by
pressing the F12 key. This means that all the official drug information can be found readily and accurately.
Most users testify to looking up information far more often than they used to, and this can also only be to
the patient's welfare. Doctors also have easy access to a wide range of up-to-date medical information built
into the program and a portal into HCNs vast array of online medical resources.
Deficiencies
MD still has a number of shortcomings. The information a doctor gets out of their notes - paper or electronic
- is only as good as the care with which they maintain them. MD can't force good record or summary keeping,
though it does make the job easier - if the doctor is committed to learning and using the package.
Unfortunately in a group practice, not all doctors may be equally keen, and the stragglers can badly affect
the value of the system for everyone.
The program has an extensive but deficient recall system, to allow patients to be contacted about routine
follow-up like Pap smears and immunisations. This aspect of the program is actually quite poorly written,
though there is the intention to improve it in forthcoming versions. The handling of abnormal test results
also needs improving.
Another annoying failure of the package is the inability for the doctor to create short-term reminders for
themselves. Consider a patient with a moderately high blood pressure noted for the first time. In a paper
based system the doctor will just underline the result and this will remind them to recheck next time.
Similarly if the patient mentions an issue in passing that needs follow up, but isn't to be dealt with at
that visit. MD lacks the capacity to mark such issues for followup in a seamless manner. What is really
needed is an inbuilt equivalent of a sticky note to remind the doctor of important issues to follow up at
subsequent visits.
There is no doubt that MD is here to stay and almost certainly will continue to dominate the market. It is
well written and the company is reasonably responsive to the requests of doctor users. The program is
incredibly cheap - $200 per year per practice regardless of the number of users, and that includes four
upgrades per year (necessary because the details of the government drug lists change that frequently). MD has
a help desk that is the model for every other software company - friendly, accurate and helpful; completely
free and though based in Queensland, available on a 1800 number. A rumoured $5 million dollars a year in
advertising paid by pharmaceutical companies probably explains this. In return the companies get their
product ads flashed up on the screen every time the doctor prints off a script. Whether such advertising is
to the patient's benefit is another question the profession has grappled with for years.
The package is password protected so medical records are at least as secure as their handwritten equivalents.
Nevertheless data corruption is always a possibility, and with it the loss of medical history. All doctors
backup their data - but do they do it as well as they should?
Benefits to Patients
It can be hoped that MD will lead to medical records being a little better organised than they often have
been in the past. There is no doubt that this aspect of medical care makes a big difference to good outcomes
over the long term - particularly in patients with multiple illnesses and drugs.
MD is very good at picking up and preventing some basic medical mistakes and allowing the dedicated doctor to
delve more deeply into the exponentially growing knowledge base of modern medicine in ways that paper-based
doctoring does not allow. And if, as is hoped, the program saves doctors a bit of time, then more effort can
be made in addressing preventative health issues and long-term medical goals.
It has been a long time coming but doctors are rapidly taking up IT in medicine. When MD is finally able to
generate notes and prescriptions that are as illegible as doctor's handwriting, we will know that the era of
medical computing has arrived.
About the Author:
David Ringelblum (doodie@melbpc.org.au) is a Melb PC member and a
GP in Rowville.
Reprinted from the November 2000 issue of PC Update, the
magazine of Melbourne PC User Group, Australia
