Integrated Analysis of Quality Use of Pathology Program ... · Integrated Analysis of QUPP Final Reports – 22 June 2012 – v0.3 3 Executive Summary The Quality Use of Pathology

Integrated Analysis of Quality Use of Pathology Program (QUPP) Final Reports

A Summary Report for the Australian Department of Health and Ageing

Medical Benefits Division

Canberra 22 June 2012

Cognitus Pty Ltd Jane Carstens

IntegratedAnalysisofQUPPFinalReports–22June2012–v0.3

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Table of Contents

Executive Summary ...................................................................................................... 3 General Findings from the Integrated Analysis ....................................................................................................................................... 4 Consistent Themes Identified from the Integrated Analysis .................................................................................................................. 5 Conclusion .................................................................................................................................................................................................. 6

Abbreviations ................................................................................................................. 8

Introduction .................................................................................................................... 9 Background................................................................................................................................................................................................. 9 Terms of Reference.................................................................................................................................................................................. 10 Structure of the Document ..................................................................................................................................................................... 10

Promoting Evidence-Based Practice ...................................................................... 12 Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................... 14 Revision of Manual of Use and Interpretation of Pathology Tests (2004) .......................................................................................... 17 RCPA Manual Transformation Project (2010) ........................................................................................................................................ 18 An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ............................................................................................................... 20 Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ........................................................................................................................................................................................................ 22 A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................... 25 Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003) ........................................... 27 Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ......................................................................................................................................................................................... 30 A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................................................................................... 34 Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) .................................................................. 35 Common Sense Pathology (2006)........................................................................................................................................................... 38 Common Sense Pathology Publication Series (2011) ............................................................................................................................ 39 Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ........................................................ 40 Structured Pathology Reporting Standards for Cancer (2009) ............................................................................................................. 41 Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ............................................................... 42 Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) .. 43

Risk Minimisation ....................................................................................................... 46 RCPA – Quality Assurance Programs Key Indicator Project (2004) ...................................................................................................... 47 Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ............................. 51 Performance Monitoring of External Quality Assurance (Current) ...................................................................................................... 53 NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................................................................................................................... 54 Key Incident Monitoring & Management Systems (Current) ............................................................................................................... 55

Quality Assurance and Capacity – New Technology ........................................... 59 Virtual Microscope (2005) ....................................................................................................................................................................... 60 High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................................ 61 Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008)................................................................ 62 Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)....................................... 63 Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................................................ 64 PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................................................................................................... 67 Establishment of a Molecular Genetics Quality Assurance Program (Current) .................................................................................. 67 MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ....................................... 68

eHealth Capability ....................................................................................................... 70 Pathology Informatics Working Party (2003)......................................................................................................................................... 71 Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................. 73 Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................................. 74 Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004) ............................................................................................................................................................ 76 Supporting HL7 for Health Informatics Standards (2004) ..................................................................................................................... 77 A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ............................ 78 Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ............................................................................................................................. 82 Padlok On-line Pathology Ordering System (2005) ............................................................................................................................... 83 Information Extraction from Narrative Pathology Reports on Melanoma (2008) .............................................................................. 85


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Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................................................................................................ 87 Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................................. 88 Standardisation of Pathology Terminology and Units (Current) .......................................................................................................... 89

Pathology Requesting and Reporting – Requester and Consumer Focus .... 90 Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ...................................................................................... 92 AUSLAB Retest Interval Trial Project (2003) .......................................................................................................................................... 94 AUSLAB Retest Interval Project (2004) ................................................................................................................................................... 96 Home Monitoring of Warfarin Therapy in Children using the Coaguchek

TM Point of Care INR Monitor (2003) .............................. 98

Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004) ................................... 99 Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ............................................................................................................................................................. 105 Quality Use of Pathology Services Education Program (2006) ........................................................................................................... 109 Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ....................................................... 111 Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) . 113 Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ....................................................................................................................................................................................... 118 Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................................................................................................. 120 The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) .. 123 Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) .................................................................................................................................................................. 124 iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) . 126 iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ......................................... 127 Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011)............................................................................... 128 Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ......................................... 133

Workforce Capacity and Competence ................................................................. 135 PathWay (2005) ..................................................................................................................................................................................... 136 The Australian Pathology Workforce Crisis (2008) .............................................................................................................................. 137 Review of Pathology Specialist Development Pathways (2010) ........................................................................................................ 143 Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................................ 147 Survey of the Pathology Workforce (2011).......................................................................................................................................... 150 Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011) .................................... 153

Consumer Focus and Information Strategies ................................................... 157 Quality Use of Pathology Consumer Consultation Project (2010) ..................................................................................................... 157 Benefits and Risks of Pathology Testing (Current) .............................................................................................................................. 159 Lab Tests Online

AU Stage 1 (Current) .................................................................................................................................................... 160

Access Initiatives – Raising Awareness .............................................................. 164 Optimising Health Benefits for Aboriginal People who take Warfarin (2009) .................................................................................. 164 Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ............................................................................................ 166 Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ............................................. 169

Communication Strategy and Stakeholder Engagement ............................... 171 Report from the National Workshop on Safety and Quality in Pathology (2007) ............................................................................ 172 The Second National Workshop on Safety and Quality in Pathology (2008) .................................................................................... 174 Best Practice in Pathology Requesting and Reporting Workshop (2009) .......................................................................................... 175 Pathology Workforce Workshop (2011)............................................................................................................................................... 177

Appendix A – Report Summaries Relevant to Different Themes................. 181


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Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,including

projectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresentinvestment

andcouldinformthefuturestrategicdirectionoftheprogram.ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:1. PromotingEvidence-BasedPractice2. RiskMinimisation3. QualityAssuranceandCapacity–NewTechnology4. eHealthCapability5. PathologyRequestingandReporting–RequesterandConsumerFocus6. WorkforceCapacityandCompetence7. ConsumerFocusandInformationStrategies8. AccessInitiatives–RaisingAwareness9. CommunicationStrategyandStakeholderEngagement.


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The number of reports within each theme is presented in Figure 1.

Figure 1 – Report numbers by Category

[alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachoftheninethemes’]

General Findings from the Analysis

TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:

Theme Original projects

Follow on initiatives

and projects

PathologyRequestingandReporting–RequesterandConsumerFocus

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PromotingEvidence-BasedPractice 16 10eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology 8 4WorkforceCapacityandCompetence 6 10RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement

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ConsumerFocusandInformationStrategies 3 4AccessInitiatives–RaisingAwareness–2outof3 3 2Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteachtheme,thenthenumberof

followoninitiativesandprojects’]

Pathology Requesting & Reporting –…

Promoting Evidence-Based Practice

eHealth Capability

Quality Assurance and Capacity – New …

Workforce Capacity and Competence

Risk Minimisation

Communication Strategy and Stakeholder…

Consumer Focus and Information Strategies

Access Initiatives – Raising Awareness

0 2 4 6 8 10 12 14 16 18


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Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresultsbeing

uploadedontotheNationalElectronicHealthRecordSystemforconsumers. Standardisedrequestformsandeducationofalllevelsofhealthpractitioners

abouttheimportanceofcompletingtheinformationontheseforms. DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)

regardingevidence-basedpathologyrequesting. Investigateincludingpatient-specificadviceforGPsonpathologytestresults. FocusonincreasingGPs’understandingofthepathologytestingprocess.

Consistent Themes Identified from the Analysis

Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:1. Theneedforincreasedinformationresourcesgeneratedbyreliablesources

aboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.

2. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentoftheirmedicaltraining.


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3. Producingreliableconsumerinformationaboutpathologytesting,and

keepingconsumersinformedaboutcurrentissues/advanceswithinpathology.

Conclusion

TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.


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Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander Medical

Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee


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Introduction

Background

TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.

FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.TheprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedbyDoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.

Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:1. Quality Consumer Services:Todevelopandimproveconsumer-focused,

accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;

2. Quality Referrals (Requesting/Ordering):Tosupportreferralpracticesthatareinformedandfacilitatedbybestpracticeprofessionalrelationshipsandprotocolsbetweenreferrersandproviders;thatareinformedbyevidence;thatmaximisehealthbenefits;andthatinformandengageconsumers;and


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3. Quality Pathology Practice:Tosupportprofessionalpracticestandardsthat

meetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.

Inrecentyearstherehasbeenanincreasingfocusonthefundingofinitiativesaimedatdevelopingandtestingstrategiestominimiseerrorandpromotepatientsafety.ThisworkisrelevanttothestrategicfocusoftheNationalPathologyAccreditationAdvisoryCouncil.FurtherinformationontheQUPPcanbefoundontheDepartmentofHealthandAgeingwebsiteathttp://www.health.gov.au/qupp.

Terms of Reference for the project

DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:

toconductacomprehensivereviewofQUPPprojects/initiativestodateincludingprojectresultsandrecommendations,and

toproduceadocumentthatwillformarecordofpastandpresent

investmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.

TheanalysiswastocovertheQUPPinvestmentthathasoccurredoverthepasttenyearswhichwouldrecordtheinvestmenttodatemadeonthequalityuseofpathology.Itisexpectedthatthisdocumentwouldalsoprovideapotentialbasisforanyfutureevaluationoftheprogram.

Structure of the Report

ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:

1. PromotingEvidence-BasedPractice2. RiskMinimisation3. QualityAssuranceandCapacity–NewTechnology4. eHealthCapability5. PathologyRequestingandReporting–RequesterandConsumerFocus6. WorkforceCapacityandCompetence7. ConsumerFocusandInformationStrategies8. AccessInitiatives–RaisingAwareness9. CommunicationStrategyandStakeholderEngagement.

Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings


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Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see


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Appendix A – Report Summaries Relevant to DifferentThemes.

Promoting Evidence-Based Practice TheQualityUseofPathologyProgram(QUPP)hasinvestigatedwaystopromoteevidence-basedpracticeofpathologythrough16projects(Table2).Whilepathology,byitsnature,isanevidence-baseddiscipline,thequalityuseofpathologyisbestservedwhendiagnosticdecisionsbytreatingpractitionersare


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alsobasedonsoundmedicalevidence.Todevisestrategiestopromotethisoutcome,existingdatabanksofpathologyorderingpatternsandtheirimpactonpatientoutcomesmustbebrokendownandanalysed,theuseoftechnologytosupportbetterdiagnosticoutcomesexploredandtheuseandawarenessofexistingresourcesandbest-practiceevidence-basedinformationtosupportdiagnosticdecisionsmustbemadeavailabletotreatingpractitioners.Medicalschoolsarealsopivotaltoevidence-basedpracticeinpathologyrequestingasnewgenerationsofmedicalpractitionersemergewithmoreinformationandresourcesavailabletoinformtheirpracticethantheirpredecessors.Thiscanalsobeahindrancetotheirpracticeasinformation‘overload’,thelackoftimetoeitheraccessordigestthisinformationandclinicalmentoringbasedonestablishedprotocols(whichmaynolongerbeinformedbybest-practiceevidence)caninfluencediagnosticandpathologyorderingdecisions.Commonissuesidentifiedthroughthisintegratedanalysisincluded: ensuringtreatingpractitionersandmedicalstudentswereawareofexisting

evidence-basedresourcesandwereutilisingthemtotheirfullcapacity incorporatinglaboratorymedicineintothecurriculumofmedicalschoolsina

meaningfulandsustainableway.Basedontheseissues,areasforfutureconsiderationtopromoteevidence-basedpracticefocusprimarilyoninformationdisseminationandstrategiestoincorporatepathologyintothecurriculumandteachingpracticesofmedicalschools.Theyinclude: Deviseastrategyto‘remind’doctorsabouttheexistenceandusefulnessof

theRoyalCollegeofPathologistsofAustralasia(RCPA)Manualatspecifiedtimeintervals.

Developguidelines/protocolsforpathologytestsforcommonconditions. Developaframeworkfordecisionsupportforgeneralpractitioners(GPs)

investigatingtirednessingeneralpracticebasedonelementsidentifiedinAProjecttoExaminetheUtilisationofPathologyTestsintheInvestigationofTirednessinGeneralPractice(2002)onpage25.

Focusonimprovingtheeducationofmedicalstudentsinundergraduatetraininginstitutions(universitiesandteachinghospitals)acrossAustraliainlaboratorymedicine.

Instigateglobalguidancebypathologistsregardingoveralldiagnostictestingstrategies,especiallyforjuniormedicalofficers(JMOs)intheformofclinicalpathwaysand/orviaaconsensualapproachwithinclinicalteamsorunits.

InvestigatetheviabilityofplacingpathologistsinhospitalwardstomentorJMOs.

Investigatetheviabilityofprovidingdetailedauditandfeedbackregardingtest-orderingpractices.

ImprovetheknowledgebaseofJMOsthroughtargetededucation. Developevidence-based,bestpracticeguidelinesfortheappropriateuseof

pathologyforGPs. CommonwealthinvestmentinNationalPrescribingService(NPS)academic

detailingstrategiesfordiagnosticservices.


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Requestereducationanddecisionsupportguidancestatements,especiallyfortheuseofthefullbloodcount(FBC),thyroidfunctiontests(TFT),multibiochemicalanalysisandliverfunctiontestsinmonitoringchronicdisease.

LiaisewithNationalHealthandMedicalResearchCouncil(NHMRC)/guidelinedevelopersregarding:

o addingan‘investigations’sectionintoguidelineso standardisingpathologyterminologyo includingpathologyrepresentationonguidelinedevelopment

workinggroups. Exploretheuseofonlinetoolsfortrainingandsupportofqualitypathology. ExplorehowtheRoyalAustralianCollegeofGeneralPractitioners(RACGP)

andtheRoyalCollegeofPathologistsofAustralasia(RCPA)canworktogethertointegrateandenhancetheutilityofthePathologyDecisionSupportTools(PDSTs)totheclinicalpracticeofrequesterssuchasanaccessiblelinktotheRCPAManualviaGP’sdesktops.

Possibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics

[alt=“ThefollowingtableliststhesixteenprojectnamesandgrantrecipientsunderthePromoting

EvidenceBasedPracticetheme”]

Project Name Grant Recipient/s

1 EvaluationoftheImpactonPathologyPracticeoftheManualofUseandInterpretationofPathologyTests(2001)

HealthcareManagementAdvisors

2

RevisionofManualofUseandInterpretationofPathologyTests(2004)

RoyalCollegeofPathologistsofAustralasia(RCPA)

3

RCPAManualTransformationProject(2010)

RCPA

4 AnHistoricalAnalysisofPathologyOrderingbyGeneralPractitionersbetweenApril1998andMarch2001fromtheBetteringtheEvaluationandCareofHealth(BEACH)Program(2002)

UniversityofSydney

5 Evidence-PracticeGapinGPPathologyTestOrdering:AComparisonofBEACHPathologyDataandRecommendedTesting(2009)

UniversityofSydney

6 AProjecttoExaminetheUtilisationofPathologyTestsintheInvestigationofTirednessinGeneralPractice(2002)

LuminisPtyLtd

7 AnalysisofCurrentPracticesinRelationtotheTeachingofPathology(LaboratoryMedicine)(2003)


8 AnalysisofCurrentLaboratoryMedicine(Pathology)TeachingPracticeinPrevocationalandGeneralPractitionerVocationalTraining(2003)


9 AMechanismfortheDevelopment,ImplementationandEvaluationofEvidence-Based,Best-PracticeClinicalGuidelinestoFacilitateQualityUseofPathologyTests(2003)

TherapeuticGuidelinesLtd

10 AcademicDetailingSupportingBetterOutcomesfromDiagnosticTechnologies(2004)

DrugandTherapeuticsInformationService(DATIS)

11 CommonSensePathology(2006) RCPA


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12 CommonSensePathologyPublicationSeries(2011) RCPA13 ImprovedPathologyReporting,EducationandPractice(IPREP)

forColorectalCancer(2009)UniversityofNSW

14 StructuredPathologyReportingStandardsforCancer(2009) CancerInstituteNSW15 PromotingandExpandingStructuredPathologyReportingof

Cancer(Stage2)(Current)RCPA

16 Evidence-Based,Best-PracticePreventionofBloodBorneVirusTransmissioninHealthCareSettingsProgram(PBBV)(2009)

SouthEasternAreaLaboratoryService(SEALS)

Table 2: Reports summarised for Promoting Evidence-Based Practice

Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001)

Description ThisprojectsoughttoevaluatetheeffectivenessoftheManualofUseandInterpretationofPathologyTestsasaresourceinAustralia.TheManualwasfirstproducedin1990bytheRoyalCollegeofPathologistsofAustralasia(RCPA)underthenewlyestablishedPathologyEducationProgram.Itsaimwastoprovideobjectiveclinicalguidancetorequestingmedicalpractitionersonthemostappropriateteststouseinthediagnosisand/ormanagementofspecificmedicalconditions.Thesecondeditionwasproducedin1997(andmadeavailableonlineviatheRCPAwebsite–http://www.rcpamanual.edu.au-in2000)andwidelydistributedtogeneralpractitioners(GPs),interns,residents,registrarsandseniormedicalstudents.AthirdeditionwasreleasedbytheRCPAviatheirwebsiteinAugust2001.

Grant Recipient HealthcareManagementAdvisors

Aims

togatherinformationastohowwidelytheManualhasbeendisseminated,andhowGPsandothermedicalpractitionersuseitinavarietyofsettings

toascertainwhyGPsmaynotusetheManualandwhethertherearemoreappropriatebutalternativemeansofassistingthemtoorderandinterpretpathologytests.

Objectives

todeterminetheextenttowhichtheManualwasdisseminatedtoGPs,interns,residents,registrarsandmedicalstudents

todeterminetowhatextentGPsareawareoftheManual todeterminethelevelofuseoftheManualingeneralpracticeandpublicand

privatehospitals todeterminehowGPsusethemanual todeterminetheextentoftheimpactoftheManualonpathologytest

selectionandtestvolume todeterminetheimpactoftheManualonpatientcareinbothmetropolitan

andruralsettings


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toestimate,wherepossible,thefinancialimpactoftheManualonMedicareandotherhealthcarecosts

todeterminewhyGPsmaynotusethemanual todiscoverwhatinformationGPsrequiretohelpthembetterorderand

interpretpathologytestsaspartofclinicalcare todiscoverhowtheinformationshouldbedisseminated.These aims and objectives were achieved by this project.

Findings Feedback from 621 GPs (47.8% response rate) indicated that: 75%ofrespondentswereawareoftheManual mostreceiveditfromtheRCPAinbookform useoftheManual(bythosewhowereawareofit)was86.6% 86%useditintheprevioussixmonthsandindicateditwasarelevant

resource themostimportantfactorsinfluencingusewasitsreadyaccessibility(51%)

andtheinformationwasrelevant(48%) thedirectimpactoftheManualwasverysmall(0.4%ofallpathologytests

influencedbytheManual),althoughitwasimportantforunusualorinfrequentlyorderedtests.

Feedback from 813 hospital doctors (9% response rate) indicated that: 61.5%(500)ofrespondentswereawareoftheManualpriortoreceivingthe

questionnaire awarenessbyinternyearincreasedfrom31%forthosewhowereinternsup

to1980,78%for1998(soonaftertheManualwasreleased)and52%in2001

67%ofthoseawareoftheManualindicatedtheyhadusedit theuseoftheManualwaslowestamongstinternrespondents(57.6%)and

highestamongstregistrars(68.9%)andresidents(68.3%) ofthosewhousedtheManual,32%didsointhepreviousthreetosix

months,23%withinthelastmonthand7%withinthelastweek theManualwasusedtodirectlyinform1.5%ofallpathologyrequests 86%indicateditdidnotchangethenumbersofpathologyrequests,butitdid

modifythetestprofileonabout50%ofoccasionswhereitwasconsulted theManualwasseenasanimportantreferenceresourceinthehospital

environmentduringtheformativeearlyworkingyearsinadoctor’scareer. Analysisoforderingpatternsviade-identifieddatafromtheHealth

InsuranceCommission(HIC)indicatedtherewerethreetestbundleswheretheManualprovidedspecificguidanceandallowedanalysis:

1. thyroidfunctiontest(TFT)2. ironstudiesversusserumferritin3. extractablenuclearantigenantibodies.

General conclusions were: doctorswhowereawareoftheManualaccepteditasanimportantreference

resourceandcontinuetouseit


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thelackofreprinting/distributionsince1997resultedinreducedawareness doctorssupportedthedevelopmentofanupdatedversion thetargetpopulationneedstobeperiodicallyremindedofitsexistence

throughappropriateeducationforums hospitaldoctorswouldbenefitbyhospitalsdevelopingalinktotheManual

ontheRCPAwebsiteviapathologyresultsreportingsystems futureManualsshouldbedistributedtonewmedicalgraduatesineachyear

ofcurrency.

Recommendations 1. ArevisedManualbedevelopedanddistributedtoGPsandnewmedical

graduates.2. FuturedevelopmentandreleaseoftheManual(orequivalentresource)

shouldincludeperiodic(atleastannual)distributiontograduating/new-graduatedoctorsandaremindersenttoallrelevantdoctorsaboutitsexistence.

3. SufficientcopiesofanyfutureManualshouldbeproducedtosatisfydemandbeyonditsinitialdistribution.

4. HospitalstobemadeawareoftheRCPAwebsiteversionoftheManualandencouragedtolinkittotheirpathologyreportingsystem.

5. AppropriateGPeducationandinitiativesshouldaccompanythedistributionoffutureversionsoftheManual.

6. ThefutureManual,orsimilarresources,shouldbedevelopedinvariousformatsincludingbook/hardcopyandelectronicformsandvariousstrategiesfordisseminations(includingassociatededucationalinitiatives)beadopted.

7. ConsiderlinkingthedevelopmentoffutureversionsoftheManualtoincorporatetheNationalAssociationofTestingAuthorities(NATA)requirementforlaboratoriestoproducesimilarresources.

8. ContinuetodevelopfutureversionsoftheManualinconjunctionwiththeRCPAandotherappropriateprofessionalcolleges.

9. Recommendationsforfutureprintedversionsincluded: colourcodekeyselectionssimilartotheMedicareBenefitsSchedule

(MBS)model includeanindex includehighlevelcostinformation includebasic‘operational’informationsuchastubecolours,collection

proceduresetc. includeguidelines/protocolsforpathologytestsforcommonconditions includesomeinformationaboutHIClimitationsoftests includespecificinformationontests,testfrequency,testbundlesand

acceptableabbreviationsfortests includeusefulsupplementarytestsandtestsnotindicatedbasedonthe

results identify‘normal’rangesandsensitivityindicatorsfortestresults includeturnaroundtimes considerationofproducingtheManualsincelaboratoriesproducesimilar

resourcesundertheNATArequirementforaccreditation.


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Key Project Learnings

Thesingledistributionin1997withoutfollow-upreducedawarenesslevelsamongstnewlygraduateddoctors.Only30%of2001internswereawareofandhadusedtheManual.

Manyhospitalsproducetheir‘own’versionoftheManualsettingoutorderingpracticesexpectedatthathospital.

ProvidingtheManualineitherhardcopyorelectronicformattoallmedicalstudentgraduatesensuresaccesstotheManual.

Theinitialcomponentofhospitalwork(internandfirstyearspostgraduation)providedthemostimportantknowledgeaboutpathologyorderingaslittlewasincorporatedintouniversityeducation.

Itmaybemorewidelyusedifprovidedtoeach‘ward’asopposedtoeachdoctor.

Follow on Initiatives and Projects

RCPAManualTransformationProjectonpage18.

Areas for Future Consideration

Deviseastrategyto‘remind’doctorsabouttheexistenceandusefulnessoftheManualatspecifiedtimeintervals.

Developguidelines/protocolsforpathologytestsforcommonconditions.

Revision of Manual of Use and Interpretation of Pathology Tests (2004)

Description ThisprojectupdatedthecontentoftheManualofUseandInterpretationofPathologyTests,andmadeitavailableviatheRoyalCollegeofPathologistsofAustralasia(RCPA)website(http://www.rcpamanual.edu.au/)inaformatfacilitatingsearching,downloadingandincorporationintoothersoftware.

Grant Recipient RCPA

Aim

toproviderecommendationsforfuturedirectionsincludingabusinessplanforfutureupdatinganddistributionoftheManualindependentofgovernmentfunding.

This aim was achieved by this project.

Findings

TheManualisquiteauniquepublicationbothwithinAustraliaandinternationally,andtheabsenceofcompetitorpublicationsoffersscopeforlimitedsaleswithinAustraliaandpotentiallyoverseas.

TheManualhasthepotentialtogenerateincomefromdistributioninseveralformats:


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o CDversiono printversiono labrequirementssubscription.

ThereissignificantdemandforprintandCDversionsoftheManualfromgeneralpractitioners(GPs),butsignificantresistancefromthemtopayingforit.

ThereappearstobeanawarenessamongstGPsthattheManualisbeingusedbytheCommonwealthasabehaviourchangeinterventiontochangepathologyordering,andintroducingstrongDigitalRightsManagement(DRM)provisionscreatesthepossibilityofanegativereactionfromGPgroups.

Recommendations 1. FutureversionsoftheManualcontinuetobedevelopedbytheRCPAin

conjunctionwithotherappropriateprofessionalcolleges.2. TheInternetandPDAversionsoftheManualcontinuetobeavailableatno

costandthroughunrestrictedaccessviatheInternetsite.3. Aregistrationprocessanddifferentiallicensingarrangementsbeundertaken

forthefollowingformatsoftheManual:o CDversion–non-commercialandcommercialonCDand

downloadableo printondemandhardcopyversiono subscriptionversion(CD,downloadandprint)o internationaldistributiono individuallaboratoryrequirementssubscription.

4. AduallicensingsystemshouldbeexaminedfortheManual.5. ThefollowingformsoflicensingbeimplementedfortheManual:

o non-commercialuseo singlepurchaseCDorhardcopybooko commercialuselicenceso subscriptionlicenceo internationallicensing.

Key Project Learning

TheManualitselfcontinuestoberecognisedasanimportantresourceforassistingpathologyorderingandinterpretation,andtobeusedbythemajorityofthosesurveyed.


RCPAManualTransformationProject(2010).

RCPA Manual Transformation Project (2010)

Description ThisprojectsoughttoupdateandtransformtheRoyalCollegeofPathologistsofAustralasia(RCPA)Manualtoreinforceitspositionasthepre-eminentsourceofpathologyinformationforhealthcarepractitioners,anddevelopaseriesof


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evidence-basedPathologyDecisionSupportTools(PDSTs)toguidereferringpractitionersinrequestingpathologytestsforthediagnosisandongoingmanagementandmonitoringoftheirpatients.


Aims and Objectives 1. toconveneaSteeringGrouptooverseetheupgradeoftheManualand

provideadvice,makedecisionsandcommentonanyamendmentstotheexistingManual

2. toreviseandupdatethecontentofthecurrentRCPAManual3. toupgradetheformattingoftheRCPAManualsoitiscomparabletoLab

TestsOnline(LTOAU),andalsotocreatealinkbetweenthetwowebsitessothetwoproductsareassociated

4. todevelopPDSTsanduploadthetoolsintotheRCPAManual.These aims and objectives were achieved by this project although a link to LTOAU could not be established due to the underlying technical format of the respective websites, as well as the way the content was set out. However, an external link to the LTOAU website was included on the RCPA Manual website.

Outcomes

Atthetimeofthereport,43PDSTswerecompletedandplacedontheRCPAManualwebsite.

TheManualhasbeenredevelopedtomakethewebsitemoreuser-friendly. TheRCPA’sinternalwebdeveloperwascontinuingtoattendtoongoing

maintenanceofthewebsite. Between22April2010and13December2010,38,470uniquevisitorshad

visitedtheRCPAManual67,756timesandviewed288,474pages.Italsoreceivedabout5,000uniquevisitors,8,500visitsand36,000pageviewsmonthly.

Finding

TheRCPAManualcontinuestobeusedbygeneralpractitioners(GPs)andotherreferringdoctorsthroughoutAustralia,andprovidesahandyreferencematerialformedicalstudents.

Recommendation 1. FutureworktotheManualwebsitemayinclude:

o developingaspecialversionforhandhelddevicessuchasaniPhoneorBlackberry

o promotingthewebsiteinternationallyo maintenanceo backupo regularcontentrevisionbasedonnewinformationo integrationwiththesoftwareusedbytheGPsandtheotherdoctors

(e.g.RoyalAustralianCollegeofGeneralPractitioners[RACGP]Primary Care Side Bar).


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ThefinalformattingbytheRCPA’sinternalwebdevelopertookconsiderabletimeduetotechnicalissuesbeforethePDSTsweretransferredontotheliveRCPAwebsite.


Exploretheuseofonlinetoolsfortrainingandsupportofqualitypathology. ExplorehowtheRACGPandtheRCPAcanworktogethertointegrateand

enhancetheutilityofthePDSTstotheclinicalpracticeofrequesterssuchasanaccessiblelinktotheRCPAManualviaGP’sdesktops.

An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002)

Description Thisprojectsoughttoanalysechangesinpathologyorderingpatternsingeneralpracticebetween1998and2001andthepossiblecausalrelationshipsbetweenanyidentifiedchangesandotherfactorsbyundertakingananalysisoftheBetteringtheEvaluationandCareofHealth(BEACH)databetweenApril1998andMarch2001.

Grant Recipient UniversityofSydney

Aims and Objectives

toinvestigatechangesinpathologyorderingpatternsingeneralpracticebetweenApril1998-99andMarch2000-01,andthepossiblerelationshipsbetweenanyidentifiedchangesandotherfactors

Specifically: toinvestigatechangesinpathologyorderingpatternsoverthreeyears toinvestigatetheextenttowhichcharacteristicsofgeneralpractitioners

(GPs)havechangedoverthethreeyearsoftheprogram toinvestigatetherelationshipsbetween:

o changesinpathologyorderingandinGPcharacteristics(particularlyGPage)

o pathologyorderingandmorbidityundermanagemento pathologyorderingandlengthofconsultationo pathologyorderingandprescribingbehaviour,imagingordered,

therapeuticproceduresundertakenandclinicaltreatmentsprovided toinvestigatethefactorsthattogethersignificantlycontributetopathology

orderingbehaviour.These aims and objectives were achieved by this project.

Findings

TherehasbeenasignificantincreaseinpathologytestorderratesbyGPsbetween1998-99and2000-01.


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Therehasonlybeenasmallincreaseintheproportionofproblemsforwhichpathologyisordered,buttherehasbeenaverystrongmoveawayfromorderingasingletestperproblemtoorderingthreeormoretestsperepisode.

Themajorincreasewasforrequestsforchemicalpathology(+22.6%),withotherareasshowingsmallerincreases;Immunology(+20.1%),haematology(+13.5%),tissuepathology(+10.7%),microbiology(+5.5%),cytogenetics(+0.5%),infertility/pregnancytests(+1.5%).Therewasadecreaseinthenumberofsimplebasictests(-11%)andcytopathology(-1.2%).

Theoverallpathologyorderrateincreasedbyapproximately22%. Therewasaninverserelationshipbetweenpathologytestorderingand

pharmaceuticalprescribing,andapositiverelationshipbetweenpathologytestorderingandimagingtestorders,buttheirimpactonoverallratesofotherclinicalactivitieswasminimal.

Theincreasesarereflectedinpathologyorderedforallpurposes,particularlyfordiagnosticandpreventativecareandotherpathology,andtoalesserextentinmonitoringpathology.

Theprovenrelationshipbetweenconsultationlengthandpathologyorderingdidnothaveanyimpactonthechangesintotalpathologytestsorderedovertime.

WhileorderratesaresignificantlyrelatedtoGPcharacteristics,therehasbeennochangeinthecharacteristicsofGPssothisrelationshipcannotbethecauseofincreasedpathologytestorders.

Someoftheincreasecanbeexplainedbyincreasedmanagementratesofafewcommonconditions,however,themajorityofthemeasuredincreasecannotbeexplainedbyfactorsmeasuredinthisstudy.

ExternalinfluencessuchaschangesintheMedicareBenefitsSchedule(MBS),systemchangessuchasincreasedcomputerisation,andpossiblyincreasedfearoflitigationmustbeconsideredaspossibleinfluencesonpathologyorderratesofGPsovertheperiodofthisstudy.

Higherorderingrateswereassociatedwith:o largerpracticeso ruralandremotepracticeso higherproportionsofworking-ageadultpatients(aged15-64years)o highermanagementratesofproblemsassociatedwiththebloodand

blood-formingorgans,theendocrineandmetabolicsystems,thecirculatorysystem,pregnancyandfamilyplanningandurinogenitalproblems

o highratesofMedicareLevelC(long)consultations. Factorswhichmayhavebeeninfluentialinalteringthepatternsofordering

includechangestoguidelineswhichpromotemoreintensivemonitoringofpatients,amovetocomputerisedordering,medicalindemnityconcernsandincreasingemphasisonmanagingchronicdiseases.


TheincreasesinthenumberandcostsofpathologytestsasrecordedbytheHealthInsuranceCommission(HIC)datadidnotnecessarilyreflectthetrueorderingpatternsofGPs.

Independentoftheeffectofvariablesassociatedwithhigherorderingrates,pathologyorderratesincreasedwithtime.


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AsignificantincreaseinpathologytestorderratesbyGPscouldnotbecompletelyexplainedbyfactorsmeasuredinthisstudy.


AsecondstageofthisprojectwasundertakenasEvidence-PracticeGapinGPPathologyTestOrdering:AComparisonofBEACHPathologyDataandRecommendedTesting(2009).

Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009)

Description ThisstudysoughttoidentifyGPpathologyorderingpatternsfromBettering the Evaluation And Care of Health (BEACH) Programdata2000-2007forhighcost,highuseandinappropriateitemstoenableanalysisofthepatternsagainstpublishedbest-practiceguidelines.Italsosoughttoexaminegeneralpractice(GP)pathologyorderingpatternsintheBEACHdataforproblemsmanagedingeneralpractice:

whichwereaNationalHealthPriorityArea ifpathologyorderingwascommoninthemanagementofthecondition ifthepathologyorderingbehaviourofGPshadchangedforthe

managementoftheproblembetween2000-2002and2006-2008(thedurationofthestudy).

Onthisbasis,Type2diabetes,hypertension,lipiddisorders,weakness/tiredness,‘healthchecks’andoverweight/obesitywereselectedforinvestigation.‘Healthchecks’problemsincludedcheck-upsrecordedbyGPsatencounterswithpatientsaged15yearsandover,andoverweight/obesityincludesproblemsmanagedthatwerelabelledbyaGPas‘obesity’or‘overweight’forpatientsaged18yearsandover.Allofthesixproblemsinvestigatedinthisstudyaccountedfor12.1%ofallproblemsmanagedin2000-08,andformorethanone-quarter(25.7%)ofthetotalpathologytests/batteriesrecordedbyGPs.


Aims and Objectives

toinvestigatetheextenttowhichGPs’pathology-orderingbehaviourforselectedproblemsalignswithrecommendationsmadeinnationalandinternationalguidelinesforthemanagementoftheseproblems(datausedwasfromaBEACHstudyovereightyearsfromApril2000tomarch2008)

toidentifywhetherchangeshaveoccurredinthepathologyorderedfortheselectedproblemsoverthelasteightyears,andwhetheranymeasuredchangereflectsachangetobe‘more’or‘less’inlinewithguidelinesrecommendations

toidentifytheextenttowhichmeasuredchangeshavebeentheresultofchangesin:

o themanagementrateoftheproblemand/or


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o thelikelihoodofpathologybeingorderedinthemanagementoftheproblemand/or

o explorethenumberofpathologytests/batteriesoftestsbeingordered.

These aims and objectives were achieved by this project.

Findings

Thepathologytestordersincreasedsignificantlyforallsixproblemsovertheperiodofthisstudy.Theseincreaseswereindependentofchangesinthemanagementrateoftheproblemandaccountedforabout31%ofthenationalincreaseinpathologytestsorderedforallproblemsfrom2000-2002and2006-2008.

IncreasesinthepathologyorderratesforType2diabetesandhypertensionwereduetoanincreaseinthelikelihoodofatleastonetestbeingordered,andanincreaseinthenumberoftestsorderedpertestedcontact.

Onlythelikelihoodoftestingincreasedforweakness/tirednessandoverweight/obesity.

Onlythenumberoftestsorderedpertestedcontactincreasedforlipiddisorders/healthchecks.

GPorderingbehaviouralignedwellwithguidelinerecommendationsforlipiddisorders(75.5%ofpathologytests/batteriessupported),weakness/tiredness(71.7%),Type2diabetes(72%)andhypertension(65%).Thelevelofsupportforlipiddisordersandhypertensionislikelytobeover-estimatedastestswereprimarilyrecommendedforinitialassessmentofnewlydiagnosedcaseswhereasthemajorityofpathologyorderedfortheseproblemswasforongoingmanagement.

Pathologytests/batteriesorderedbyGPsfor‘healthchecks’andoverweight/obesitydidnotalignwellwithrecommendedtesting.Only24.3%ofpathologytests/batteriesrecordedfor‘healthchecks’and50.9%foroverweight/obesitywererecommendedintheguidelines.

ThenumberoftestsorderedbyGPspertestedproblemincreasedovertheperiodofthisstudyandpotentiallyfurthercompoundedtheissueofdecipheringtruepositiveresults(realchange)fromfalsepositiveresults.Forexample,fullbloodcounts(FBCs)wereoneofthemostfrequentlyorderedtestsbutitwasonlyrecommendedinthemanagementofweakness/tirednessandintheinitialinvestigationofhypertension.Therefore,theresultssuggestGPsmayhavebeenopportunistically/routinely-orderingFBCswhenorderingbloodtests.

Theguidelinesreviewedweremorbidity-basedandcouldnotprovideguidancethatisapplicableforallpatients,especiallythosewithmultiplechronicconditions.

Recommendations 1. Providingguidanceonthevarianceofresultsinlongtermmonitoring

(coefficientofvariance)andlikelihoodofabnormaltestresultswhenmultipletestsareorderedmayimprovetheinterpretationandappropriateorderingofpathologytestsinprimarycare.

2. Thelimitationsofthisstudymeantthelevelofsupportcouldnotbedeterminedfor10-24%ofpathologytestsorderedforeachmorbidity.Either


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testswererecommendedforaspecificclinicalsituationthatcouldnotbeevaluatedwithBEACHdata,orGPsorderedbatteriesoftests(e.g.multibiochemicalanalysis)forwhichsupportcouldnotbedetermined.Furtherresearchisneededtodeterminewhethertheuseofthesetestsissupported.

3. Guidelinesandguidanceregardingpathologytestscouldbeimprovedby:o providingadequateadviceonthepathologytestsrequiredinthe

ongoingmanagementofeachcondition(e.g.recommendationsregardingmonitoringlongtermmedication)includingdetailonthefrequencyanddurationforwhichtestingisrequired

o providingadviceonthepretestprobabilityofdisease,particularlywhenrecommendinginvestigationofpossiblecausesofsecondarydisease

o informingGPsofthelikelihoodofintra-individualvariationwhenmonitoringlong-termconditions.Usingmedicalrecordsoftwaretoprovidegraphicalpresentationofresultsofrepeatedpathologytestswithmarkerstoindicatethecoefficientofvariationmaybeuseful

o educatingGPsonthelikelihoodoffalsepositiveswhenorderingmultiplepathologytests,particularlyinthecontextoflowpretestprobabilityofdisease

o standardisingterminologyusedtorefertopathologytestingtohelpGPslocateinformationregardingpathologytestingwithinguidelines.

4. TheclinicalindicationsfororderingFBCs,thyroidfunctiontests(TFTs),multibiochemicalanalysisandliverfunctiontests(LFTs)inthelong-termmonitoringofchronicconditionsneedsclarification.Furtherresearchorreviewofliteraturetodeterminethepretestprobabilityofunderlyingdiseasemaybeusefulindevelopingguidanceontheuseofthesetests.

5. EnsuringGPscanaccessresultsofpreviouslyorderedpathologytests(regardlessofwhoorderedthetest),andthatresultsareeasilyaccessiblewithintheelectronichealthrecordmaydecreasetherateofrepeatedpathologytesting.

6. ThelengthofguidelineswasperhapsthebiggestbarriertoGPsusingthem,particularlyasaquickreferencepointtolocateinformationaboutbestpracticeforpathologyordering,andwhentheyarenotapplicableintheclinicalcontextofmultiplemorbiditiesforonepatient.Therefore,developingotheravenuestoprovideguidancetoGPsaboutpathologyorderingmaybeusefulsuchasshortproblem-orientatedstatementsofrecommendedpathologytestsrelevanttothestageofmanagement(initialdiagnosisorlonger-termmanagement).

7. Adviceontestinginlong-termmanagementneedstoincludeinformationonexpectedintra-individualvariation(biologicalandanalytical),intervaltoretestanddurationforwhichmonitoringisneeded.Informationonthelikelihoodoffalsepositiveresultswhenorderingmultiplepathologytestsshouldalsobeprovided.

8. Wherethereisnoevidenceavailable,problem-basedconsensusstatementsshouldbedevelopedwithinvolvementofpracticingGPs.Thesenewguidancestatementscouldbeincorporatedintodecisionsupportsystemswithinelectronichealthrecords,linkedatthepointofthedecisiontoorderpathologytestsforthatproblemandatthepointofreceiptofresults.


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LocatingrelevantAustralianguidelineswasnotastraightforwardprocess.Therewasnocentrallistingoftheavailableevidence-basedguidelines,andtheorganisationcreatingtheguideline/guidancedocumentvariesdependingonthemorbidity.TheNationalInstituteofClinicalStudies,whichispartoftheNationalHealthandMedicalResearchCouncil(NHMRC),wasdevelopinganationalclinicalpracticeguidelinesportalatthetimeofthereport.

GuidelinesareusuallynotdesignedforGPs.Theyareoftenverylongdocuments(often200+pageslong)anditisunrealistictoexpectGPstoreadlongdocumentsforallthemorbiditytypestheymanagement.

Informationregardingrecommendedpathologytestingwasoftendifficulttolocateinguidelinesastherewasoftennospecificsectionthataddressedinvestigationstobedone.Therewasalsomixedterminologyusedwithintheguidelinestorefertotestingsuchas‘diagnostictesting’,‘laboratoryinvestigations’,aswellasinthespecifictestnameorthediseasetobetestedfor.

Recommendationsregardingpathologytestinginthelong-termmanagementofconditionswereoftennotprovidedinguidelines.

ThevariationoftestresultswasoftennotdiscussedinguidelinesorothersourcesofGPguidance,withmostguidelinesprovidinga‘targetlevel’withoutprovidingfurtherdetail.


ThedevelopmentoftheNHMRCclinicalguidelinesaroundobesity.


Requestereducationanddecisionsupportguidancestatements,especiallyfortheuseofFBC,TFTs,multibiochemicalanalysisandLFTsinmonitoringchronicdisease.

LiaisewithNHMRC/guidelinedevelopersregarding:o addingan‘investigations’sectioninguidelineso standardisingpathologyterminologyo includingpathologyrepresentationonguidelinedevelopment

workinggroups.

A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002)

Description Thisstudysoughttoexaminetheutilisationofpathologytestsingeneralpracticewheninvestigatingtiredness.Theclinicalrecordsselectedfortheprojectencompassedaseven-yeartimeframefrom1April1994to25April2001.Thesamplewasrandomlysortedand345patientswerevalidated.

Grant Recipient LuminisPtyLtd


26

Aim

toexaminetheutilisationofpathologytestsintheinvestigationoftirednessingeneralpractice.

Objectives

todemonstratetheindicationsofpathologyintheinvestigationoftirednessingeneralpractice

toidentifyandfollowasampleofpatientswithtirednessandreviewthemanagementprocessesattheseencounters

toassesspatienthealthoutcomes todevelopandpilotcomputer-basedguidelinesforgeneralpractitioners

(GPs)investigatingtiredness.The aim and most objectives were achieved by this project. The final objective was partially met, with the study providing information that will enable progress to be made in the area of decision support.

Findings

SignificantlymorefemalesthanmalesvisittheGPwithtiredness. Olderpatients(>44years)comparedtoyoungerpatients(<44years)visit

theGPmorethanoncewithtiredness. Therewasameannumberof3.12testsrequestedperpatient. ThemostcommontestsorderedbyGPswere:

o fullbloodcountexamination(27%)o urea,electrolytesandcreatinine(18%)o thyroidfunctiontests(11.8%)o liverfunctiontest(10.8%)o testsfordiabetes(9.2%)o erythrocytesedimentationrate(8.7%).

Testslesscommonlyrequestedwere:o ironstudies(7%)o folatetests(3%).

Morefemales(56%)thanmales(46%)hadatleastonepathologytestordered,witholderpatientshavingsignificantlymorepathologytestsordered.

14%ofpathologytestswerereturnedabnormal,andonly3%ofthesepatientshadasignificantoutcomebasedonanabnormalpathologytestresult.

Patientswithahistoryofdepressionweresignificantlymorelikelytobetiredaftersixmonthscomparedtoapatientwithoutahistoryofdepression.

Asageincreases,thelikelihoodofhavingapathologytestincreases. Asthenumberofvisitsincreasesthentheprobabilityofhavingapathology

testsalsoincreases. Asageincreases,theprobabilityofhavinganabnormalpathologyresult

increases. As‘noproblem’changesto‘physical’thereisanincreasedchanceofan

abnormalresult,andchangesfromphysicaltopsychosocialalsoincreasesthechanceofanabnormalresult.


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Tirednesslastinggreaterthanfourtosixmonthsismorefrequentlyassociatedwithpsychologicalconditions.

Recommendations 1. Acompletebloodpicture,andpossiblefastingbloodsugarlevel,maybethe

appropriateandonlyinitialpathologyrequiredtoinvestigatetiredness.2. GPsshouldalwaysconductaclinicalreviewtodetermineifthereisevidence

ofdepressionorotherpsychologicalcondition,reviewthepatient’slifecircumstancestodecidewhetherstressesinwork,homeorrelationshipscouldbeafactor,andaphysicalexaminationtodetermineiflaboratorytestsarenecessary.

3. ApilotdecisionsupportstudyutilisingthefindingsofthisstudyhassignificantpotentialtomoveGPstomoreappropriatepathologyorderingandbetterpatientmanagement.


Theevidenceforpathologytestsconfirmingadiagnosisrelatedtotirednessislimited.

Evidence-basedguidelinesforinvestigatingadultpatientswithfatigueoflessthansixmonthsdurationweredevelopedinOntario.


DevelopaframeworkfordecisionsupportforGPsinvestigatingtirednessingeneralpracticebasedonelementsidentifiedinthestudy.

Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)

Description Thisprojectinvestigatedlaboratorymedicine(pathology)teachingpracticeandcurriculuminundergraduatetraininginstitutions(universitiesandteachinghospitals)acrossAustralia.


Aims and Objectives

todeterminewhatiscurrentlybeingtaughtinregardtolaboratorymedicineinthemedicalcurriculum

toidentify:o ifcurriculacontentcomplieswithcurrentevidenceandbestpracticeo ifcurriculaaddressthepatternsand/orprevalenceofclinical

presentationsthatoccurwithinvariouspracticeenvironmentso what,whereandifapplicable,whygapsorinconsistenciesare

occurringinthecurrentteachingoflaboratorymedicineo anybarrierstotheeffectiveteachingoflaboratorymedicineo incidenceswherelaboratorymedicineteachingprogramsare

currentlyworkingwell toascertainwhoisteachinglaboratorymedicine


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toascertaintheoverseasexperienceinteachinglaboratorymedicinetomedicalstudents

toproviderecommendationstotheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)onwaystoimprovetheteachingoflaboratorymedicinetoenablemedicalstudentstodevelopbetterpathologyorderingandinterpretingskillstoassistinmanagingtheirpatients.

These aims and objectives were achieved by the project.

Findings

PathologyandlaboratorymedicineisintroducedinthefirstyearofprimarilyProblemBasedLearning(PBL)courses,andinthemiddleofmoretraditionallystructuredcourses.

Thenumberofcontacthoursforpathologyandlaboratorymedicineisestimatedatbetween250and300acrossallcurricula.

Ethicsandmedico-legalissuesareincorporatedintoallcurricula. Thevalueoforderingtestsforpopulationscreeningiscoveredinall

curricula. Thebasicknowledgeunderpinninglaboratorymedicineislargelytaught

throughlectures,tutorialsandpracticals. Theroleoflaboratorysessionsisdecliningacrossallmedicalschools. Allcurriculaprovideforstudentstogainexperienceintheuseofbasicpoint

ofcaretestsandcollectionofspecimensduringclinicalrotations. Computersareusedextensivelyinmedicalcurriculawithschoolsdeveloping

awiderangeofresourcestosupportstudentlearning. Thereisastrongemphasisondevelopingclinicalreasoninginthenew

curricula. Thefocusofteachinglaboratorymedicineisincreasinglyondisease

presentation. Therewerelimitedcaseswherethefinancialaspectsoftestingwere

considered. Arangeoftextswereused. Therewassomevariationintheinvolvementofpathologistsinteachingwith

anatomicalpathologiststhemostrepresentedinacademicdepartments. Cliniciansareextensivelyinvolvedinteachingstudentsintheirclinical

rotations. Anumberofissuesrelatedtobarriersandopportunitiesforimproved

teachingoflaboratorymedicinetoundergraduateswereidentified. Servicedemandsinpubliclaboratoriesandhospitalswerenotedasabarrier

togreaterpathologistinvolvementinteachingroles. Thereisadangerthatgoodhabitslearnedinundergraduateprogramscanbe

unlearnedshortlyaftergraduationasgraduatesundertaketrainingwithinclinicalteamsinpublichospitals.

IfcurrentteachingoflaboratorymedicineinAustraliaistoeffectivelypreparestudentstousepathologytestsappropriatelyintheirfuturepractice,theliteraturesuggeststhatteachingapproachesshould:

a. provideafirmgroundinginbasicbiomedicalsciencesandpathologyintheearlypartofthecurriculum

b. developanunderstandingofthelinkbetweenpathologyandclinicalpresentation


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c. facilitatethedevelopmentofsoundclinicalreasoningd. providestudentswithanunderstandingoftheapplicationof

pathologytestsasacomponentofteachingatthebeginningoftheirclinicaltraining.

Recommendations 1. Createafractional,temporarypositionineachmedicalschooltoprovide

supportandassistanceinvariousareas,andevaluatetheimpactofsuchpositionsafterabouttwoyears.

2. Commissionastudytoidentifyissuesorsituationsthatpresentdifficultiesforstudentsandrecentgraduatesinappropriatelyorderingandinterpretingpathologytestsandpresentthemtoaworkshop.

3. Commissionananalysisoflaboratorymedicineeducationinpostgraduateyearsoneandtwo.

4. Circulatethecorecurriculumdevelopedbytheheadsofacademicpathologydepartments,incollaborationwiththeRoyalCollegeofPathologistsofAustralasia(RCPA),tomedicalschoolsasaguideforfuturedevelopmentofcurricula.

5. DevelopaversionoftheManualofUseandInterpretationofPathologyTeststhatbecanstoredandaccessedonhandheldsystemssuchasPalm®,andanabridgedpocketversionofthisManualbedevelopedcoveringteststhatarelikelytobeusedonaregularbasis.

6. Providestudentswithmoreopportunitytovisitworkinglaboratoriestoimprovetheirunderstandingoftheprocessbywhichspecimensaremanagedandonhowreportsareprepared.

7. Specificallytargetedteachingfocusingonareaswhichundergraduatestudentsandrecentgraduatesfinddifficultwouldbebeneficial.

8. Supportclinicalteacherstomodelgoodpracticeintheuseandinterpretationofpathologyteststoimprovetestorderingandinterpretationpracticesamongstudents.

9. Expandtherangeofclinicalenvironmentsinwhichstudentsreceivetheireducation,trainingandexperiencetoenablethemtodevelopskillsappropriateformanagingthechronicandsubacuteconditionstheywillencounterintheirprofessionalpracticeinthecommunity.


ComputerAssistedPatientSimulationsforEducationintheRationalUseofInvestigations–FinalReportforPhase1(iNvestigateProject)(2010) onpage 124.


Focusonimprovingtheeducationofmedicalstudentsinundergraduatetraininginstitutions(universitiesandteachinghospitals)acrossAustraliainlaboratorymedicineaspertheaboverecommendations.


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Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003)

Description ThisprojectsoughttoundertakeananalysisofcurrentLaboratoryMedicine(Pathology)teachingpracticeinpre-vocationandgeneralpractitioner(GP)vocationaltraining.


Aims and Objectives

toprovideacomprehensiveanalysisofhowlaboratorymedicineiscurrentlytaughtduringpre-vocationalandvocationalGPtraining

toidentifywheregapsexistinthecurrentteachingoflaboratorymedicineinpre-vocationalandvocationalGPtraining

toidentifyoptionsforteachinglaboratorymedicinemoreeffectivelyinpre-vocationalandvocationalGPtraining.


Findings Pre-vocational and Vocational GP Training Therelianceofclinicalteachinghasmeantpre-vocationalandvocational

trainingarecloselyrelatedtothepatternsandprevalenceofconditionswithinthepracticeenvironment.

Theoverallapproachtopre-vocationaltraininginAustraliaiscomparabletothatinotherEnglishspeakingcounties,withanemphasisonward-basedteaching.

ThecurriculumcontentforJuniorMedicalOfficers(JMOs)variesconsiderablywithinandacrossjurisdictions,asdoestheextenttowhichpathologytestorderingisincorporatedwithinthecurriculum.

Thecontentofteachingisdependentontheclinicalrotationandtheviewsandpracticesoftheconsultant,andoftheclinicalteammoregenerally.

Wherefinancialaccountabilitywastheresponsibilityofclinicalunits(atleasttosomeextent),theuseofpathologywasincorporatedintowardmeetingsandfeedbackprovidedtoJMOs.

Theprominenceofbedsideorward-basedteachinginthecurriculaforJMOscontributestoahighdegreeofvariationbetweenhospitalsites,andbetweenclinicalunitswithinasingleinstitution.Thisincreasestheimportanceofthepracticeofseniorclinicians.

Gaps in the Current Teaching of Laboratory Medicine Thereislimitedinvolvementofuniversitymedicalschoolsinvocational

trainingcomparedtootherEnglish-speakingcountries. Theuseandinterpretationofpathologytestshasalimitedfocuswithinthe

trainingprogramforGPregistrars. Therearedifferentprioritieswithgeneralpracticecomparedtoteaching

hospitalpractice.


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Theinvolvementofpathologistsinclinicalteachingandreviewofcasesislimited,partlyduetothelimitednumbersofpathologistsandthedemandsplacedonmodernlaboratories.Therewasalsominimalglobalguidancebypathologistsregardingoveralldiagnostictestingstrategies.

MostattentionisfocusedontestsJMOsdidnotorderratherthanonthetestsordered.ThereportedlackofconsensusamongseniorclinicianswasidentifiedbyJMOsasafactorthatlimitedtheirabilitytogainanunderstandingofappropriatepractice.

AJMOisunlikelytoquestionorchallengethepracticeofaseniorcolleagueintheexistingcultureinthemedicalprofessionwhichischaracterisedbyautonomy,competitivenessandhierarchy.Forexample,JMOsorderteststhatparticularconsultantsalwaysrequesttoavoidtheriskofembarrassmentduringwardrounds.Thereisalsoexaminationandfeedbackregardingwhatwas‘not’ordered,sooverorderingispracticedtoavoidembarrassment.

JMOshavelimitedaccesstoorexperienceinalaboratory,butthereisvariationacrosssiteswithgreateraccesstobothpathologistsandthelaboratoryinruralsites.

Barriers to improving how JMOs learn about the ordering and interpretation of pathology tests include:

thelackofincentivesforlaboratoriestoreduceordering thelackofconsensusamongstconsultants medicolegalconcerns makingpathologyteachingrelevantandinteresting thebalancebetweenstaffspecialistsandvisitingmedicalofficers increasingsub-specialisation theviewofthelaboratoryasa“blackbox” changedworkinghoursforJMOshavereducedtherangeofcasesthey

seeandtheextenttowhichtheyareinvolved theshortageofpathologists.

Options For Teaching Laboratory Medicine Interventionswhichtargetonlyonefactorcontributingtotestorderingare

likelytohavealimitedimpact.ThelinkagebetweeneducationofJMOs,feedbacktoconsultantstaffandbuildingconsensusaroundanacceptedevidencebaseappearstopresentacomprehensiveapproachtochangingpractice.

Akeyconsiderationonthevalidationofknowledgewithinthemedicalprofessionrelatestothelocationofthesourcewithinaprofessionalhierarchy.

Personalpreferencesandknowledge,theenvironmentinwhichpracticeoccursandthefeedbackprovidedwithinthatenvironmentaffectstheapproachtakentoorderingtestsbyindividualmedicalofficers.

Giventherelianceonclinicalteaching,bothprevocationalandvocationaltrainingarecloselyrelatedtothepatternsandprevalenceofconditionswithinthepracticeenvironment.

Wherehospitalshaveintroducedprotocolsfortheutilisationofhighcosttests,JMOsindicatedtheywereusefulininformingthemofappropriate


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practice,anddiminishingtheriskoffindingthemselvestakingapositionthatmaybeinconflictwiththeirconsultant.

Internsandresidentsidentifiedregistrarsasamajorsourceofinformationguidanceandteaching.

General Findings Thereisahighlevelofcontactmaintained(usuallybytelephone)with

pathologistsinrelationtotestsorderedandtheirinterpretation. Registrarstypicallyorderconsiderablylesstestswhentheymovefrom

hospital-basedpracticetocommunity-basedgeneralpractice. Patientexpectationscaninfluencethedecisiontoorderpathologytests. Therearelimitedincentivestodevelopmoreeffectiveapproachestotheuse

ofpathologyassavingsweredivertedtootherareasofthehospitaloperation.Initiativestoreducevolumeoftestsorcostsshouldfocusonawholesystemapproachratherthanonaspecificunitorsectorofahospital.

Barriers to change include: patientexpectations concernregardingpossiblelitigation environmentinwhichprevocationaltrainingoccurs potentialconflictofinterestforpathologistsemployedintheprivatesector perceptionofgovernmentsourceinformationandmaterial lackofdirectcosts.

Recommendations 1. TheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)should

considerallocatingresourcestosupporttheexpansionoftheRationalInvestigationOrdering(RIO)collaborative.

2. DoHAshouldconveneaworkinggroupwithrepresentativesoftheStatesandTerritoriestogainsupportforarequirementthatacomponentofsavingsresultingfromtheRIOcollaborativebeallocatedtosupportincreasedinvolvementofpathologistsinthetrainingofJMOs.

3. AcriterionforthesupportofindividualproposalstotheRIOcollaborativeincludeaprojectcomponenttoemphasisethevalueandimportanceofclinicalassessmentincludinghistorytakingandphysicalexamination.

4. FundingshouldbeallocatedtosupporttheRoyalCollegeofPathologistsofAustralasia(RCPA)todevelopaManualforUseandInterpretationofPathologyTestsasamoduleofcurrentGPpracticemanagementsystems.

5. AworkinggroupinvolvingDiagnosticsandTechnologyBranch,RoyalAustralianCollegeofGeneralPractitioners(RACGP)andtheRCPAshouldbeestablishedtodevelopapublicityprogramraisingawarenessthatorderingpathologytestsisnotanindicatorofthequalityofmedicalcarebeingprovided.

6. TheCommonwealthshouldsupporttheRACGPandRCPAtoprepareapathologyauditpackageforGPs.

7. TheCommonwealth,inseekingtosupportthebroaderimplementationoftheRIOprogram,negotiateswithStateandTerritoryHealthAuthoritiesforallocationofaspecificproportionofsavingsgeneratedtoprovidetimeforpathologiststobelocatedonwardsinmajorteachinghospitalsinalljurisdictions.


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8. ComprehensiveapproachestoprovideopportunitiestoenhancethelearningachievedbyJMOsshouldbedevelopedby:

o improvingtheknowledgebaseofJMOsthroughtargetededucationo providingdetailedauditandfeedbackregardingtestordering

practiceso developingconsensusregardingtheappropriateapplicationof

pathology.9. OpportunitiesforimprovinghowJMOslearnabouttheorderingand

interpretationofpathologytestsinclude:o theestablishmentofprotocolsreflectingconsensusregarding

appropriatetestorderingo theimplementationoftheRIOprogrammoregenerallyo thefocusonhighvolume,lowcosttestso theapplicationofsavingsgeneratedthroughpathologyo theincreasedroleofpathologistsonthewardso includingGPandcommunityrotationsinJMOtrainingo utilisingcomputertechnologytoreduceduplicationandinappropriate

orderingo increasingtheemphasisongoodclinicalhistorytaking.

10. OpportunitiesforimprovingtraininglearningandpracticerelatedtopathologytestorderingandinterpretationforGPsundergoingvocationalinclude:

o afocusonprevocationaltrainingo inclusionoftheManualforUseandInterpretationofPathologyTests

onsoftwaresuchasMedicalDirectoro establishmentofanindependentadvisoryserviceo educationofpatientstomodifyexpectationso developmentofanationalmodulerelatedtopathologytestingo developmentofasupportedContinuingProfessionalDevelopment

(CPD)auditpackageforGPso focusoncommunicationskillso inputbypathologiststokeepthemup-to-date.


BenefitsandRisksofPathologyTesting(Current) onpage159.


Instigateglobalguidancebypathologistsregardingoveralldiagnostictestingstrategies,especiallyforJMOs,intheformofclinicalpathwaysand/orviaaconsensualapproachwithinclinicalteamsorunits.

InvestigatetheviabilityofplacingpathologistsinhospitalwardstomentorJMOs.

Investigatetheviabilityofprovidingdetailedauditandfeedbackregardingtestorderingpractices.

ImprovetheknowledgebaseofJMOsthroughtargetededucation.


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A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003)

Description Thisreportfocusedoninappropriatepathologytestinginhealthcareandhowbesttofacilitateevidence-basedbestpracticeinthefaceofrapidlyexpandingknowledge,risingconsumerexpectationsandgovernmentconcernsaboutunsustainableincreasesinhealthcosts.

Grant Recipient TherapeuticGuidelinesLtd

Aim

torecommendamechanismforthedevelopment,implementationandevaluationofevidence-based,bestpracticeclinicalguidelinestofacilitatequalityuseofpathology.


Findings

Theliteraturereviewrevealedthatguidelinesaloneareusuallyunsuccessfulinimplementingpracticechange.

Amechanismisrequiredtocoordinateandlinkpathologyguidelinesdevelopment,softwarevendorsandeducationalserviceproviders.

Cliniciansandconsumerswantintegratedandconsistentknowledgeresources(pathologyand/orradiologicalexaminations,therapeuticand/orpreventativemanagementandpatienteducation),notanumberofoverlappingandinconsistentresourcesindifferentformatslackingacommonclinicalproblemindex.

Coreclinicalguidelinesresourcesshouldbe:o accessiblefromthehealthworker’selectronicdesktop(general

practice[GP]andhospitalpractice)o enteredthroughacommonclinicalproblem(includingcommon

synonyms)o displayedinasimilarformato ideallyhaveatwotofivesecondresponsetimeo belinkedtorelatedresourceso ultimatelybecapableofassistingrecommendedactions.

Variouslevelsofcomputeriseddecisionsupportarepossible. Consumerswantbettercommunicationwiththeirhealthprovidersabout

diagnostictests,andmanywouldappreciatetheopportunitytoaccessconsumerfriendlyinformationabouttestsrecommended,includingtheirlimitationsandimplicationsoflikelyresults.

Therearevariedviewsaboutthecontentandformatofbestpracticeclinicalguidelinesfortheorderingofpathologytests.

ItisdifficultforGPstodistilevidence-based,bestpracticerecommendationsfromtheincreasingvolumesofscientificliterature.

Animportantconsiderationisthelimitedresearchbasewhenitcomestotheappropriateuseofpathologyandbestpractice.


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AnumberofstudiesreportedareductioninpathologytestingratesafterguidelineswereintroducedintoAustralianhospitals.

Recommendations 1. Developamechanismforthedevelopmentofpathologyguidelines.2. Developanappropriateformatfortheguidelines.3. Disseminateandimplementtheguidelines.4. Incorporatetheguidelinesintocomputerdecisionsupportsystems.5. Assesspractitioneracceptanceoftheguidelines.6. Assesstheeffectivenessofguidelinesininfluencingpatientoutcomes.7. Developrelatedpatienteducationalmaterial.Principles guiding this report’s recommendations were: Themechanismshouldensurethatpathologyguidelinesareproduced

accordingtobest-practiceprinciples. Themechanismshouldbringtogetherkeyinformationproviderswho

currentlyproviderecommendationsconcerningpathologytestsinordertofacilitateconsistencyofrecommendationsandavoidunnecessaryduplicationofeffort.

Themechanismsshouldfacilitate(overalongertime-frame)theintegrationofelectronicpathologyguidelinesintomorecomprehensive,machinereadable,electronicinformationresourcestoenablecomputerisedpoint-of-caredecisionsupportandpracticeevaluation.Thiswillrequirebringingtogetherpathologyandotherprofessionalstoachievethis.

Themechanismneedstoaugmentprintandelectronicpathologyguidelineswithholistic,multi-dimensionaleducationprogramstoachievechange.


Developevidence-based,bestpracticeguidelinesfortheappropriateuseofpathologyforGPs.

Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004)

Description Thisprojectsoughttodemonstrateproof-of-conceptforanationalprogramformoreinformeduseoftheProstateSpecificAntigen(PSA)testbyAustralianpractitioners,andtofurtherinvestigatetheusefulnessofacademicdetailing(AD)forsupportofbetteroutcomesfromtheuseofdiagnostictechnologies.ThiswasanextensionofworkontheCommonwealthofAustralia’sproof-of-conceptprojectforanationalprogramformoreinformeduseofthePSAtestbyAustralianGeneralPractitioners(GPs):1February2001to31August2003.ItalsoincorporatedinformationfromthestudyoncolorectalcancerandHelicobacter pylori (H. Pylori)visitingprogrammes.

Grant Recipient DrugandTherapeuticsInformationService(DATIS)


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Aims and Objectives

todemonstrateproof-of-conceptforanationalprogramformoreinformeduseofthePSAtestbyAustralianpractitioners

tofurtherinvestigateusefulnessofacademicdetailingforsupportofbetteroutcomesfromtheuseofdiagnostictechnologies.


Findings PSA Screening Approximately50%ofGPs(n=162)surveyedinMelbourneadheredtothe

currentAustralianguidelineswithrespecttoPSAscreening. ManyGPsdidnotsupporttheideaofPSAscreeningforavarietyofreasons

althoughtheyviewearlyknowledgeofprostatecancerasbeneficial,regardlessofwhattheguidelinesorevidencepropose.

ManyGPsarestilllikelytobeinfluencedbytheirownanecdotalexperience. ManyGPsareconfusedregardingthecontroversyandpotentialrisksand

benefitsofPSAscreening,andtherewasuncertaintyabout‘whichwaytogo’whenfacedwithapatientrequestforPSAscreening.

OnlyaverysmallnumberofGPswereinterestedinalternativePSAmeasurements(e.g.freetototalPSA,PSAvelocity),orintheconceptsofsensitivity,specificityandpositivepredictivevalue(PPV).

Medico-legalissuesareamajorinfluenceonGPsfulfillingpatientrequestsforPSAscreening.Thepotentiallong-terminfluenceofthisisthestandardofcareofferedbyGPsmayultimatelybedeterminedbyfearofmedico-legalrepercussionsratherthanbeingbasedonbestpractice.

GPswithyoungerpatientstendedtoorderfewerPSAtests,whileGPswitholderpatientstendedtoordermore.

ManyGPssupportedshareddecision-makingandrecognisedtheimportanceofhelpingpatientsunderstandthebenefitsandrisksofPSAscreening.

ManyGPsfoundwrittenmaterialadvantageousinassistingwithshareddecisionmaking,whiletheelectronicdeliverymodeofinformationwasnotanimportantissue.

AhighproportionofGPscommentedfavourablyontheMr.PHIPmaterials. ManyGPswantedtoretainthevisualdetailingcardsfromtheprostate

cancertopic. ManyGPsaffirmedthatinthecurrentmedico-legalclimateregardingPSA

testingitwasmoreimportantthanevertobeawareoftheevidenceandtoremain‘balancedandsensible’aboutthescreeningissue.

IttookthreeorfourvisitsbyDATIStochangeGPbehaviourorattitudetoPSAscreening(recordedduringcolorectalcancerscreeningvisits).

Colorectal Cancer Screening TherewasmixedusedofcolorectalscreeningamongstGPs. Therewasincreasedinterestincolorectalscreening,especiallythefaecal

occultbloodtest(FOBT)aftertheDATISvisits. Thereweremixedconcernsaboutthedifferentscreeningmethodsinterms

ofpatientexperienceandbarrierstousingtheme.g.dietrestrictions,handlingstools.

AsmallproportionofGPsaskedtokeeptheDATISdetailingaids.


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TherewasmixedresponsestotheMrPHIPmaterials.H. Pylori TherewasinterestamongstGPsaboutH. pyloriandclinicalmanagement

strategies. Gastro-oesophagealrefluxdisease(GORD),non-ulcerdyspepsia(NUD)and

non-steroidalanti-inflammatorydrugs(NSAIDS)wereissuesrelatedtoH. pylorithatGPswereuncertainabout.

ManyGPsusedprotonpumpinhibitors(PPIs)asaninitialstrategyforuninvestigatednon-GORDdyspepsia.

Themostestablishedandfrequentlyusednon-invasiveH. pyloritestwastheureabreathtest(UBT).

Therewasmixedreactionstothe“test&treat”or“search&treat”strategiesforlong-termPPIusers.

MayGPsagreedthatPPIswereoverusedandshort-termusecanleadtolong-termuse.

ManyGPsviewedserologyfavourablyonthesecondDATISvisit.Overall(OnlythefindingsrelevanttopathologyhavebeenincludedasopposedtofindingsspecificallyrelatedtotheDATISservice.) TheDATISacademicdetailingprogramonthetopicsofpathologytestsin

prostatecancer,colorectalcancer,type2diabetes(notincludedinthisreport)andH. PyloriinfectionhasahighacceptabilityamongstGPindifferentAustralianStatesandwaseffectiveinimprovingGP’sknowledgeandself-reportedpractice.

ParticipatingGPshighlyvaluedtheDATISeducationalvisitsandmaterials.AcommonthreadinfeedbackfromGPswastheyvaluedtheinformationprovidedintermsofitsimpartiality,clinicalrelevance,practicality,thoroughresearchandmethodofpresentation.

Recommendations 1. AnationalstrategyforachievingmoreinformedchoicesbetweenGPsand

theirpatientswithrespecttoprostatecancerissuesisurgentlyneededincontemporaryAustralia.

2. DATISservice-oriented-ADisamethodologysuitabletobeusedasafoundationwithinaneedednationalstrategy.Ithasbeenshowntobeeffectiveinthe1998-99studyrelativetocheaperapproacheswhichwerefoundtobeineffective.

3. AnumberofuncertaintiesaboutDATISservice-oriented-ADinthiscontextneedtobeexaminedbeforeexperimentallyderivedevidenceabouttheeffectivenessofDATISmethodscouldreasonablybetranslatedintopublichealthpolicyaction.


Medico-legalaspectsofPSAscreeningwereamajorissueforthemajorityofGPsvisited,andperhapsthegreatestsinglemotivatorastowhyGPsfulfillpatientrequestsforthePSAtest.

ManyGPsfeelvulnerableandunconfidentwhendealingwiththeissuesandcontroversysurroundprostatecancerscreening.


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CommonwealthinvestmentinNationalPrescribingService(NPS)academicdetailingstrategiesfordiagnosticservices.

Common Sense Pathology (2006)

Description CommonSensePathology(CSP)wasapublicationseriesproducedprimarilytoassistGPsindeterminingappropriatepathologytests.Itranforsixeditions,comprisedaseparatelyboundeight-pageA4supplementwithgraphicartworkand/orphotosappropriatetothetopicandwasincludedintheAustralian Doctormagazine.AlleditionswerepostedontheRoyalCollegeofPathologistsofAustralasia(RCPA)website(http://www.rcpa.edu.au)withinonemonthofpublication.


Aim

toimproverationalandcost-effectiveutilisationofpathologytests.It is not clear if this aim was achieved although general practitioners (GPs), other doctors and medical students indicated the CSP articles were a valuable source of information.

Outcomes [alt=“ThefollowingtableliststheeditionoftheAustralian Doctormagazine,againsttheCSParticleandtheauthor/s”]

EDITION ARTICLE AUTHOR/S 7April2006 Malabsorption DrDannyStielandDrPaulO’Farrell2June2006 ViralHepatitis ProfYvonneCossart7July2006 MicroUrine ProfSydBellandDrAlexOuthred4August2006 Genital

InfectionDrAndrewDaleyandDrSuzanneGarland

1September2006 Lipids DrDavidSullivanandDrDavidTognarini3November2006 IronStudies DrAlanRMcNeilandEmeritusProfJackMetz

CSParticlesontheRCPAwebsitereceived340‘hits’bytheendofDecember

2006. TheRCPAcoveredallitsadministrativecosts,andtheauthorsoftheCSP

articleswerenotpaid,andnorwastheCSPEditor,astheseroleswerehonorary.

Findings

AnAustralian DoctorgeneralreadersurveyfoundthatCSPwasavaluablesourceofinformationforGPs.

Pathologistswerekeentocontributetothepublicationasauthorsastheyconsideredittobeaneffectivecommunicationtool,werehelpingGPsandinvolvingtheminthepathologyprocess.


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CSPhelpspreventunnecessarytestingresultingincostsavingsandavoidanceofinvasiveteststhatarenotwarranted.

CSPpromotesgoodpatientcareandcosteffectivepatientmanagementbyhelpingtopreventpotentialmisdiagnosesthatmayoccurbyomittingimportanttests.

CSPsavescostsofhealthcareasmanagementcanbeinstigatedatanearlierstageofdisease.

Recommendation 1. DrMatthewMeerkin,RCPACSPEditor,suggestedthatacompilationofthe

last24issueswouldbeausefuladditiontothelibraryofGPs,pathologistsandmedicalstudents.


Asthepathologistswritingthearticlesdonatedtheirtime,theissueoftimelineswasmanagedby:

o securinganauthor’sagreementtowritethearticleswellinadvancewhereverpossible

o providingregularremindersfordeadlineso shorteningdeadlinesfordeliveryofarticlestotheRCPAtoallowfor

unforeseendelays. Toensurethetonewasappropriatefortheintendedaudience:

o authorswereaskedintheirletterofinvitationtowriteatalevelwhichwilleducateGPswithexplanatoryguidelinesprovided

o theRCPACSPEditorsometimesrequestedsendingthearticletoaGPwithaninterestinthespecifictopicbeforepublicationtotestitseffectiveness.

Difficultieswithearlyarticlesexceedingthewordlimitimposedbythepublisherdidnotrecur,andtheselimitswereclearlydefinedincorrespondencetoprospectiveauthors.Timewasalsobuiltintodeadlinestoenablearticlesthatweretoolongtoberevised.

Follow on Initiatives and Projects CommonSensePathologyPublicationSeries(2011).

Common Sense Pathology Publication Series (2011)

Description TheCommonSensePathology(CSP)publicationseriesforgeneralpractitioners(GPs)highlightsareasthataretopicalorproblematicindiagnosisormanagement.ThetopicsarechosenafterconsiderationoffeedbackfromAustralian Doctormagazineresearchabouttopicsofinterest,aswellasviafeedbackfrompathologistsaboutareasoftheirpathologyspecialtythatappeartobeconfusing,controversialorfrequentlymisunderstoodbyGPs.CSPwasdeliveredwithAustralian Doctormagazineto21,000recipients(whichessentiallyencompassedeverypracticingGPinAustralia).All2010/11editionswerepostedontheRoyalCollegeofPathologistsofAustralasia(RCPA)website(http://www.rcpa.edu.au/)withinonemonthofpublication.Issuesdatingback


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to2002werealsoavailableontheAustralian Doctorwebsite(http://www.australiandoctor.com.au/).


Aims and Objectives

toproduceaseriesofarticlesonareasthataretopicalorknowntobeproblematicwhenitcomestodiagnosisandmanagementbyGPs

toprovidepractical,relevantinformationaboutappropriatepathologyorderingforGPs.

Theseaimsandobjectiveswereachievedbythisproject.

Outcomes [alt=“ThefollowingtableliststheeditionoftheAustralian Doctormagazine,againsttheCSParticleandtheauthor/s”]NUMBER EDITION ARTICLE AUTHOR/S

1 29October2010 TiredAlltheTime DrSteveFlecknoe-Brown2 18February2011 GeneticInvestigationof

ChildrenDrSuiYu&DrNicolaPoplawski

3 1April2011 VitaminD DrMargaretJanu4 3June2011 CoeliacDisease DrDavidGillis

Findings

Australian Doctors’ownresearchhasshownthatclinicalinformationisthemostpopularareaofthepublicationwithresearchsuggestingover85%ofallGPsarereadingsectionsentirelyfocusedonclinicaltopics.

ReedPublishingadvisedtheybelieveCSPservedasausefuladjuncttothepromotionofappropriateordering,interpretationandfollow-upofpathologytestingbyAustralianGPs.

Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009)

Description Thisprojectsoughttoidentify,designandpilottheuseofsynopticformsandreportingprotocolsforcolorectalcancer.

Grant Recipient UniversityofNewSouthWales

Aims and Objectives

toidentify,designandpilottheuseofsynopticformsandtheimplementationofprotocolsthatwillreducereportvariabilityandpromoteconsistencyandreliabilityofpathologyreportingincolorectalcancer

theIPREPteamwillconsultwithpathologists,surgeonsandoncologiststopromotecommunication,collaborationanddisseminationofknowledgeregardingbestpracticeguidelinesandevidence-basedreporting.


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Outcomes

Thesynopticsurgicalrequestformandsynopticsurgicalrequestreportweredesignedforthereportingofcolorectalcancercasesalongwithasetofaccompanyingguidelines.

ThesedocumentsweredistributedintheircurrentformtoallindividualpathologistsandpathologylaboratorieswhichservicedtheSouthEasternandIllawarraAreaHealthService(SEIAHS).Theyweredistributedviaface-to-facemeetingswithacontactpathologistineachlaboratory.

AdditionalelectroniccopiesofthedocumentswerecirculatedviaemailandcouldbedownloadedfromtheColorectalCancerResearchConsortium(CCRC)website.

Thedocumentswerealsodistributedtooncologistsandsurgeonsthroughattendanceatmultidisciplinaryteammeetingsateachhospital.

AreviewofpathologyreportsfromeachpathologylaboratorywithintheSEIAHSwasconductedatthreedifferenttimepointstovalidatethepracticaluseofthesynopticdocumentsandguidelines.

Nationalconsensusandexpertopinionwastobesoughtforthecolorectalsynopticreportsandguidelines.

Colorectalworkingpartymeetingswereconductedon:o 24October2008inaface-to-faceforumo 18December2008viateleconferenceo 12February2009viateleconference.

Thisworkingpartyincludedmedicalspecialistsfromthefieldsofpathology,surgeryandoncology,aswellastheprojectmanagersoftheIPREPandCancerInstituteNSW(CINSW)StructuredPathologyReportingStandardsforCancer(2009) project.

TheIPREPprojectmanagerattendedbi-monthlyworkingpartymeetingswiththeCINSWprojectmanagerandrepresentativesfromtheRoyalCollegeofPathologistsofAustralasia(RCPA)andCancerAustraliatofinalisetheguidelinesforratificationfrombothofthesebodies,andforsubmissionoftheguidelinesforapprovalfromtheNationalE-HealthTransitionAuthority(NeHTA).


StructuredPathologyReportingStandardsforCancer(2009).

Structured Pathology Reporting Standards for Cancer (2009)

Description Thisprojectsoughttoleadthedevelopmentofanagreedmethodandstructurefordeveloping,disseminatingandmaintainingguidelinesforstructuredpathologyreportingofcancer.

Grant Recipient CancerInstituteNSW


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Aim

toleadthedevelopmentofanagreedmethodandstructurefordeveloping,disseminatingandmaintainingguidelinesforstructuredpathologyreportingofcancer.


Outcomes

Thesixprotocolsdevelopedwere:melanoma,prostate(radicalprostatectomy),lung,colorectalandlymphomabasedontheFrameworkdocuments.TheNationalBreastandOvarianConsortium(NBOCC)agreedtoreformattheirguidelinestothedevelopedframework.

WorkwasalsoinprogresstodevelopHealthLevelSeven(HL7)messagingstandardsandarchetypesinconjunctionwiththeNationalE-HealthTransitionAuthority(NEHTA)


AkeypartofthisprojectwasdevelopingtheFrameworkforDevelopingProtocolswhichwasthenusedtodevelopsixcancerspecificprotocols.

FeedbackfrompublicconsultationonfiveofthesixprotocolshighlightedanumberofpointsonthegeneralstructureandapproachoftheprotocolswhichenabledtheFrameworkcommitteetorevisethedocuments.Thiswillassistdevelopersoffutureprotocols.


PromotingandExpandingStructuredPathologyReportingofCancer(Stage2)(Current).

Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current)

Description Thisprojectisseekingtopromoteandexpandtheuseofstructuredreportingofcancer.Thefinalreportisdueon16June2012.

Grant Recipient RoyalCollegeofPathologistsofAustralasia(RCPA)

Aims and Objectives

toundertakeanationalprogramofeducationonthepreviouslydevelopedcancerprotocols(breast,melanoma,lung,lymphoma,colorectalandprostate)

todevelopfurtherprotocolsinconjunctionwithinternationalbodies toundertakealiteraturereviewofpathologycancerreportstoprovide

informationonbestpracticereportingformatsthatenhancetheirunderstandingandreadabilitywiththeaimofcontributingtoimprovedpatientcareandsafety


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tosharethefindingsoftheliteraturereviewtoprovideadviceandfeedbackandparticipateasamemberoftheCollaborativeManagementGroupandasapartnerwiththeUniversityofMelbourneandDianellaCommunityHealthontheprojectEffectiveCommunicationofPathologyResultsinRequestingPractitionersandConsumers(Current)onpage 133

toworkcollaborativelywithProfessorJonPatrickattheUniversityofSydneytodevelopamodeltoautomaticallyreviewprotocolcontentanddevelopabaselineforthestructuredreportingofcolorectalcancer.

This project is current and the aims and objectives are in the process of being achieved.

Outcomes Theproject’saimsandobjectivesarebeingachievedinthefollowingstages: Establishgovernancefortheproject. Establishongoingmaintenanceandupdateprotocolsincludingpublication

andmediarelease. Developadditionalprotocolsandaformatforreportingstructured

information.Inaddition,workwithotherorganisationstoenabletheuseoftheprotocols.

Developadditionalprotocolsavailableforothercommoncancersincollaborationwithinternationalorganisations.

Reportonupdatingandpublicationofprotocolsandcommencealiteraturereviewofpathologycancerreports.

AuditofcolorectalstructuredreportinginassociationwiththeClinical Language Processor Engineproject.

CompletionoftheprojectandprovisionofaFinalReport.


Possibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.

Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009)

Description Thisprojectsoughttodevelopspecificlaboratoryguidelinesandrecommendedprocedures(theGuidelines)toensurebestpracticeindealingwithsuspectedcasesofBloodBorneVirus(BBV)transmissioninhealthcaresettingsandthusreducethelikelihoodandimpactofBBVtransmission.

Grant Recipient SouthEasternAreaLaboratoryServices(SEALS)

Aims and Objectives

todevelopspecificlaboratoryguidelinesandrecommendedprocedurestoensurebestpracticeindealingwithsuspectedcasesofBBVtransmission

tocreateanAustralia-wideforumfordiscussionoftheguidelines


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toidentifyfacilitiesineachStateformolecularepidemiologyinvestigationstudies

toadvisepublichealthprofessionals,pathologists(includingtheRoyalCollegeofPathologistsofAustralasia[RCPA])andpolicymakersonthebest-practiceevidence-basedlaboratoryproceduresindealingwiththesecases

tointerfacewithhealthcareworkersandthecommunityatlargeonbasicinformationonBBVtransmissionviaconsultation,websiteandcollaboration.

These aims and objectives appear to have been achieved. The report states some were still in progress of when it was tabled, specifically to continue developing guidelines and methods for testing and investigation, and to develop evidence-based models and analysis of protective factors for BBV infection.

Outcomes

Laboratoryguidelinesweredevelopedcomprisingfivesections:1. principlesforoutbreakinvestigations2. specimenhandling,transportandstorage3. testingprotocolsforBBVinvestigations4. BBVgenotypingandsequencing5. laboratoryrequirementsforBBVinvestigations.

AdraftoftheBBVwebsitewasinstigatedwhichisaneducationalblogdesignedtoprovideanopenforumfordiscussiononcommunityissuesrelatedtoBBV,particularlyintheareaoflaboratorytesting.

SpecificBBVfacilitieswereidentifiedinfourmajorStatesformolecularepidemiologyinvestigationstudies.

DevelopmentofaneducationalwebsiteforhealthcareworkersandthecommunityonbasicinformationonBBVtransmission.Thiswasunderconstructionatthetimeofthereportat:http://www.bloodborneviruses.org.au/.

Recommendations 1. Continuedevelopmentofguidelinesandmethodsfortestingand

investigation,includingreversetranscriptionpolymerasechainreaction(RT-PCR)andsequencingprotocolsforthemolecularepidemiologyofBBVstomaintaintheseBBVfacilitiesasamodelofbestpracticeintheinvestigationandpreventionofBBVtransmission.

2. Developevidence-basedmodelsandanalysisofprotectivefactorsforBBVinfection.ThiswillresultinthedevelopmentofpracticalpoliciesforBBVtransmissionandpreventioninhealthcaresettings(liaisonhadalreadybeenestablishedwithPathWest,VictorianInfectiousDiseaseReferenceLaboratory[VIDRL]andNSWHealth).


ThemaindifficultywasmeetingdeadlinessetbytheAustralianGovernmentDepartmentofHealthandAgeingduetotheswineflupandemic.Mostvirologyexpertsandinfectiousdiseasescommitteeswereunavailableduetourgentissuesrelatedtothepandemic.


IntegrationofprotocolstoNationalBBVTestingPolicies.


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46

Risk Minimisation Riskminimisationinpathologypractice,fromcollectionofasampletoreportingtheresults,isparamounttothequalityuseofpathology.TheQualityUseofPathologyProgram(QUPP)hassoughttoaugmentthesolidbasisinriskminimisationbuiltbymultiplestakeholderssuchastheRoyalCollegeofPathologistsofAustralasia(RCPA),theRCPAQualityAssuranceProgramsPtyLtd(RCPAQAP)andtheNationalAssociationofTestingAuthorities(NATA)throughfiveprojects(Table3).Keyareasinriskminimisationincludeidentifyingearlywarningsignsthatcanidentifypoorlyperforminglaboratories,andassistingpathologylaboratoriestoidentify,measure,monitorandinvestigatepotentialoractualerrorswhichmayposeapotentialrisktopatientsafety.Theseprojectsalsohighlightedsomekeyprojectlearningsregardingstrategiestomonitor,measureandassesslaboratoryperformance,andhighlightedthesignificantchallengethatthemajorityoferrors(75%)inpathologyoccuroutsideoftheofthepathologylaboratories’control.Basedontheselearnings,areasforfutureconsiderationfromallreportssummarisedinthischapterinclude: Standardisekeydefinitionsandtermsforincidentmonitoringandreporting. Considerstrategiestoaddresstheissueoferrorsoccurringwhenanon-

pathologypersoncollectsapathologysample.[alt=“ThefollowingtableliststhefiveprojectnamesandgrantrecipientsundertheRiskMinimisationtheme”]

Project Name Grant Recipient/s

1 RCPA–QualityAssuranceProgramsKeyIndicatorProject(2004)

RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)

2 PilotLaboratoryAssessmentandPeerReviewMechanismforPathologyKeyPerformanceIndicators(2007)

RCPAQAP

3 PerformanceMonitoringofExternalQualityAssurance(Current)

RCPAQAP

4 NATAFileAudit–RiskAnalysisofAssessmentNonConformancesIdentifiedinPathologyLaboratoryAssessmentAccreditation(Current)

NationalAssociationofTestingAuthorities(NATA)

5 KeyIncidentMonitoring&ManagementSystems(Current)

RCPAQAP

Table 3: Reports summarised for Risk Minimisation


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RCPA – Quality Assurance Programs Key Indicator Project (2004)

Description Thispilotprojectdevelopedamechanismtoidentifypoorlyperforminglaboratoriesonacontinuingbasis.Itarosefromrecommendation5.1oftheCorrsChambersWestgarthreporttitledThe Evaluation of Australian Pathology Laboratory Accreditation ArrangementsfortheAustralianGovernmentDepartmentofHealthandAgeing2002(CorrsChambersWestgarthLawyers)whichstates:

thattheDHAandtheHICseekthecooperationoftheRCPAQAPtoestablishexplicitexternalqualityassuranceperformancecriteria,initiallyinchemicalpathologyandgynaecologicalcytology,andamechanismfortheRCPAQAPtoidentifyrelativelypoorlyperforminglaboratories.

ThispilotwasthefirststageinthisprocessanddevelopedKeyPerformanceIndicators(KPIs)forchemicalpathologyandcytopathologythatcouldpotentiallybeusedtoidentifyanearlywarningalertsystemofpoorlaboratoryperformance.

Grant Recipient RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)

Aims and Objectives

todeterminewhetherqualityassurancedatacanbeusedasanearlyindicatorofpoorlyperforminglaboratories

todevelopamodelorindicatorthatwillselectthelaboratoriesmostprobablyneedingreview

todeterminewhetherthesameorasimilarmodelorindicatorcanapplytoalldisciplinesofpathology.


Outcomes

ANationalPathologyAccreditationAdvisoryCouncil(NPAAC)SteeringCommitteewasestablishedtooverseetheproject,andtwoKPIworkinggroupsforeachdiscipline(chemicalpathologyandcytopathology)wereestablishedtoassisttheproject.

TheprojectgroupsandSteeringCommitteedeterminedthemethodologyforthepilotshouldbebasedona‘peerreviewprocess’ratherthana‘standards’approach.

Laboratorieswerereviewedindividuallytoensuretheirassessmentincludedonlyrelevantdatainthefollowingfourstepprocess:

1. Selectionofthepeergroupofthelaboratoryunderreview.2. Selectionoftheassessmentprocess.3. Processthelaboratory’sdata,theirpeersandrankingperformance.4. ConsolidatealldatatoobtainaKPI.

Itwasconsideredthataneedexistedtodevelopamoredetailedfeedbackofqualityassurance(QA)performancetohelplaboratoriesimprove.Itwas


48

envisagedthePeerReviewCommittee(PRC)wouldaddressthisissue.Mostlaboratorieswouldalsobecomplementedongoodperformance,withthisprogramidentifyingpotentialproblemsearlier,butalsoprovidingpracticalandusefulguidancetoparticipants.

Chemical Pathology Program TheChemicalPathologyProgramcomparedalaboratory’sperformancewith

alllaboratoriesintheirpeergroup(thosethatdidthesametesting)andthenrankedtheirperformanceagainsteachother.

TheQualityAssuranceProgram(QAP)datawasmodeledusingvariousstatisticaltests.ThebesttooltodeveloptheKPIrankingacrossthewholelaboratoryforallanalyteswasconsideredtobetheCoefficientofVariation(CV%).

Anumberofkey/criticalanalyteswereidentifiedandrankedforeachlaboratoryusing‘TotalError’.

Alllaboratorieswouldreceiveareportoftheirperformance. ThesetofassessmentcriteriarecommendedforChemicalPathologywas:

o aKPI<0.05o aparticipationrateintheQAPof<80%o alateresultrateof>10%o aresultcorrectionrateof>5%

IfthelaboratorymetthesecriteriatheywouldbereferredtothePRCtoassessiftherewasaproblem.

Theprogramrequiredsomefurtherminorrefinements,butwasanticipatedtobeimplementedonatrialbasisin2005.

Cytopathology KPI Program AsimilarprocesstotheChemicalPathologyProgramwasdevelopedwith

eachlaboratoryrankedagainstitspeers. ItwasonlymodeledinGynaecologicalCytopathology,andrequiredfurther

refinementoverthefollowing12months. TherecommendedassessmentcriteriaforCytopathologylaboratorieswas:

o aKPIrankinthelowest10thpercentileoftheirpeergroupo morethantwomajorerrorsinanyprogramo lessthan75%ofresultssubmittedo morethan50%ofresultssubmittedafterthedeadline.

IfalaboratorywasidentifiedasfallinginsidetheassessmentcutoffrangestheywouldbereferredtoaPRC.

Fourscoreswerecreatedforrankinglaboratoriesdeterminedfromasetof20slides.Adiagnosiswassuppliedbythelaboratoryforeachslidewhichwasscoreddependingonwhetherthetargetresponse(10),anacceptableresponse(9)anunacceptableresponse(4)oramajorerror(-1)wasreported.

Reviewofthevalueofthescoresmayberequiredtoensuretheyprovidedtherequireddiscriminationofperformance.Furtherattentionmayberequiredintheclassificationofacceptable,unacceptableresponsesandthoseconsideredmajorerrors.

Itwassuggestedthatascytopathologywouldnothavesufficientdataforanalysisinasix-monthtimeframe,thatrolling12monthdatabereviewedeverysixmonths.


49

Theseguidelineswillbeextendedandmodifiedasrequiredfornon-gynaecologicalcytology.

Peer Review Committee ThePeerReviewCommittee(PRC)wastobeestablishedforeachdiscipline

andwouldformasub-committeeoftheMedicalTestingAccreditationAdvisoryCommittee(MTAAC)oftheNationalAssociationofTestingAuthorities(NATA).

ThePRCwastobemadeupof:o twoRCPAFellowsfromtherelevantdisciplineso twootherrelevantprofessionalso tworepresentativesfromtherelevantQAOffice,onebeingthecurrent

chairpersono oneNATArepresentativeo oneGovernmentrepresentative.

ThePRC’sstructurewastobetrialedinthenextstageofthePilotProject,withnopecuniaryactiontakenuntiltheprocesshadbeenagreedtobytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA).

ItwastheresponsibilityofthePRCtodetermineifthelaboratoriesreferredtoitwereperformingbadly,oriftheywereatthebottomofaveryhighperforminggroupoflaboratories.IftherewasaconcerntheywouldbereferredtoNATAforanaccreditationvisitordeskaudit.

Ifalaboratoryisenrolledinanon-RCPAQAPqualityassuranceprogram,theyshouldstillberequiredtosubmitreportssimilartothoseprovidedbyRCPAQAPPtyLtdtotheMTAACPeerReviewSubcommittees.

Findings

Thereareteststhataregenerallydonewellbyalllaboratoriesandteststhatarenotdonewellbyanylaboratories.Thisisduetothedevelopmentstageorlevelofthetest.Poorperformanceofalaboratoryshouldbebasedonthelaboratory,andnotontheanalyte.Basedonthisinformation,laboratoryperformanceshouldbemeasuredbytheteststhataregenerallyperformedwellbyalllaboratories.

KPIsareatooltoassistinidentifyinglaboratoriesthatmayneedreview.Nocomputerprogramhasthesubtletytounerringlyindicateamandatorylaboratoryreview.Thereisacceptancethatevenafterthepeerreviewprocesshadsuggestedtherewasaproblem,theKPIwouldonlybeusedasaflagtonotifyNATAthatthelaboratoryrequiredsomeformofreview,whetherasaformalvisit,paperauditorsomewhereinbetween.

TheChemicalPathologyqualityassuranceprogram(QAP)analysisandreportappearedtohaveahighlevelofacceptancebytheprofessionandparticipants.

TheCytopathologyKPIProgramwasmoredifficulttodevelopbecauseitisaqualitative(opinion-based)specialtyratherthanaquantitative(measurable)specialty.

TheimplementationoftheCytopathologyKPIProgramrequiredaculturalshiftamongstcytologists,andmayrequireareviewoftheQAP.PreviousQAPshavebeenviewedasa“testandteach”ratherthanmeasuringperformance.


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Duetothesmallnumberofcytologistsinanylaboratory,KPItestingmaybeviewedasanindividualassessmentratherthanalaboratoryassessment.Consideringthe‘pilot’natureoftheprogram,thishascausedconcernswithsomelaboratories.

Cytopathologysuffersfromthedifficultiesofprovidingsuitabletestmaterialsinthequantitiesandvarietythatcreateequitableassessmentamonglaboratoriesduetothequalitativenatureofthetestingprocess.Someofthedifficultiesmayberectifiedinthefuturewiththeintroductionofvirtualmicroscopy.

CarefulinterpretationoftheKPIdataisessential.Poorperformancemustbecomprehensivelyassessedanditispossiblethatinsomecasesthepoorestperformersmaystillbesatisfactoryforpatientcare.

Recommendations 1. Extendtheprojecttootherdisciplines,withblood-bankingthenext

recommendedareatoundergothisprocess.2. Fundingoptionsbeyondthepilotprogramshouldbeinvestigated.3. Educatetheprofessionabouttheprojectandfurtherrefinementovertimeof

theKPIprocess.4. InformotherQAprovidersofthisinitiative.5. Furtherstudieswouldbeinvaluableastheprocessproceeds,particularlyfor:

a. ‘critical’analytesb. sizeoflaboratoryc. methodstoidentify‘gamingandcollusion’d. year-to-yearconsistency.

6. Finalisesoftwaredevelopmentondatafrom2002onwards.7. ProcessanddistributeJanuarytoJune2004data.


Itwasfeltthatwhilegraphicalreportingwasinitiallyusefulinrankinglaboratories,theKPIplotshouldnotbereportedbacktothelaboratoriestoavoidthepotentialtopromotetheir‘ranking’forcommercialadvantage.Asthepurposeisprimarilytoidentifypotentiallypoorlyperforminglaboratories,theaddedinformationregardingrelativerankingswasconsideredirrelevantandmayraiseadditionalconcerns.

Determiningthecut-offpointfor‘poorlyperforming’laboratorieswasnotaneasytask.Theyweresubjectedtoseveralmodelsandseveralroundsofevaluation.

TheRCPAQAPneededtoobtainlegaladviceregardingthefeasibilityofawaiverwithrespecttoliabilityforlaboratoriesthatsignedupforparticipationinthisproject.ThisisbecauselaboratorieswhoseKPIreportsweresubmittedtothePRC,followedbyasubsequentinspectionbyNATAandanyotherstepsintheprocess,mayotherwiseresorttosuingtheRCPAQAPforeconomicloss.

Follow on Initiatives and Projects PilotLaboratoryAssessmentandPeerReviewMechanismforPathologyKeyPerformanceIndicators(2007).


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Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007)

Description Thisprojectarosefromrecommendation5.1oftheCorrsChambersWestgarthreporttitledThe Evaluation of Australian Pathology Laboratory Accreditation ArrangementsfortheAustralianGovernmentDepartmentofHealthandAgeing2002(CorrsChambersWestgarthLawyers)whichstates:

thattheDHAandtheHICseekthecooperationoftheRCPAQAPtoestablishexplicitexternalqualityassuranceperformancecriteria,initiallyinchemicalpathologyandgynaecologicalcytology,andamechanismfortheRCPAQAPtoidentifyrelativelypoorlyperforminglaboratories.

ThefirststageofthisprojectdevelopedKeyPerformanceIndicators(KPIs)forChemicalPathologyandCytopathologythatcouldpotentiallybeusedtoidentifyanearlywarningalertsystemofpoorlaboratoryperformance.ItwasidentifiedthatafurtherstepwasrequiredinthedevelopmentofKPIstoassessiftheywereavalidtoolforthispurpose.Thisresultedintheproject’ssecondstageasrepresentedbythisproject.


Aims and Objectives

establishmentofPeerReviewCommittees(PRCs)forChemicalPathologyandgynaecologicalCytopathology

pilotextensionoftheKPIassessmentandreviewprocessasdevelopedintheinitialproject

addresstheissueoftheNationalPathologyAccreditationAdvisoryCouncil(NPAAC)producingastandardorotherdocumenttoprovidelegislativebackingtotheprocess

fundingoptionfortheKPIassessmentandreviewprocessinthelongtermtobeinvestigated

theRCPAQAPneedstoobtainlegaladviceregardingthefeasibilityofawaiverwithrespecttoliabilityforlaboratoriesthatsignupforparticipation

educationoflaboratoryparticipantsontheKPIassessmentandreviewprocess

potentialfurtherrefinementoftheKPIsisrecognisedasbeingalogicaldevelopmentoftheprogramandbeneficialtotheimprovementofdiagnosticcapabilities.


Outcome

Thisprojectdemonstratedtheneedforanappropriateprofessionalreviewoftheproposedmechanismsforthedevelopmentofaneffectiveearlywarningsystemtodetectpotentiallypoorlyperforminglaboratories.


52

Findings

TheresultsofthepilotprojecttoevaluatetheuseofKPIstoidentifypoorlyperforminglaboratorieshasmeanttheSteeringCommitteecouldnotrecommendtheuseofKPIsasaformalmonitoringprocessforpoorlyperforminglaboratoriesaspartofNPAAC.

TheChemicalPathologyKPIshavebeenidentifiedasausefulinternalqualitytoolforlaboratoriestouse.

ThepoweroftheKPImethodologyisverydependentontheamountofdatathatcanbeanalysed,andasaconsequence,theKPIshavebeenmoreusefulinChemicalPathologythaninCytopathology.

TheinformationtohandsuggeststhatKPIsandthePRCprocesscanidentifylaboratorieswithpoorExternalQualityAssessment(EQA)performance,butthisdoesnotnecessarilyequatetopoorratingsatanon-siteassessment.

ThelowestKPIlaboratorieswerenotdistinguishedbymoreadverseassessmentoutcomeswhencomparedwiththehighestKPIgroup.

ThemethodologiesusedsuggestedthecurrentKPIswerenotasensitivetestofoveralllaboratoryperformancewhencomparedtoassessmentfindings.

ThecorrelationoftheKPIsandNationalAssociationofTestingAuthorities(NATA)assessmentsdidnotsupporttheiruseasan‘earlywarningsystem.’

TheKPIsascalculatedforthisprojectwerebasedsolelyonqualityassuranceprogram(QAP)performance.Theirnameinfersthiscorrelateswithactuallaboratoryperformance,however,thisdoesnotappeartobethecase.

Recommendations 1. ThefrequencyoftheKPIreviewforChemicalPathologyshouldbeeverysix

months.2. Cytopathologydoesnothavesufficientdataforasix-monthreview,soit

shouldhaveanoverlapping12monthrevieweverysixmonths.3. KPIsarenotavalidtooltouseforidentifyingpoorlyperforming

GynaecologicalCytopathologyLaboratories,andasaconsequencetheSteeringCommitteerecommendsthattheyNOTbeimplementedintheexistingformat.

4. TheKPIsforChemicalPathologyappearedtobeofsomeuseinidentifyingpoorlyperforminglaboratoriesandarewellacceptedbylaboratoriesasausefulinternalqualitytool.However,duetothepoorcorrelationbetweenlaboratoriesknowntobepoorlyperformingandtheKPI,theSteeringCommitteecouldNOTrecommendtheintroductionofKPIsinChemicalPathologyasaformaltoolenshrinedinNPAACStandardstohelpidentifypoorlyperforminglaboratories.However,becauseoftheusefulnessoftheKPIinChemistrytoevaluateperformancebasedonqualityassurance(QA)data,andpotentiallyusefulinrankinglaboratoriesoverallperformance,theRCPAQAPwillcontinueproducingtheKPIsforChemicalPathologyandthiswillbeincludedwithintheservicesitofferstoitsparticipants.

5. TheSteeringCommitteeconsidereditappropriatetocontinueaPeerReviewMechanismforChemistryonatrialbasis.

6. TheSteeringCommitteeconsidereddevelopingKPIsinBloodTransfusionsonapilotbasisasuseful.

7. QAPdatainCytologyexpressedasKPIshasnotprovenusefulasapredictorof“poorlyperforming”laboratories,althoughalargenumberofmajorerrors(e.g.greaterthanthree)inaQAPmaystillbeausefultriggerforreview.


53

8. ExaminationoftherelationshipofPerformanceMeasurestoNATAAssessmentfindingsshouldbethesubjectofafurtherstudy.

9. TheroleandmembershipofthePRCanditsTermsofReferenceneedtobeexploredfurther.

10. LegaladvicetotheRCPAQAPregardingfeasibilityofawaiverwithrespecttoliabilityforlaboratoriesthatsignedupforparticipationincludedtherecommendationthatidentifyinginformationneverbereleasedtothePRCingeneral,butonlytoNATA.TheyalsoadvisedseekingalegalagreementwithNATAtoensurethatNATAneverdisclosestheidentifyinginformationtoathirdparty,andthattheiractionsbelimitedtoanacceleratedreviewofthelaboratoryinquestion.

11. Ongoingfundingforanyfurtherprojectsneedstobeconsidered.12. PotentialfurtherrefinementoftheKPIswasrecognisedasbeingalogical

developmentoftheprogramandbeneficialtotheimprovementofdiagnosticcapabilities.

13. TheworkundertakenatPacificLaboratoryMedicineServices(PaLMs)regardingKPIsforquantitativepathologyworkcouldformthebasisforfurtheranalysisoftheirfindingstoprovidethescientificcommunitywithaclearunderstandingofwhichtestsneedtobeconcentratedonintermsoffurtherdevelopmentandqualityimprovement.


ThereweredelayscompletingtheprojectrelatedtoKPIsoftwareandtheworkforcecrisisinpathologymeaningthetimepathologistscouldgivetothisprojectonavoluntarybasiswasrestricted.ItalsosometimestooklongperiodsoftimetogettheCommitteetogethertoreviewdatawhichalsodelayedtheproject.


PerformanceMonitoringofExternalQualityAssurance(Current) NATAFileAudit–RiskAnalysisofAssessmentNonConformancesIdentified

inPathologyLaboratoryAssessmentAccreditation(Current).

Performance Monitoring of External Quality Assurance (Current)

Description Thisprojectisinvestigatingifanearlywarningsystemcanbeestablishedtohelpminimiserisktopatientsandassistlaboratoriesinaddressingexternalqualityassurance(EQA)concernsearly.TheRoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)previouslyranaRCPA–QualityAssuranceProgramsKeyIndicatorProjecttrialwhichwillberevisitedforchemicalpathology(datahadbeencollectedoverfouryears).KPIsarenowbeingdevelopedforotherpathologydisciplines,notablyanatomicalpathologyandtransfusionserology,andevaluatedasindicators.ThisprojectwillharmonisewithcurrentKeyIncidentMonitory&ManagementSystems(KIMMS)initiatives.


54

Grant Recipient RCPAQAP

Aim

todeveloppathologylaboratoryperformancefromanumberofperspectives.

Objectives

toexaminepathologylaboratoryperformancefromanumberofperspectives toestablishaworkingpartywiththeTherapeuticGoodsAdministration

(TGA)todevelopwaystoidentifysub-standardtestsandkitsthatcanhaveadirecteffectonpathologylaboratoryperformance

toreviewfouryearsofKPIdataandcorrelatewithNationalAssociationofTestingAuthorities(NATA)accreditationvisits

toestablishKPIsystemsanddevelopsoftwarefortransfusionserologyandanatomicalpathology

tosetbenchmarksforeachKPIdiscipline todevelopnovelprotocolstouseongoingEQAresultstomonitor

performance toestablishmechanismstouseEQAdatatohelpmonitorqualityoftests.This project is current and the aim and objectives are in the process of being achieved.

Outcomes AsatDecember2011thefollowinghadbeenachieved: KPIsystemsandbenchmarksforacceptableperformancehadbeen

developedandfinalisedfortransfusionmedicine,cytopathologyandanatomicalpathology

asecondroundconsultationphaseontheproject’sdraftframeworkhadbeencompleted

softwaredevelopmentincludeddefinitionofoverallprojectspecificationdocumentation,scopingofanatomical,transfusionandcytopathologyprogramspecificationsandproductionofprojectdesigndocumentation

finalisationofthedesignofPerformanceSummaryReportsforanatomicalpathology,cytopathologyandtransfusionmedicine

acumulativescorefortransfusionmedicinedevelopedtoreflectperformanceoversixsurveys

theRCPAQAPiscurrentlyexploringtheissueofsendingparticipantreportsdirectlytoNATA.

NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current)

Description TheNationalAssociationofTestingAuthorities(NATA)isconductingananalysisofnon-conformancesidentifiedduringitsassessmentsofpathologylaboratoriesagainsttheaccreditationmaterialsoverthepastthreetosixyears.Thisproject


55

complementsotherQUPPfundedinitiatives,suchasthePerformanceMonitoringofExternalQualityAssuranceprojects,aspartofthepathologyriskminimisationstrategiestoimprovepatientsafetyfollowingthe2009Budgetinitiativetocontinuethedevelopmentofkeyperformanceindicatorsandotherriskidentifiersinpathologyserviceprovision.

Grant Recipient NATA

Aims and Objectives

toidentifycommonissuesandtrendsinpathologylaboratoryassessment toestablishtrendsandpatternsinpoorlyperformingpathologylaboratories toexaminecorrectiveactionsthatarecurrentlybeingundertakenby

laboratoriestoaddressdeficienciesdocumentedinassessmentreports todevelopabasistoarticulatestrategiesthatwilladdresscausesofpoor

performance.This project is current and these aims and objectives are in the process of being achieved.

Outcome

NATAhasdevelopedriskmatricestoassistwiththeirexaminationofcommonissuesandtrendsinpoorlyperforminglaboratories,andiscontinuingtoprogresstheirreviewoffiles.

Key Incident Monitoring & Management Systems (Current)

Description TheKeyIncidentMonitoringandManagementSystems(KIMMS)ofPathologyLaboratoriesassistpathologylaboratoriestoidentify,measure,monitorandinvestigateincidentsinpathologywhichhavethepotentialtocauseharm,andinvestigatetherootcauseoftheseincidentssotheyareminimised,whichinturnwillminimisepotentialharmtopatients.Italsoaddressesthequalityassurance(QA)issuesintheareasofbothanalyticalandnon-analyticalerrors.Thepre-analyticalphasefocusesonidentification/labelingofthesampleandthesamplerejectionrates,whilethepost-analyticaloftestingexaminesresultscorrectedbecauseoflaboratoryerrorandresultsreportedtothewrongdoctor.Theprojectanalysedthe2007-2008KIMMSpilotdatacollection.


Objectives

toassistlaboratoriestomeasureandmonitorincidentsinthepre-andpost-analyticalphasesinthepathologyrequest-test-reportcycle

toprovidedatacollectionandreportinginfourareas:1. pre-andpost-analyticalphases2. howeachincidentwasidentified(bythelaboratoryorbyacomplaint)3. theoutcomeoftheincident(actualorpotentialpatientharm)


56

4. overallincidentrateasapercentageofworkloadeachquarter toraiseawarenessofsafeworkpracticeswhichwillinturnreduceerrors

andincreasepatientsafety toreducethenumberofincidentsinpathologylaboratorieswhichwill

directlyimpactonpatientsafety.These objectives were achieved by this project, although the final objective is a longer-term deliverable.

Outcomes

TheRCPAQAPmadeasubmissionunderPartVCoftheAustralianHealthInsuranceAct1973fortheKIMMSprogramtobeformallydeclaredasaQualityActivitytoprotectlaboratoriesfromlitigationduetodatacollectiononadverseincidents,especiallythosewhovoluntarilydisclosethisinformation.

TheRCPAQAPhasemployedthreeInformationTechnology(IT)stafftomovesoftwaredevelopmentinhouse.ThenewsoftwaredevelopedwillbehousedonRCPAQAPserversunderRCPAQAPcontrol,andwillbearepositoryfortheaggregatedKIMMSdata.

KIMMSdatawillraiseawarenessofunsafeworkpracticesandprovideinformationtotherelevantsectionsofthemedicalcommunitysotargetedsolutionscanbeimplementedtoimprovepatientsafety.

KIMMSwillintroducegradedclassificationofpatientharmin2010. KIMMSdatacanbeutilisedtosetachievablenationalbenchmarksforgood

pathologypractice.

Findings

KIMMSdataconfirmedtheirqualitysystemcapturesmostincidents(97%)allowingthepathologyservicetocorrecttheproblembeforetheycausepatientharm.

KIMMS2007&2008pilotshowedthatbetween70-80%ofsamplemisidentificationproblemswereduetospecimensnotmeetingminimumlabelingrequirementofprovidingtwoidentifiers(e.g.nameanddateofbirth).

Theoverallincidentratewas0.7%in2007(fourthcycle)and0.9%in2008.Althoughtheseratesarelow,thenumbers(114,000incidentsannuallyfromonly24laboratoriesisasmallfractionofAustralianpathology)indicatethestaggeringresourcesusedtostopnon-laboratoryerrorsaffectingpatientsafety.Thesesimpleerrorsareallpreventable.

Overall,pre-analyticalincidentsaccountedforthemajorityofincidents(85-90%in2008)whichisconsistentwiththeliterature.

Post-analyticalphaseoftestingincidentrateswere0.01%ofallaccessions.Theseincluderesultsretractedduetoanerrorbythelaboratoryandthenre-issued,andverylowlevelswhereresultsweresenttothewrongdoctor.

Theincidentratesinthepre-andpost-analyticalphaseoftestingisunder-reportedasmanylaboratoriesdonotcurrentlyrecordtheseincidentsinawaythatallowseasyconsolidatedreporting.

Theabsoluterateatwhichpre-analyticalproblemsoccurredexceededtherateatwhichanalyticalproblemsoccurredasmeasuredinthedetailsframeworkforqualityassuranceprograms(QAPs).


57

Thereisaneedtoaddresspoorsamplecollectiontechnique. Incidentratesincreasedduringthisstudyasparticipantsimproveddata

extractionandcapturetechniques,butshouldeventuallystarttofallas:o pathologyservicesimprovedtheirprocesseso KIMMSraisedawarenessofproblemso varioussectionsofthemedicalcommunityareeducatedinsafework

practices. Laboratoryinformationsystems(LIS)neededtobeconfiguredtocapturethe

dataatthetimeofentryofpatientinformationintothesystem.

Recommendations 1. Standardisingkeydefinitionsandtermsforincidentmonitoringand

reportingisanissuethatneedstobeaddressedtoaccommodatecomparisonofdata.

2. ContactLISproviderstodiscussincorporatingKIMMSdatarequirementsintofutureversionsofLISsoftware.


Thesignificantchallengethatpathologyservicesexperienceisthemajorityoferrors(75%)arenotcausedbypathology.Mostoccurwhenasampleiscollectedbyanon-pathologypersonandareduetopatientmisidentification,incorrectsamplecollectionandthesamplebeingmislabeled.Theseinappropriatepracticescanjeopardisepatientsafety,particularlyforirreplaceablesamples(neonates,biopsymaterialandspinalfluids)wherethelaboratoryhasnooptionbuttoprocessthesampleandprovidea(qualified)result.

ManyparticipantsinthepilotstudydislikedtheKIMMSclassificationofactualandpotentialharmtopatients.

Feedbacksuggestedamoreaccuratemeasureforsamplerecollectionswouldbesamplerejectionsaslaboratoriescouldcapturethisdata.

Evaluatingtheoutcomeofanincidentcausedconfusionandconcernformanyparticipants.

ThepilotphaseofthisprojecthighlightedthedifficultylaboratoriesexperiencedinextractingorcollectingofdatafromcurrentLISwhicharenotsetuptorecordandreport/extractthisdata.A2006questionnairesenttoallpilotparticipantshighlightedthat45%orparticipantscollectedincidentdatamanually(inanexercisebook)andafurther30%recordeddatainaspreadsheetoradatabase.

Bothpilotdataandfeedbackindicatedthatpathologyserviceswerenotsystematicallycollectingdataonincidents,whileotherswhodowerenotdoingsoinamannerthatallowedcomparisonorpeerreview.


PromotionofsuccessfulstrategiesontheRCPAQAPwebsite.


Standardisekeydefinitionsandtermsforincidentmonitoringandreporting. Considerstrategiestoaddresstheissueoferrorsoccurringwhenanon-

pathologypersoncollectsapathologysample.


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59

Quality Assurance and Capacity – New Technology Technologyisbecominganintegralpartofhealthcareandhasthecapacitytoaugmentdiagnosticcapabilitiesatboththepointofcare(PointofCareTesting[PoCT])andinthelaboratory/hospitalsetting.Qualityassurance(QA)issuesareparamounttoensurenewtechnologywillproducereliableresults,especiallyintheemergingareasofPoCTandgenetics.Ensuringtechnologyalsohasthecapacitytodeliverqualityoutcomesintothefuturebeforeaninvestmentismadeisalsoanongoingissueinhealthcare.TheQualityUseofPathologyProgram(QUPP)enabledprojectstodevelop,defineandeducatestakeholdersaboutthequalityassuranceandcapacityofnewtechnology.Eightprojects(Table4)coveredareasfromgeneticstoPoCT,withamajorissuearisingbeingQAissuesassociatedwithPoCT.TheemergingareaofgeneticswasalsotargetedwithprojectsthatsoughttodefineandinformstakeholdersaboutbestpracticeandQAissuesinthisarea.PoCTandgeneticsarealsodynamicareaswithinformationandcapabilityincreasingrapidly,sometimesfrommonthtomonth.Theseareasunderpintheareasforfutureconsiderationincluding: FurtherpossibleworkbytheGeneticsWorkingPartysetupunderthe

PathologyFundingAgreement. InvestigatetheframeworkforPoCTinGeneralPracticerecommendedbythe

Point-of-Care Testing in General Practice Trial (http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pathology-poctt-index.htm).

InvestigateanddefineQAissuesforPoCT.[alt=“ThefollowingtableliststheeightprojectnamesandgrantrecipientsundertheQualityAssuranceandCapacity–NewTechnologytheme”] Project Name Grant Recipient/s 1 VirtualMicroscope(2005) RoyalCollegeofPathologistsof

Australasia(RCPA)2 HighResolutionScanningMicroscopyforQuality

AssuranceandEducationalApplications(2009)RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)

3 DevelopmentofaQualityAssuranceModuleforHumanPapillomaVirusTesting(2008)

RCPAQAP

4 PreparingforGenomicMedicine:NationalAuditandDevelopmentofaBestPracticeApproach(2009)

RCPA

5 Policies,ProceduresandGuidelinesforPoint-of-CareTesting(2011)

RCPAQAP

6 PoCTTraining,Certification,SupportandSkillMaintenanceProgram(AustralianPoCTPractitionersNetwork–APPN)(Current)

AustralasianAssociationofClinicalBiochemists(AACB)

7 EstablishmentofaMolecularGeneticsQualityAssuranceProgram(Current)

RCPAQAP

8 MAWSON–AnOnlineRepositoryofGeneticDatatoAidReportingofMedicalGeneticTests(Current)

UniversityofSouthAustralia

Table 4: Reports summarised for Quality Assurance and Capacity – New Technology


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Virtual Microscope (2005)

Description TheVirtualMicroscope(VM)isacomputersystemconsistingofbothsoftwareandhardwareforscanningmicroscopicimagesofcells,tissuesandbodyfluidsandconvertingthemintoadigitalimage.ThetechnologyallowstheimagestobetransferredtoaCDandtotheInternet,andisparticularlybeneficialforqualityassurance,trainingandeducationalpurposes.TheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)providedfundingtotheRoyalCollegeofPathologistsofAustralasia(RCPA)forthisprojectandtheVMwasinstalledon2August2004.Theprojecttimeframewas1March2004to31January2005,withregularupdatessubmittedforthelifeoftheassetuntil2009.


Aims and Objectives

tointroducevirtualmicroscopetechnologyasameansofdeliveringhighqualityimagestolaboratoriesintheRoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)andotherqualityassuranceprograms

tousevirtualmicroscopytechnologytodevelopeducationpackagesforTraineesandFellows

tocollaboratewithUniversityMedicalSchoolsandotherpathologyorganisationstoprovidedigitalimagesforeducationalprogramstobenefitregistrars,medicalpractitionersandmedicalscientists

tocoordinatetheuseofthevirtualmicroscopytechnologyforotherpathologyrelatedorganisationswithqualityassuranceprograms.


Outcomes

Pilotsurveyswereundertakenin2007and2009,withCDdeliveryofimagesratedhigherthanonlinedelivery.

SurveyresultswerepresentedasaposterattheInternationalSocietyforLaboratoryHematology(ISLH)conferenceinMay2009.

AscanningservicewasestablishedbytheRCPAHaematologyQualityAssuranceProgram(QAP)forclientswithinandoutsidetheRCPA.

CandidatesfortheRCPAHaematologyFellowshipparticipatedinmockexaminationsessionsforthepreparationoftheirrigorousmorphologyexamination.

SlidescanninghasbeenprovidedtotheUniversityofTasmaniafortheireducationmaterials.


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Findings

VirtualmicroscopycannotyetcompletelyreplaceglassslidesurveysbecausesomelaboratorieshavedifficultieswithdownloadingduetorestrictivepoliciesforsoftwareinstallationorslowInternetconnection.However,itisausefuladjuncttothecurrentRCPAQAPglassslidehaematologymorphologyprogramwithparticipantschoosingtoreceivethedigitalimagesonlineoronCDs.

Highresolutionvirtualslidesofbloodandbonemarrowsmearsarepracticalalternativestoglassslidesetsforeducationandtraininginhaematologymorphology.


Onechallengewasongoingtechnicalproblemswiththeoriginalsystem.ItwascompletelyreplacedbythemanufacturerinMarch2006underthewarrantyagreement.

Follow on Initiatives and Projects HighResolutionScanningMicroscopyforQualityAssuranceandEducationalApplications(2009).

High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009)

Description ThisprojectsoughttoexpandoftheuseoftheVirtualMicroscopepurchasedin2004fortheVirtualMicroscopeprojectbyprovidinghighqualitydigitalslidesforeducation,trainingandqualityassuranceactivities.


Aims and Objectives

toestablishakeyresourceindigitalmicroscopy toprovidehighqualitydigitalimagesforqualityassurance,educationand

trainingpurposes.These aims and objectives were achieved by this project.

Outcomes

AlldiagnosticmodulesoftheAnatomicalPathologyQualityAssuranceProgramcontainedsomevirtualmicroscopeimagesin2007.

Twonewmoduleswereestablishedusingvirtualmicroscopeimagesonly. VirtualmicroscopeimageshavebeenpreparedonbehalfofTheAustralian

AnimalProficiencyStandardsProgramforinclusionintheirqualityassuranceprogram.

AtrainingprogramwasdevelopedtorespondtonewHER2positivebreastcancertargetedtherapy.

Aninitialpilotprogramusingweb-basedsoftwarewasundertakenin2006consistingofanumberofquestionsanddigitalimagesforinterpretation.


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SlidesfromcompositeblockswereprovidedforlaboratorytestingwitheachindividualsubmittinginterpretationoftheHER2CISHstainingthroughDigitalSlidebox.

Approximately3500slideshavebeenscannedsince18March2008foreducationandtrainingpurposes.

Variousorganisationsandinstitutionshaveusedtheslidescanningtechnologyforslideseminarsandeducationalpurposes.AprojectonbehalfofAnimalHealthAustraliahasdigitalisedalargereferencesetofveterinaryslidesfortheeducationofveterinarypathologists.

VirtualimagesofglassslidescaseswereputontheAnatomicalPathologywebsiteforparticipantstoreviewwhenrespondingtosurveysandreviewingresults.

SlidesfromtheCytopathologyQAPhavebeenscannedforpilotsurveysintheirprogram.

AlargecollectionofslidesfromthePrinceofWalesMedicalResearchInstitutehasbeenscannedfortheproductionofratbrainatlases.

Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008)

Description Theprojectsoughttodevelopaqualityassuranceprogram(QAP)forthetestingofhumanpapillomavirus(HPV)DNAbypathologylaboratories.Twopilotstudieswereproposed,butonlytheresultsofPilotStudyOnewereincludedinthisreport.


Aims and Objectives

toestablishthebestmaterialandpreparationmethodforspecimenstoissuetolaboratoriesasameansofassessinglaboratorytestingperformanceforHPVDNA

topreparetwopilotstudiessothatthemostsuitablemediumforHPVDNAspecimenscouldbefullyevaluated(DrySwabandPreservCytspecimens)

toimplementstabilitystudiesduringthepilotstudystage toenlist20participantsforeachpilotstudywhowerecommittedto

providingfeedbackandsuggestionstoimprovewitheachsurvey toenlistfurthermembersoftheHPVDNAcommitteesothateachstageof

theprocessindevelopingaqualityassurance(QA)modulecouldbefullyevaluated.

todevelopanappropriatequestionnaireandwebsitedataentryscreensthatwouldbemodified/adjustedinresponsetoparticipantfeedback/suggestions.

Most aims and objectives were achieved by this project, although it did not specifically address the best material and preparation method for specimens to


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issue to laboratories as per the first point above. Stability studies to confirm that shipping specimens at ambient temperature did not affect the integrity of the specimens were also ongoing.

Outcomes Feedbackforthewebsitedataentryincluded: Thenumberofdigitsforenteringnumbersneededtobeextended(thiswas

fixedimmediately). Therewassomeconfusionwiththeunitoptionsavailableandbeingusedby

participants.ThiswasreflectedintheresultsdownloadedattheconclusionofthesurveyandwouldbeaddressedforPilotStudyTwo.

TheuseofmultipleparticipantnumbersforthosereceivingboththePreservCytandDrySwabspecimenscausedsomeconfusion.ThisisuniquetothepilotstudiesandwillbesimplifiedoncethespecimentypehasbeendecidedandimplementedafterPilotStudyOne.

Findings

PilotStudyOneshowedtheutilityofaqualityassuranceprogramforthetestingofHPVDNA.

ThenumberofparticipantstestingtheDrySwabpanelwaslowerthanforthePreservCytspecimensanddirectcomparisonbetweentestingthesesamplesmaynotbeappropriate.

ThereturnedresultssuggestthereisgreatervariabilityamongparticipantsusingamplificationmethodsthanthoseusingHybridCapture.

Recommendations 1. PossiblesurveyresultscouldbeusedduringthenextrevisionofNational

PathologyAccreditationAdvisoryCouncil(NPAAC)Guidelines.2. Theformulationofasecondpilotstudyshouldcontinuetakingintoaccount

thecopynumberevaluatedandinconsistenciesnotedbetweenparticipantswithvaluesandunitsreportedfortheHybridCapturemethodology.

Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)

Description Thisprojectinvolvedanauditofgenetictestingactivity,developmentofanonlinecatalogueofgenetestsandgeneticlaboratoriestoassistclinicians,developmentofguidelinesforreportingofgeneticteststomedicalpractitionersandanationalevaluationofmoleculargeneticqualityassuranceprograms(QAPs)inAustralia.


Aims and Objectives

tointegratecurrentgeneticentriesintheRCPAManualOnlinewiththenewlistingbeingdeveloped

tocompletethereviewofsubmitteddatafromlaboratories


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toconductacomprehensivetestrunusingsubmitteddatafromlaboratories toreviewandeditsubmittedown-databyeachlaboratory thereviewofresourcesbytheRCPAManualOnlineeditorialcommittee.These aims and objectives were achieved by this project.

Outcomes

Thefirstnationalsurveyofgenetictestingactivityacrossallserviceprovidersandregionsthatcaninformpolicydecisions.

Thefirstnationalonlineandupdatedcatalogueofgenetestsandgeneticlaboratoriestoassistclinicianstofindwhichlaboratoryisofferingatest.

Thefirstnationalguidelinesforthereportingofgeneticteststomedicalpractitioners,includingastructureforsynopticreporting.ThisisbeingincorporatedintotherevisionoftherelevantNationalPathologyAccreditationAdvisoryCouncil(NPAAC)standards.

Thefirstinternationalstandarddealingwithsamplerequirementsingenetictesting.


The catalogue of genes, genetic tests and genetic laboratories was established as a component within the RCPAManualTransformationProject(2010).


FurtherpossibleworkbytheGeneticsWorkingPartysetupunderthePathologyFundingAgreement.

Policies, Procedures and Guidelines for Point-of-Care Testing (2011)

Description Thisprojectwasacomprehensivereviewandanalysisofnationalandinternationalpoint-of-caretesting(PoCT)qualitymanagementregulationpoliciesandprotocols.


Aims and Objectives

toreviewthecurrentregulatoryrequirementsandprofessionalopinionwithregardtotheimplementationandqualitymanagementofPoCT

tosummarisecurrentlyavailableinternationalstandards,regulatoryprocedures,governmentpolicy,evidence-basedguidelinesand/orauthoritativeguidelinesorstatementsfromprofessionalcollegesorassociationswhichdescribeproceduresunderwhichPoCTmaybeperformedingeneralpracticeorthecommunity.


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Findings (OnlyfindingsapplicabletoAustraliahavebeenidentified;forinternationalfindingspleaserefertotheoriginalreport.) Use and Implementation of PoCT Devices PoCTisnotasingleunifiedentityanddifferentcircumstancesmayrequire

differentsolutions. Aprincipalconclusionarisingfromthequalitymanagementaspectofthe

AustralianGovernmentfundedmulti-centrePoint-of-Care Testing in General Practice Trial(http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pathology-poctt-index.htm)foundthetrialmodelprovidedaframeworkthatworkedwithinthecurrentregulatoryenvironment.ThisframeworkcouldformthebasisfortheimplementationofPoCTingeneralpracticemorebroadly.

Point-of-Caredrugtestingisgenerallydesignedtoscreenforthepresenceofdesignateddrugsorgroupsofdrugs.

Quality Assurance Inorderforequivalentclinicaldecisionstobemade,theaccuracyand

reliabilityoflaboratorytesting,includingPoCT,shouldnotbesitedependent. TheadvantagesofPoCTtestinglargelydependonproofofacceptable

analyticalperformance.Thisconceptdominatespolicystatementsfromgovernmentagenciesofmanyjurisdictions,articlespublishedinpeer-reviewedjournalsandstatementsmadebyinternationalprofessionalcommentatorsonPoCT.

Therearemany‘official’andprofessionallybasedstandardsandguidelineswhichdefinethemannerinwhichPoCTshouldbeimplemented,managedandtheperformancequalitycheckedandmaintained.Most,ifnotall,professionallybasedguidelinesfollowasimilartemplateandprovidesimilarinformationwhichincludesspecificreferencetoqualitycontrolandqualityassurance.

Regardlessoftheparticularassayormethod,PoCT,incommonwithalllaboratorytesting,requiresregularqualitycontrolandexternalqualityassessment(EQA)toassureacceptableperformance.ThereisalsoagrowingliteraturedescribingthepotentialandactualerrorsarisingfrompoorlycontrolledPoCTwhileinspectionandaccreditationprocesseshavebeenverysuccessfulinachievingthegoalofreducingPoCTerror.

Therequiredanalyticalperformanceofatest(fitnessforpurpose)isdeterminedbyitsintendedclinicaluseandnotbythelocationwheretestingoccurs.Theaccuracyandreliabilityoflaboratorytesting,includingPoCT,shouldbeequivalentirrespectiveofthetestingsiteforequivalentclinicaldecisionstobemade.

ThePoint-of-Care Testing in General Practice Trial providedconfirmationthatqualitymanagementpracticesarerequiredforPoCT.

ForPoCTtoprovidevalueinthegeneralpracticesetting,aneffectivequalitymanagementsystemisessential.Cliniciansneedreassurancethattheir


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decisionsarebasedonreliable,accurateandpreciseresultstoensurepatientsafetyisnotcompromised.

Actualclinicaltrialsorlarge-scalereviewstoassesstheeffectivenessofPoCTaremuchlessnumerousthanpublicationswhichdescribethepotentialrisksassociatedwithPoCTandissueswithspecificdevicesorwithspecifictests.

Cost Issues TheinnovationandfunctionalityofPoCTbringsmanychallengesforhealth

carefundingauthorities,particularlythevalueitmaybringtothepatientcareprocess.

PaymentformosttypesofPoCTisavailablethroughMedicareprovidedsuchtestingisundertakenbyanaccreditedpathologyservice(laboratory).

Withtheexceptionofspecialfundingarrangements(suchasQualityAssuranceforAboriginalandTorresStraitIslanderMedicalServices[QAAMS])orStateGovernmentsponsoredpublichospitalPoCTtesting,onlyaccreditedPoCTlaboratoriesmayreceiveGovernmentreimbursementor(Medicare)testingfees.

Whencostsofimplementingaqualitysystemareraised,therealquestiontoaskishowmuchispoorqualitygoingtocostorhowmuchisitcostingnow?Theprincipalissue,particularlywhendiscussinghealtheconomics,istheinfluenceof“costshifting”,intermsofpoorqualityofonesectorofthehealthsystemsaddscoststoanothersectorasincreasedresourcerequirements.PoorqualityinlaboratoryandPoCToftenresultsinincreaseddoctorvisits,additionalunnecessarytestprocedures,inappropriatelychangedmedicationoradditionalunnecessarymedicationand/orhospitalisation.Therealcostofnotidentifyingtestingproblems,orunnecessaryrepeattestingandpoorpatientoutcomes,isoftenhiddenuntilaqualitysystemhasbeenimplemented.


Itisanticipatedthatthisworkwillbepromotedinascientificjournal. PoCTTraining,Certification,SupportandSkillMaintenanceProgram

(AustralianPoCTPractitionersNetwork–APPN)(Current).


InvestigatetheframeworkforPoCTinGeneralPracticerecommendedbythePoint-of-Care Testing in General Practice Trial (http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pathology-poctt-index.htm.)

InvestigateanddefineQAissuesforPoCT.


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PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current)

Description Thisprojectisseekingtoestablishatraining,competencyassessmentandongoingeducationinfrastructureforPoint-of-CareTesting(PoCT)deviceoperatorsknownastheAustralianPointofCarePractitionersNetwork(APPN)

Grant Recipient AustralasianAssociationofClinicalBiochemists(AACB)

Aim

toprovideaccesstoatrainingandsupportservicethatwillallowPoCTdevicestobeoperatedbyhealthpersonneltoadequateclinicalstandards.

This project is current and this aim is in the process of being achieved.

Outcomes

CoreeducationandassessmentmoduleshavebeenestablishedforcompetencyintheoperationandmaintenanceofPoCTdevicesinsettingsoutsidelaboratories(suchasgeneralpractices)whichcanbedeliveredbyRegisteredTrainingOrganisationsandusedunderrelevantaccreditationframeworksasabasisforcompetencyassessment.

TheDiabetesModuleshavebeenapprovedbytheRoyalAustralianCollegeofGeneralPractitioners(RACGP),theAustralianCollegeofRuralandRemoteMedicine(ACRRM)andtheRoyalCollegeofNursingAustralia(RCNA)ascountingpointsfortheircontinuingpersonaldevelopmentprograms.

TheINR(InternationalNormalisedRatio)AnticoagulationModulehasbeenapprovedbytheACRRM.

TheLipidsModuleiscompletewithmodulesforPoCTforcardiacmarkersandcardiopulmonaryresuscitation(CPR)currentlyindevelopment.

Guidelines,whereavailable,havebeenincludedintothecontentofthemodules.

InDecember2011almost800peoplewereregisteredasAPPNmembersandover620competencyassessmentshadbeenperformedwiththeproportionofcompetencytestspassedcontinuingtoincreaseasthematerialcontentincreased.

Establishment of a Molecular Genetics Quality Assurance Program (Current)

Description Thisprojectisseekingtoimproveexistingandnewqualityassurance(QA)modulesforexternalassessmentofmoleculargenetictests.

Grant Recipient RCPAQualityAssuranceProgramsPtyLtd(RCPAQAP)


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Aim

toimprovethequalityofgenetictestinginAustralianlaboratoriesbyestablishingastand-aloneprogramfortheexternalqualityassessmentofmoleculargeneticswithinthecurrentqualityassuranceprogramprovidedbyRCPAQualityAssuranceProgramsPtyLtd.

Objectives

toestablishanexpandedmethods-basedexternalqualityassessmentofmoleculargeneticprogramforincorporationintotheMolecularGeneticsQualityAssuranceProgram(MGQAP)whichwillbetrialedinthelatterpartof2009forintroductionasaformalRCPAQAPProgramin2010

tochangeadministrationoftheexistingHumanGeneticsSocietyofAustralasia(HGSA)ProgramintotheestablishedRCPAQAPwithjointadministrationbytheRCPAQAPandHGSA

todevelopnewtechnicalmodulesfortheexternalqualityassessmentofmoleculargenetics

todevelopproceduresanddocumentationtoallowInternationalLaboratoryAccreditationCooperationG13:2000standardaccreditation

toestablishtheproceduresanddocumentationtoallowMGQAPtooperateasaself-fundedstand-aloneprogramafterthecompletionoftheproject.

This project is current and the aim and objectives are in the process of being achieved.

Outcomes

NineMGQAPmoduleshavebeendeveloped. Alaboratoryhasbeenestablishedtoenableaccuratepreparationofgenomic

DNAsamplesforqualityassuranceandsampleexchangemodules,togetherwithaDNAbankwhichiscurrentlyexpandingwithadditionalsamples.

WorkhascommencedinpreparationfortheaccreditationoftheMGQAPincludingholdingdiscussionswiththeNationalAssociationofTestingAuthorities(NATA)foraplannedassessmentinJune2012.

Asampleexchangeregistryhasbeenestablishedforsmallertestnumberswherenoformalqualityassuranceprogram(QAP)currentlyexiststoassistlaboratoriesincomparingtestresults.

Abasicinformativewebsiteisplannedforearly2012withamorecomprehensivesiteplannedforamidyearrelease.

MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current)

Description Thisprojectisdevelopingadatabase(theMAWSONDatabase)toholdgeneticdatacollectedsemi-automaticallyfromparticipatingAustraliangeneticlaboratoriesforuseasareferencetooltoenablebest-practicereportingofgenetictesting.Thedatabasecanbehandedovertoasuitableorganisationtoallowittooperateasaself-fundedstand-aloneprogramafterthecompletionof


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theprojectwiththeintentofmaximisingparticipation.DatawillalsobeuploadedfromtheMAWSONDatabasetotheInternationalHumanVariomeProject(HVP).Moreinformationcanbefoundat:http://www.mawsonproject.com.

Grant Recipient UniversityofSouthAustralia

Aim

todevelopadatabase(theMAWSONDatabase)thatwillretaingeneticdatacollectedsemi-automaticallyfromparticipatinglaboratories.Thesedatawillbeaccessibletoagroupofcollaboratingmedicalgeneticlaboratoriesintheformofa“virtuallabmeeting”toenablethedevelopmentofbestpracticereportingofgenetictesting.Theprogramwillinitiallyestablishadatabaserepositorywithfamilialbreastcancermutations(BRCA1andBRCA2genes)fromgeneticlaboratoriesthroughoutAustralia.

This project is current and this aim is in the process of being achieved.

Outcomes

TheprojecthassuccessfullytestedtheprototypeatFlindersMedicalCentre,SA,withpublicationofthesourcecodeforlaboratoryaccess(MawsonClient).

Undertakingfurthertestingoftheprototypeatotherlaboratorieshasdelayedtheproject.TheFamilialCancerServiceatWestmeadHospitalNSW,andtheMolecularGeneticsLaboratoryatPathologyQueensland-CentralLaboratoryhasagreedtotesttheprototype

InitialdiscussionshavebeenundertakenwiththeRCPAQualityAssuranceProgramsPtyLtd(RCPAQAP)regardingtheongoingmaintenanceandpossiblecommercialisationofthedatabasewhentheprojecthasbeencompleted

AformalagreementhasbeennegotiatedwiththeHVPtocollecteligibledatainSAandconveyittotheHVPdatabasetoallowdatacomparison.


FurtherpossibleworkbytheGeneticsWorkingPartysetupunderthePathologyFundingAgreement.


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eHealth Capability TheQualityUseofPathologyProgram(QUPP)hasenabledvariouseHealthcapabilitiesthrough12projects(Table5).TheriseoftheInternetandtherapidchangesinthescopeandcapacityofInformationTechnology(IT)providedextrachallengestomanyoftheseprojectsasevidencedbytheexpansiveKeyProjectLearningsforanumberoftheseinitiatives.TheselearningsalsoprovidedavaluablesourceofinformationandinsightaboutconductingfutureprojectswithintheeHealthparadigm.Theadventoftheabilitytoorderpathologytestselectronicallyalsorequiredanalysistoinvestigateanyimpactsontheorderingpatternsofpathology.Receivingresultselectronicallywasalsoinvestigated,especiallyfornarrativereports.KeyissuestoemergeforeHealthcapabilityincluded: softwareinstallationissuesdelayingprojecttimelines thevariedlevelsofITproficiencyandknowledgeamongtreating

practitioners findingabalancebetweenITsolutionsandtreatingpractitioner’stimeand

motivationtoimplementthesesolutions differentpathologyterminologyonpathologyreports.ThefollowingareasforfutureconsiderationineHealthCapabilitywerebasedaroundtheseissues.Theyinclude: Identifytheevidenceofbenefitsandincentivesfortheelectronic

transmissionofpathologyrequests. Optionalautomateddecisionsupport,andstandardtermsforrequestsand

results. Standardsforalertsandabnormalresults(addressedinApplicationof

PathologyInformaticstoReportingofCritical/AbnormalResultsforImprovedRequester/ProviderCommunicationandImprovedPatientCare onpage 82) andstandardsthatwouldallowforclinicaldataanalysis.

GeneralPractitioners(GPs)wouldlikemorepatient-specificadviceandarehappyforthistobeonpathologyreports.Forrequestingitmustbeatthetimeofmakingtherequest.

MarketingtheRoyalCollegeofPathologistsofAustralasia(RCPA)ManualforPathologyTestingtoGPs.

AddressquestionsfromAStudyoftheImpactoftheUseofGeneralPracticeComputerSystemsontheOrderingofPathologyonpage78whichinclude:

o Whataretherelativeranksoftheperceivedreasonsforobservedincreasesintestsorderedperepisode?

o Doescomputerpromptinghelporhindergoodpracticeinpathologyordering?

o WhatistherelativevalueofpathologyinGPpractice?o Howmuchtestingisorderedandnotdone?o Howmuchtestingisperceivedtoberepeatedunnecessarily?

BedsideaccesstoITformultiplepurposes(laboratory,radiology,dischargesummariesetc.).


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Collectalargercorporafordiseasecategoriesthataremorecomplexintheirpathologytestinganddescriptionsforsynopticreportsfromnarrativepathologyreports.

[alt=“ThefollowingtableliststhetwelveprojectnamesandgrantrecipientsundertheeHealthCapabilitytheme”] Project Name Grant Recipient/s 1 PathologyInformaticsWorkingParty(2003) RoyalCollegeof

PathologistsofAustralasia(RCPA)

2 DevelopmentofonOn-lineMaintenanceSystemfortheAustralianPathologyRequestandResultCodeSets(2003)

UniversityofSydney

3 PathologyandGeneralPracticeSoftwareIntegrationProject(PaGSIP)(2003)

UniversityofBallaratandQueenslandMedicalLaboratory

4 ChainofInformationCustodyforthePathologyRequest-Test-ReportCycleinAustralia(GuidelinesforPathologyRequestersandPathologyProviders)(2004)

RCPA

5 SupportingHL7forHealthInformaticsStandards(2004) HL7AustralasiaUserGroupIncorporated

6 AStudyoftheImpactoftheUseofGeneralPracticeComputerSystemsontheOrderingofPathology(2004)

MichaelLegg&Assoc;IRISResearch;UniversityofWollongong;DrIanCheong

7 ApplicationofPathologyInformaticstoReportingofCritical/AbnormalResultsforImprovedRequester/ProviderCommunicationandImprovedPatientCare(2004)

MaterMisericordiaeHealthServicesBrisbaneLimited

8 PadlokOn-linePathologyOrderingSystem(2005) FremantleHospital9 InformationExtractionfromNarrativePathologyReports

onMelanoma(2008)UniversityofSydney

10 AutomaticCompilationofSynopticReportsfromNarrativePathologyReports(Stage2)(2010Submittedwiththetitle:ThePathologyReporter)

UniversityofSydney

11 AutomaticPopulationofSynopticReportsfromNarrativePathologyReports(Stage3)(Current)

UniversityofSydney

12 StandardisationofPathologyTerminologyandUnits(Current)

RCPA

Table 5: Projects summarised for eHealth Capability

Pathology Informatics Working Party (2003)

Description ThePathologyInformaticsWorkingParty(PIWP)wasestablishedin2003todevelopapolicytoassistintheimplementationofhealthinformaticsforpathology.TheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)fundeditsfirstyearofoperation,andtheRoyalCollegeofPathologistsofAustralasia(RCPA)fundeditssecondyearofoperation.TheInformationandCommunicationsDivisionwithinDoHAsubsequentlytookoveralle-Healthactivities.


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Aims and Objectives

todevelopanRCPA-endorsedpolicyforinformatics topublishusefulwebsitesforpathologistsinseveraleditionsofPathology

Today todevelopPathologyInformaticseducationpackagesforTraineesand

FellowstoassistinthedisseminationanduptakeofHealthOnlineinitiatives topromoteHealthInformaticsatPathologyUpdateconferences todevelopadiscussionpaperontheroleofinformaticsandthepathologist

inpatientcare torepresenttheRCPAonvariouscommittees toparticipateintheactivitiesofHealthConnect throughvariousprojects

beingcarriedoutbyFederalandStateHealthDepartments.These objectives were either achieved or in the final stage of completion when the report was tabled. The PIWP also submitted a Laboratory Decision Support System proposal which was unsuccessful. The RCPA subsequently developed an electronic updated version of the Manual of the Use and Interpretation of Pathology Tests (see Follow On Initiatives and Projects below).

Outcomes

PIWPwaspromotedinvariousways. Adiscussionpaperontheroleofinformaticsandthepathologistinpatient

carewasindevelopmentandduetobecompletedbythenewworkingpartywhenitwasconstituted.

Informaticstrainingwastobeintegratedintothetrainees’specialtycurriculumalthoughtopicsofinteresttoalltraineeswillbepresentedtothegroup.

TheChainofInformationCustodyforthePathologyRequest-Test-ReportCycleinAustralia(GuidelinesforPathologyRequestersandPathologyProviders)reportwasnearingcompletionbytheRCPA.ThisreportwasfundedbytheQualityUseofPathologyProgram(QUPP)butnotendorsedbytheQualityUseofPathologyCommittee(QUPC)astheynoteditrequiredfurtherrefinement.

Findings

InformaticsandelectronichealthrecordsareanimportantandintegralpartofthefutureoftheAustralianhealthcaresystem.

Newapproachestotechnologywillbemorereadilyacceptedbyaprofessioniftheyareintroducedasanadjuncttoexistingprofessionalpracticeratherthanasanewandunfamiliardisciplinewithitsownphilosophyandlanguage.

Incorporatinganappropriatelevelofinformaticsskillandexpertiseintothepracticeofpathologywillbefacilitatedifthecontributionofinformaticsiscouchedintermsofexistingpathologypractice.


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RevisionofManualofUseandInterpretationofPathologyTestsonpage17

toupdateitscontentandmakeitavailableviatheRCPAwebsiteinaformatfacilitatingsearching,downloadingandincorporationintoothersoftware

TheChainofInformationCustodyforthePathologyRequest-Test-ReportCycleinAustralia(GuidelinesforPathologyRequestersandPathologyProviders)reportonpage76.

Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003)

Description Thisprojectsoughttodevelopanon-linemaintenancesystemforpathologyrequestandresultcodesets.ItfollowedworkbyStandardsAustraliatoprovideacommonsetofrequestcodesforusebysoftwaremanufacturersinbuildingsystemsfortheelectronicorderingofpathology.


Aims and Objectives

toreviewthecodesetproducedbyStandardsAustralia toupdatereferencestothePathologyServicesTable(PST)toallowthecode

settobeincorporatedintotheMedicareBenefitsSchedule(MBS) tobuildanonlinefacilitytocaterformultiplepurposes tousethesameplatformforothercodesets toundertakeadditionalworktoaccommodatepathologyresultcodes.Secondaryobjectiveswere: toprovideareferenceterminologyforthecodingofpathologyrequestsfor

research toprovideamaintainedlistof“abbreviations”tobeusedonpathology

accountstomeettherequirementoftheAustralianHealthInsuranceActintheidentificationofthebilledprocedure.


Outcomes

Phase1-ConductadesktopaudittocheckeachcodeentryinthetablesetoutintheStandardsAustraliaReportagainstitsreferenceinthePathologyServicesTable.

Phase2–Developanon-linemaintenancesystemforthePathologyRequestCodeset.

Phase3–Conductadditionalworktotheon-linemaintenancesystem. Phase4-CommencehostingtheOn-lineMaintenanceSystems(developedin

phasestwoandthreeoftheproject)bytheUniversityofWollongong.


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TheOn-lineMaintenanceSystemfortheReportCodeSetwasdemonstratedandhandedovertoStandardsAustraliaIT-14-6-5fortheiruseincommencingwiththemaintenanceofthefortheirusetobeginthemaintenanceofAUSPRPtheAustralianPathologyReportCodeseton7November2003.

Recommendations 1. Encourageimplementationofthelistsbypathologypracticesandthemedical

softwareindustry.2. EnsuretheuseofthecodesetsinGovernmentprojectssuchas

HealthConnect.3. IncorporateRequestCodeSetintotheMBS.


Therewasmoredifficultyingettingadequatetestcodeliststhanbuildingthewebsite.


IntegrationwithNationalE-HealthTransitionAuthority(NeHTA)workprogram.

Version1.04oftheRequestCodesetwasincorporatedintotheupdateoftheAS4700.2ImplementationofHealthLevelSeven(HL7),Version2.3.1Part2:Pathologyordersandresults.

Pathology and General Practice Software Integration Project (PaGSIP) (2003)

Description Thisprojectsoughttoimplementtheelectronictransferofpathologyordersfromgeneralpractitioners(GPs),andpathologyresultsbacktoGPs,usingHealthLevelSeven(HL7)messagingstandardsandPublicKeyInfrastructure(PKI)security.TheCommonwealthwantedtheseprojectsbasedonthe“AustralianHandbookonPathologyMessagingusingHL7Version2.3.1”aspublishedbyStandardsAustralia.

Grant Recipients UniversityofBallarat;QueenslandMedicalLaboratory

Aims and Objectives

demonstratetimesaving,effectiveandconsistentorderingofpathologyorders

demonstratetimesaving,effectiveandconsistenttransferofpathologyresults

demonstrateaninfrastructureandGPdesktopprocessesthatenablepathologydatatobebetterhandledbytheGP

demonstrateimprovedaccuracyofdatacapture,facilitateimprovedpathologyworkflowandincreaseaccuracyofmatchingresultstoorders.


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These aims and objectives were only partially achieved due to delays in getting the messaging system installed and working satisfactorily. This resulted in only one GP practice in Ballarat effectively sending and receiving pathology HL7 messages.

Findings

Codesetswouldplayausefulpartinfurtherpathologyorders/reportsprojects.

Theeaseofuseoftheprocessfororderingpathologytests,andtheabilitytotrackorderingofpathologytests,wereadvantagesofthismessagingsystem.

DelaysintheinstallationprocesscausedsomeunrestwithGPs,however,oncethetrialcommencedandthebenefitsofthesystemweredemonstratedtherewasacceptanceofthesystem.

Recommendations 1. TheuseofHL7messagingcapabilitiesHL72.3.1shouldbeencouragedwithin

generalpracticepathologyinformationsystemproviderstofacilitatefurthertrials.

2. Incorporatethespecifiedchangestothe‘PathologyHandbook’asidentifiedinthisproject.

3. ConductaworkshopforallpathologyinformationsystemsprovidersandpracticemanagementproviderstoencouragethemtodevelopHL7messagecapabilitiestoHL72.3.1asaminimum.

4. Conductasecondtrialwithalaboratorytoreceiveelectronicpathologyrequestsandsendelectronicpathologyresults.Runthetrialoveranextendedperiodoftimetodemonstratetheeffectivenessofelectronicmessagingonpracticeandlaboratoryworkflowandimprovedpatientcare.

5. UsepathologyordercodesintheACTHealthInformationNetworkPilottostreamlineorderingpathologytests.

6. ImplementandtrialtheuseofatomiseddatatounderpinelectronicdecisionsupportinGPsoftware.

7. Conductcostingofbenefitsofelectronicrequestprocessingtopathologypractices.


ProceduralissuesweremanyandvariedandrangedfromthosespecificallyrelatedtotheGPpracticemanagementsoftware,thelaboratoryinformationsystem,PKIimplementationsandArgussoftware.

TheprocessforobtainingHeSA/PKIlocationcertificatesshouldbestreamlined.

Athoroughriskanalysistoexaminethehardwareandsoftwareinfrastructureofthepractice,andacompletereviewofcurrentworkpractices,shouldhavebeenimplementedatthecommencementoftheproject.

AtleastoneGPshouldhaveparticipatedinsteeringcommitteemeetings. ThereshouldhavebeencloserinvolvementofDivisioninformation

technology(IT)staffwithCollaborativeCentreforeHealth(CCeH)ITstaffthroughthedevelopmentandinstallationphasesoftheproject.

ThereshouldhavebeenacloserliaisonwithGPpracticestaff,DivisionITstaffandCCeHITstafftodeterminethemostefficientmethodofgettingsoftwareinstalled,testedandworkingsatisfactorily.


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WorkingwithgeneralpracticeinfutureprojectsrequiresconsiderablymoreinteractionwithGPsandtheirpracticestaff.Thisinvolvescompleteinvolvementofpracticestaffintheprojectprocesses,includingparticipationatsteeringcommitteelevel,thoroughpre-trialanalysisofallworkflows,hardwareandsoftwareconfigurationsandsoftwareusage.

AccesstoGPpracticesisproblematicduetotheirveryspecifictimesoflowactivitywhichwereduringlunchtimesandafterhours.However,afterhoursaccesswasdifficulttonegotiateduetosecurityandconfidentialityissuesaroundpatientdata.Thisleftlunchtimesasthemainaccessopportunitywhichresultedinalongerthananticipatedinstallationprocess.

Pathologylaboratoriesreceivehundredsofspecimensdailyforprocessing,andanyinstallationsmustaimforminimaloperationaldelays.

Ensurethoroughandcompletetestingiscarriedoutinalaboratoryenvironmentpriortoinstallationattestsites.Oncetestinghasbeencompleted,signoffbytheappropriatestakeholdersisrequired.

Implementationofsoftwareinfuturetrialsneedsrigoroustestingsothatonceinstalleditisoperatingcorrectlyandrisksofsoftwarefailureareminimised.Thisistoensureminimalimpactonpractice/laboratoryworkflowsandmaximumopportunitytoachievestatedprojectoutcomes.

Theoriginalprojecttimeframeofsixmonthswastooshorttoachievetherequiredoutcomes.Theprocessofgettingallpartiestoproducethenecessarycomponentsoftheprojectwasmorecomplicatedandlengthythanoriginallyestimated.A12monthtimeframewouldhavegivenadequatetimetoengageallstakeholdersandhaveallsoftwareworkingcorrectly.Itwouldhavealsogivenalongertimetorunthetrialandhencemoreweighttotheevaluationprocess.

Thetrialsizeandperioddidnotyieldlargenumbersofpathologyresultsandrequestsbeingtransmitted.Thismeantthestatisticalbreakdowndidnotyieldsufficientnumberstobeuseful.


IntegrationofrelevantelementsintoNationalPathologyAccreditationAdvisoryCouncil(NPAAC)requirementsandguidelines.


Identifytheevidenceofbenefitsandincentivesfortheelectronictransmissionofpathologyrequests.

Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)

Description Thisprojectdevelopedguidelinesforusebymedicalpractitionerswhenrequestingpathologytests,andforusebypathologyprovidersoperatinginbothpublicandprivatepractice.Theyarenotprescriptive.



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Aims TheGuidelinesaimto: identifywhoisresponsibleforensuringthecorrectproceduresfor

informationintegrityandtransferandrelatedprocessesarefollowedateachstageoftheRequest-Test-ReportCycle

encouragetheimplementationofsoundmanagementsystemsthatmonitortheinformationprocessescomprisingtheRequest-Test-ReportCycletoensurethehigheststandardsofpatientcarearemaintainedatalltimes

ensurepatientconsentisobtainedandprivacyisrespected createasystemthatprovidesforqualityandsafetyofhealthcareand

contributestoimprovedpatientoutcomes.These aims were achieved by this project.

Outcome

ThisreportwascompletedwithfundingbytheQualityUseofPathologyProgram(QUPP),butwasnotendorsedbytheQualityUseofPathologyCommittee(QUPC),astheynoteditrequiredfurtherrefinement.


IntegrationofrelevantelementsintorelevantNationalPathologyAccreditationAdvisoryCouncil(NPAAC)requirementsandguidelines.

Supporting HL7 for Health Informatics Standards (2004)

Description HealthLevelSeven(HL7)AustraliarequestedandwasgrantedfundingtoorganisetheselectionandattendanceofonedelegatetoparticipateintheOrdersandObservationsTechnicalCommitteeofHL7Inc.

Grant Recipient HL7AustralasiaUserGroupIncorporated

Aims and Objectives

toensureapersonofappropriateexpertiseattendstheinternationalmeetingsofHL7Inc.

toconveytheworkbeingdoneinAustraliaandrepresentAustralianinterests

tofacilitatethedevelopmentofdraftstandardsinHL7messagingforPathology

topresentnewrequirementsarisingfromthedevelopmentoftheStandardsAustraliaImplementationGuide(seefindingsandrecommendationsbelow).


Outcomes

MrRichardHardingwaschosenasthedelegatetoattendinternationalmeetingsofHL7Incalthoughhisqualificationswerenotidentifiedinthereport.


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Australianpathologyorclinicalpractices,particularlywhentheyvariedfromUSandBritishpractices,weredescribedbyMrHardingduringthediscussionopportunitiesatmeetings.

MrHardingparticipatedinarangeofmeetings,workinggroupsandteleconferences.

Finding

ItwasreportedthattheV3PathologySpecificationwouldhaveanimpactontheAustralianstandards.SomelaboratoriesandhospitalswerealreadyflaggingtheirinterestinmovingtoV3fortheirpathologymessages.


PossiblefollowupactivitiesthroughtheeHealthandpathologyfocusinthePathologyFundingAgreement.

A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004)

Description Therehadbeenanoverallincreaseatthenationallevelintheorderingofpathologytestsandintheratioofpathologytestsordered,betweenJanuary1999andDecember2001.Thisstudysoughttodeterminetheextenttowhichtheobservedincreaseinthecontentofanepisodecouldbeexplainedbytheincreaseduseofcomputersystemsfortheproductionofpathologyrequests.

Grant Recipients MichaelLegg&Associates;IRISResearch;UniversityofWollongong;DrIanCheong.

Aim

todeterminetheextenttowhichtheobservedincreaseinthecontentofanepisodecouldbeexplainedbytheincreaseduseofcomputersystemsfortheproductionofpathologyrequests.


Outcomes Phase 1 Aqualitativeassessmentbasedonfocusgroupstodeterminetheperception

ofachangeinbehaviourandattitudesaboutpathologyordering.ThesewereheldinBrisbane,SydneyandMelbournein2001withparticipantsrecruitedusinglocalnetworksofgeneralpractitioners(GPs)interestedininformatics,orthroughmasscommunicationbyDivisionsofGeneralPractice.Participantsreceivedafeeof$100fortheircontribution.

Phase 2 Aquantitativesurveyofpreference,attitudeandstatedbehavioursofGPs

aroundpathologyordering.Incentiveswereprovidedtoparticipateandahighresponserateof41%(613)wasachieved.Ofthese,91%(557)


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consentedtothereleaseofHealthInsuranceCommission(HIC)dataforthetimeseriesanalysis(Phase3)whichrepresentedanoverallresponserateof37%.

Phase 3 Aretrospectivetime-seriesanalysisofMedicarestatisticsfortwocohorts–

thoseknowntobeusingcomputerproducedpathologyrequestsandthoseusinghandwrittenrequests.Pathologyrequestingdatarelevantto532GPs,whogaveconsentforthereleaseoftheirrequestingdataaspartofthePhase2survey,wasanalysedfortheperiodJanuary1999toDecember2001.

Phase 4 AprospectivestudydesignaroundGPcomputersystemsandpathology

requestingrecommendedinthereportisablindedcrossoverstudytoinvestigatehowGPcomputersystemsmightinfluencepathologyrequestingtowardbestpractice.

Findings Phase 1 Thestrongestconcernsinfluencingpathologyordering,apartfromclinical

indications,weremedico-legalconsequencesandpatientdemand. Pathologyreportingandrequestingrankedhighlyamongusefulfunctions. GPscommonlylearnedtouseacomputerfrom“trailblazing”GPmentors

whotendedtocarryasignificantburdenfortheirpractices. GPslearnwhattheyneedtogivethemthebest“bangforthebuck”. Despitethewidespreadusageofelectronicpathologyreportingand

requesting,manyGPswerenotyetpreparedtoforgopaper. Pathologytestorderingwasinfluencedbymanyfactors. Optionalautomateddecisionsupportandstandardtermsforrequestsand

resultsareseenasdesirable.Phase 2 66%ofGPsutilisesomeformofcomputerisedorderingtorequestpathology,

with55%usingMedicalDirector(83%ofthesub-sample).Manyotherstatisticswerenotedinthereport,however,thetwohighlightedwere:

o 75%ofrespondentsreportedtheyorderedneithermorenorlesswhenusingacomputerisedorderingsystem,17%indicatedtheyorderedmoreandonly4%indicatedtheyorderedless.

o 70%ofGPsreportedimprovedpatientmanagementarisingfromtheuseofcomputerisedpathologyrequesting;52%reportedthelevelofthistobesignificant.

Asidefrommanagingpatientcare,respondentsrankedthefollowingfactorsfromhighesttolowestaccordingtotheperceivedimpactontheirrequestingbehaviour:1. medico-legalconsiderations2. patientdemand3. healthbureaucracyandadministrativerequirements4. promotionoradvicefrompathologypractices5. businessandmarketingconsiderations6. easeofordering.


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Therearedifferencesinreportedbehaviourbetweenpracticetypes:solepractitionersreportedbeingmoreinfluencedbypathologypracticesandhealthbureaucracy,whilethosefromlargerpracticesreportedestablishingproficiencyearlier.

Phase 3 Therewaslittleevidencethatthecomputerisationofdoctor’spathology

orderingsystemsledtoanincreaseinthenumbersofpathologytestsorderedperpatientincident.

Therewasatendencyforsomedoctorstochangetheirpathologyorderinghabitsduringtheobservationperiod.Thischangewasnotuniformindirectionanddoesnotexplaintheoverallincreaseinorderingnoted.

ChangesinorderingrateswereinconsistentbetweenthevariousStatesandTerritories.

Thereisnostatisticallysignificantdifferencenationallyintherateofchangeinpathologytestsperepisodebetweenthosedoctorswhodidnotuseacomputerisedsystem,andthosewhocomputerisedduringthestudyperiod.

ThefindingsfromtheanalysisofMedicareutilisationdatadidnotsupporttheviewsexpressedbyGPsinphasesoneandtwo.

Itispossibletheobservedincreaseinservicesperepisodewerecausedbysomechangeinthereportingsystem,suchashowthedataonservicesassociatedwithanepisodeisconstructed,ortherehadbeenachangeinmedicalpracticeoverthisperiod,orachangetothepopulationbeingtestedsuchasitsrelativeageing.

Phase 4 Ablindedcrossoverstudydesignwasprovidedinthereporttoinvestigate

howGPcomputersystemsmightinfluencepathologyrequestingtowardbestpractice.Thestudydesigngivestheopportunitytofurtherinvestigatepathologyutilisationdataandexpandontheobservedtrendofincreasedservicesperpathologyepisode.

General GPsfindusingtheircomputertorequestpathologyeasierthanwriting,and

believeitimprovespatientcare. PaperlesselectronicrequestsdidnotseemtobeahighpriorityforGPSsince

theyfeltpatientsstillrequiredapieceofpapertotakeaway. Whilethefactorsinfluencingpathologyordering(apartfromclinicalfactors)

weremanyandvaried,therewasgeneralagreementthatthestrongestwereconcernformedico-legalconsequencesandpatientdemand.

Softwareinterfacedesignmustallowforquick,easyandaccurateinformationentry.Keyboardentryispreferredbythosewhocantypebecauseinformationcanbeenteredwhileinterviewingthepatient.

Implementationofsystemsneedstobephasedandledbyalocalchampionandmentor.

GPsfindusingtheircomputertorequestpathologyeasierthanwriting,andbelieveitimprovespatientcare.

GPsgenerallydon’tunderstandtheimportanceofclinicalnotesforpathologypractices,andsomebelievetheyarenotusedbythepathologypractices.


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Thegreatestuptakeofcomputerisedmanagementsystemsoccursatthebeginningofthenewcalendaryear,andattheendofthefinancialyear.

Thegenerationoftestgroupsandpanelsrequiresfamiliarityandhigherproficiencywithpracticemanagementsoftwareandisthereforelikelytoincreaseovertime.

Solepractitionersindicatedthatpromotionoradvicefrompathologypracticeshasahighimpactonpathologyrequests.

GPswantmoreanalysisoftheirdataandarefrustratedwiththeircurrentsystem’scapacitytodothis.

GPswanttheirsystemtopromptactionswhereappropriate.

Recommendation 1. Theblindedcross-overstudydesignprovidedtoinvestigatehowGP

computersystemsmightinfluencepathologyrequestingtowardsbestpracticegivestheopportunitytofurtherinvestigatepathologyutilisationdataandtoshedmorelightontheobservedtrendofincreasedservicesperpathologyepisode.


Recruitmentinthefirstphaseofthestudywasdifficult.SignificantsupportfromtheDivisionsofGPswasrequired,andperhapsdirectlyfromthestudyorganisers,toobtainadequatesurveynumbers.


Optionalautomateddecisionsupport,andstandardtermsforrequestsandresults,wereseenasdesirablebyGPs.

Standardsforalertsandabnormalresults(addressedinApplicationofPathologyInformaticstoReportingofCritical/AbnormalResultsforImprovedRequester/ProviderCommunicationandImprovedPatientCare onpage 82) andstandardsthatwouldallowforclinicaldataanalysis,werealsoseenasdesirablebyGPs.

GPswouldlikemorepatient-specificadviceandarehappyforthistobeonpathologyreports.Forrequestingitmustbeatthetimeofmakingtherequest.

MarketingtheRoyalCollegeofPathologistsofAustralasia(RCPA)ManualforPathologyTestingtoGPssincemostindicatedtheydidnotuseit,orknowofitsexistence.

Questionstobeaddressedfromthisstudyinclude:o Whataretherelativeranksoftheperceivedreasonsforobserved

increaseintestsorderedperepisode?o Doescomputerpromptinghelporhindergoodpracticeinpathology

ordering?o WhatistherelativevalueofpathologyinGPpractice?o Howmuchtestingisorderedandnotdone?o Howmuchtestingisperceivedtoberepeatedunnecessarily?


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Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004)

Description Thisprojectsoughttoconsiderappropriate,effectiveandtimelyreportingofcritical/abnormalpathologyresultstoproviders.Thisinvolvedcommunicationtotherequesterordesignatedphysician,andwasvitalprimarilyforoptimumpatientcareandfortheimportantissueofavoidingcostlylitigation.ThebasisoftheapproachwastousethefunctionsoftheLaboratoryInformationManagementSystem(LIMS)toincorporateasmuchofthefunctionalityrequiredaspossible.

Grant Recipient MaterMisericordiaeHealthServicesBrisbaneLimited

Aims and Objectives

todeveloptheprocessinitiallystartedinclinicalchemistry(MaterPathologyupdatedtheirpolicyonreportingcritical/abnormalresults12monthsbeforethisprojectstarted)tobemoresophisticatedandreducetheriskof“automatic”acceptanceofthenotificationofanabnormal/criticalresult

tointroducethenewprocessintohaematologyforfullbloodcountstoinitiallydevelopandmonitor

tointroducethenewprocessintoclinicalchemistryforthegeneralchemistriesandtherapeuticdrugsoncegeneralacceptancehasbeenobtainedinhaematology

todevelopcriticalprocessforcoagulationstudiesinhaematology tointroducetheuseof“phonecode”inhaematologyandmonitor tointroduce“phonecode”useintoclinicalchemistryifsuccessfulin

Haematology toconsiderintroducingintootherdivisionsastimepermits toreducethenumberofcritical/abnormalresultsbeingmisseddueto

numbersaturationofthescientists.Itwouldalsohelpensurecontinuitywhenstaffchangesoccurandarequestingdoctorordelegatehadnotbeenabletobecontacted(ascanoccurduringmealbreaksorshiftchanges).


Outcomes

Thecritical/abnormalresultsprocesswasduetobecommencedinbloodbankandimmunologyatthetimeofthereport.

TheprocessdidnotproceedinCordBloodBankbecauseofalackofinputintothesystem,butitwasflaggedtohappenwhentheinformationwasavailableandtherewastimetoimplementit.

Verygoodaudittrailswererecordedon-linestatingwhohadbeencontacted,whentheywerecontactedandhowoften.

Clinicalstaffpositivelynotedtheincreasedtelephonecallsduetothecriticalresultflaggingprocess.

Therateofsuccessofcontactingaresponsiblepersontodelivercritical/abnormalresultsincreasedfrom94%to97%.


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Thesystemimprovedtheworkpracticesofstaffastheydevelopedgreaterconfidenceintheflaggingsystem.

Finding

Theuseofthephonecodeinmicrobiologydidnotproduceasignificantbenefit.ThiswasduetoMicrobiologistsrecordingtheirnotesina“silent”fieldintheactualreportwhichisnotfinallyauthoriseduntilalltelephonemessagesandotheroperationshavebeencompleted.Thetelephonenotificationsystemremainedtherecommendedprocessforadhocresultreporting.

Recommendations 1. Flagssetinreportsmaybeusedinthefuturewiththelaboratory’sClinical

InformationSystemasameansofhighlightingthecriticalresultsaspartofaresultsmanagementprocessintheclinicalareas.

2. Theprojectwouldcontinueinthelaboratoryintheforeseeablefutureastherulesandassociatedprocessesarerefinedfurther.


Thisprojectwastime-consumingbutworthwhile. Astheprojectgainedmomentum,andhardwaresystemschangedforthe

better,itbecamemoreacceptable. Determiningthepercentageofcritical/abnormalresultsreportedtothe

requesterwasnotpossibletoachieveasaretrospectivestudy. Itwasnotpossibletomeasuretheimpactonpatientcareinaquantitative

manner.

Padlok On-line Pathology Ordering System (2005)

Description Thisprojectsoughttoimprovelaboratoryrequestformdocumentation.

Grant Recipient FremantleHospital

Aims and Objectives

tomaximiseuseoftheon-linepathologyrequestsystembymedicalstaff todemonstratethatuseoftheon-linesystemreducestestrequesterrors toobtainfeedbackfromusersforfurtherdevelopmentoftheapplication totrialandevaluatevarious‘addon’decisionsupportfeaturessuchas

embeddedguidelines/warnings toinvestigateusefulwaysofmonitoringtestorderingpatternstoenable

feedbacktoclinicians todeterminetheadequacyofaccesstonetworkedpersonalcomputers(PCs)

inpatientareasandtheinfluencethishasonuseofthepathologyrequestsystem



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Outcomes

Theprojectachieveda50%rateofuseatthecompletionofthetrial. ThePadlokpost-implementationusersurveywasconductedinJune2004,

andanumberoffeaturesincorporatedintotheapplicationasaresult. Inthefirstninemonthsofoperationtheprojectteamconcentrateditsefforts

ontwomajordecisionsupportfeaturesintheareasof:o inappropriatetestrequestso duplicate/additionalforms.

Generalphysicianswereprovidedwithaconfidentialthree-monthauditontheaveragenumberoftestsandthede-identifiedratesforotherphysicians.Thisauditwastobeconductedmonthlyforanumberofmonthstodetermineifthisfeedbackhadaneffectonrequestingpatterns.Test-costsweresubsequentlyprovidedaswell.

Padlok-onlyworkstationswereinstalledinselectedclinicalareasandindoctors’commonrooms.

Findings Advantages ThemainadvantageofPadlokisitsresponsivenesstotherequirementsof

usersastheybecomeapparent. ThestudyfoundthatifalldoctorsusedPadlokthecompletionrateofrequest

formswouldbecloseto100%.

Use TheuseofPadloktendedtoperiodicallydropforabouttwoweekswhen

juniormedicalstaffrotationsoccurred,androseagainwhennewstaffweretrainedtousePadlok.

Testingwasnotreduced,althoughdataindicatedthatinappropriatetestinghadbeenreduced.

Padlokisthepreferredmethodinclinicalsettingswherethereisaregularphlebotomyservice,whileitwasquickerandeasiertouseahand-writtenrequestforminotherclinicalsettings.

PadlokwasusedextensivelyintheIntensiveCareUnitwheremanytestrequestswereroutineandrepetitive.

Padlokofferedsignificanttimesavingbenefitsforclinicianswhodidnothavetosourcepatientinformationthemselves,andforthelaboratoryintermsofrapidlyprocessingrequests.Illegibilitywasalsoeradicated.

PadlokwasusedtoalesserextentintheEmergencyDepartmentduetothefast-pacednatureoftheworknotbeingconducivetodoctorsleavingtheirpatientstologontoacomputer.

Padlokwasusedinthewardswithmostrequestsbeingforbloodtestscollectedduringroutinephlebotomyservicerounds.

ThePadlokpost-implementationsurveyrevealedonly9%ofrespondentshadtroubleaccessingcomputerstousePadlok.

Issues Therewereconcernsthatmakingtherequestingprocesseasiermighthave

resultedinhigherratesoftestingandincreasednumbersoftestsperpatient,butthisdidnotappeartobethecase.


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Clinicalstaffrevertedtorequestingonpaperformswhenaccesstocomputerswaspoororunavailable.

ThereweretechnicalissueswiththeconfigurationofPadlok-onlyworkstations.HospitalstaffalsorequiredaccesstootherhospitalsystemsconcurrentlywhenusingPadlok,andmedicalstaffpreferredworkstationswithaccesstomultiplesystems.

TheinstallationandmaintenanceofdedicatedpathologytestrequestingworkstationsresultedinadditionaltechnicalandmaintenancedifficultiesfortheITDepartment.

Theprojecthelpedidentifypracticeswhichwereinefficientorunsafeandimproveddocumentationandauditprocesses.

Recommendations 1. Provideaclinicalliaisonandprogrammers/trainerspositions.2. Provideabudgetforequipmentformaintenanceofthesystem.3. Padlokcouldbedevelopedintoapaperlesssysteminoneyear,andnursing

elementscouldbedevelopedconcurrently.4. Explorethemeansbywhichdoctorscanbepositivelyinfluencedduringthe

requestingprocesstoreduceredundancy,andincreaseappropriatetesting.


Keytothesuccessoftheprojectwasaprogrammerwithaclinicalbackgroundinnursingandamedicalregistrartoactasclinicalchampion.

Findingamedicalregistrarfortheroleofclinicalchampionwasverydifficult. TherewereproblemswithtimelinesduetovariousIT-relatedissues. ProblemsinSpecimenReceptionwerenotforeseen,andalaboratoryProject

Officerwasemployedtowardstheendoftheprojecttoaddressthesematters.

Problemsinthephlebotomyareawerenotforeseen,particularlythemanagementofstaffwithnofamiliarityofcomputers.

TheneedfornursingstaffinvolvementinthedevelopmentofPadlokwasnotrecogniseduntillateintheproject.

Doctorswererequestingassaysfordrugstobegiveninthefuture. Allproblemsweresatisfactorilyaddressedwithworkinggroupmeetings.


BedsideaccesstoITformultiplepurposes(laboratory,radiology,dischargesummariesetc.)isthekindofinitiativethatwillleadtomoreextensiveuseofon-linepathologyrequestinginthefuture.

Information Extraction from Narrative Pathology Reports on Melanoma (2008)

Description Thispilotstudysoughttodemonstratethatkeyelementsofonetypeofpathologyreport(melanoma)couldbedefinedinastructuredformat.Italsosoughttodemonstratethathardcopypathologyreportscouldbeaccuratelyannotatedbytrainedlinguiststoindicatethecorrectstructuredreportelementstosupporttheautomaticextractionofthoseelements.


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Aims and Objectives Nospecificaimsorobjectiveswereincludedinthereportalthoughtheexecutivesummarynoted:

Ananalysishasbeenconductedonpathologyreportsofmelanomawiththepurposeofdeterminingifhumanannotatorscanreliablyidentifythecontentsappropriatefordevisingmethodsfortheautomaticextractionofpathologyconceptsneededtopopulatestructuredreports.

The report’s authors stated all project objectives were achieved, although these objectives were not included in the report.

Findings

Linguistscanreliablyproducemoreconsistencythanpathologistsinannotatingalargecorpus*ofpathologyreports.

Thereliabilityoflinguistsbetweeneachotherisconsistentlyhigherthanbetweenthepathologists,orbetweenalinguistandapathologist.

Linguistsmissabout6%ofthetagsannotatedbythepathologist,andthepathologistsmissaboutthreetofiveasmanyassignedbythelinguists.

Thefindingssuggestthatoncelinguistsaretrainedtounderstandthelinguisticfeaturesandextentofpathologyconcepts,theycanreliablyannotateinformationtoaidtheautomaticextractionoftheseconceptsinstructuredpathologyreports.

Thestudyshowedonlythreetagswereinterpretativeandtheother19tagsweredirectlydefinedbycontent.Thisindicatestheymaybereliablyextractedbyautomaticcomputationalthoughitwilltakefurtherresearchtoestablishthisisthecase.

Thestudyalsohighlightedproblematicareasofannotatingsuchalargecorpus.

Furtherrefinementofthetrainingprocessshouldsignificantlyimprovetheperformanceofthelinguiststohavefarfewermisses,andreducetheerrorratebelow3%.

*corpus/corpora:acollectionofnaturallyoccurringlanguagetextchosentocharacteriseastateorvarietyoflanguage

Recommendation 1. Furtherresearchisrequiredtoestablishthereliabilitytowhichthese

conceptscanbedefinedandthereforeannotatedcorrectly.


Morestructuredmeetingsbetweenlinguistsandpathologistswouldhavebeenbeneficialtorevisetheconceptsetbeforeannotationofallreports.

Amorestructuredscheduleofconcepttag-setrevisionswouldhavereducedconfusionandimprovedtagdevelopment.

Thestudyidentifiedissuesabouttheoriginalpathologyreportsthatcouldproveusefulintheeducationofprofessionalpathologistsfortheirreportwriting.


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Asecondstageforthisprojectwasundertakentodevelopsoftwaretoautomaticallycompilethesynopticreports(AutomaticCompilationofSynopticReportsfromNarrativePathologyReports(Stage2)(2010Submittedwiththetitle:ThePathologyReporter))

Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter)

Description Thisstudysoughttodevelopasoftwaresystemtoautomaticallyextractinformationfrompathologyreportsforthreetypesofcancerstodisplayinformationinasynopticreportingformat.Itwasdesignedaroundthreereportcategories:melanoma,skincancerandlymphoma.


Aims and Objectives Thesewerenotspecificallyoutlinedinthereporthoweverthefollowingpointswereextractedfromtheintroduction: tocompletetheconstructionofaninformationextractionenginefor

melanoma toannotateskincancerandlymphomareports tobuildanextractionengineforskincancerandlymphoma tocreateawebsitewhereanyonecouldusetheextractionenginefortesting

theirownreports.These aims and objectives were achieved by this project.

Outcome

ThewebsitewhereanyonecouldusetheextractionenginefortestingtheirownreportshasbeenoperatingsinceFebruary2010andisavailableat:http://hitrl.it.usyd.edu.au/~KDKRWorkbench/spr/cgi-bin/spr.py.

Findings

Lymphomawasmoredifficulttoannotateandwasmorecomplexinitsdescriptionofparticularfeaturesresultinginslightlyloweraccuracyfortheautomaticprocessing.

Theresultshighlightedproblematicareasofannotatingpathologycorpora*. TheeffortofrecognisingtheSNOMEDCTcodesfordiagnoses,andthe

populationofthestructuredreportformelanoma,showthisworkhasthepotentialforimprovingtheautomaticprocessingofprosereports.

Recommendation 1. Itwilltakefurtherresearchtoestablishthereliabilitytowhichthese

conceptscanbedefinedandthereforeannotatedcorrectly.


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Thegainsfromthisapproacharelikelytocomefromdiseasereportsthathaveahighfrequencyandaremostamenabletoproducingstructuredreports.


Thethirdstageofthisprojectiscurrentlybeingundertaken(AutomaticPopulationofSynopticReportsfromNarrativePathologyReports(Stage3)).


Alargercorpora*needstobecollectedfordiseasecategoriesthataremorecomplexintheirpathologytestinganddescriptions.

*corpus/corpora:acollectionofnaturallyoccurringlanguagetextchosentocharacteriseastateorvarietyoflanguage

Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current)

Description Thisprojectbuildsontheworkofthefirsttwostagesandaimstobuildnaturallanguageprocessorsthatwillautomaticallyextractpertinentinformationandpopulateastructuredcancerreport.Thissystemwillenabletheanalysisofnarrativereportstoidentifyandextractkeycontent.


Aims and Objectives

tobuildprocessorsforthesetofmelanoma,skincancersandlymphomathatcanautomaticallypopulatetheformallydefined,structuredreport

toaddtothesystemtheSNOMEDCTencodingofthestructuredreportelements.

This project is current and the aims and objectives are in the process of being achieved.

Recommendation 1. Duetotheresultstodatewhichshowalessthansuccessfulperformancefor

lymphoma,workonlymphomashouldbeofsecondaryconsiderationinprogressingthisproject.TheextentoffurtherworkonlymphomawillneedtobediscussedwiththeRoyalCollegeofPathologistsofAustralasia(RCPA)andtheQualityUseofPathologyCommittee(QUPC).


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Standardisation of Pathology Terminology and Units (Current)

Description Thisprojectisdevelopingareferencesetofstandardisedpathologyterminologywithguidelinesfortheiruse,andstandardsforunitsofmeasure,tominimisetherisksofvariationintheirusebetweenhealthprofessionalsandpatients.Thedevelopedterminology,unitsandmeasureswillbeabletoberepresentedelectronically.


Aims and Objectives

todevelopandapprovearevisedsetofstandardunitsofmeasuretoberepresentedelectronically(StandardforUnitsofMeasure)

todevelopandapprovestandardterminologysets(SNOMEDCT,LOINCetc.),includingadvicefortheiruse(AustralianPathologyTerminologySets)

todevelopafullyspecifiedterminologyforthereportingof‘common’biochemistryitemsusedinclinicaldecisionsupport,includingadviceforitsuse(standardisationofcommonbiochemistryitems)

toreviewtheprotocolsforcancerreportingandensureterminologyisavailable,consistentandabletobeusedinelectronicdecisionsupport,includingadvicefortheiruse(terminologyforstructuredcancerreports).


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Pathology Requesting and Reporting – Requester and Consumer Focus Requestingandreportingarekeycomponentsofthepathologyprocessandimpactonthequalityuseofpathology.Thischapterincludes17projects(Table6)whichsoughttoenablemedicalstudentsandtreatingpractitionerstoaugmenttheirknowledgeandpracticeofpathologyrequestingandimproveconsumeroutcomes.Improvedreportingmethodologieswerealsoexplored,andaflow-onbenefitinmanycaseswascostsavings.Oneoftheissuesencounteredwiththesuccessfulimplementationofanumberoftheseprojectswasaresistancetochangeentrenchedpracticesandalackoffundingtoprovidesustainabilitytotheprojectsinthelongerterm.Identifying‘champions’whoshouldideallyholdseniormedicalpositionswasoneconsistentstrategyindentifiedinthisintegratedanalysistochangeentrenchedpractices.Otherissuesencounteredinthisareainclude: projectsinvolvinginformationtechnology(IT)werepronetotechnical

problemswhichincreasedprojecttimeframes lackofpathologytraininginmedicalschools lackofunderstandingbypathologyrequestersregardingtheimportanceof

completingpathologyrequestforminformation.Theseprojectsalsocollectivelyidentifiedinformation,issuesandstrategiesthatcontributedtoanoverallknowledgebasetopromotechangeandimprovefuturepractice.Someprojectswithsuccessfuloutcomesbutwerenotsustainableatthetimeoftheirimplementationmaybenefitfrombeingrevisitedastheirfindingsandoutcomesarestillapplicableinthecurrentenvironment,especiallyastechnologybecomesmoreacceptableasalegitimatehealthcaretool.Otherareasforfutureconsiderationinclude: ReviewtheAUSLABprojects(pages94and96)withaviewtoimplementing

theminstatesoutsideofQueensland. ExploretheoptionsforPersonalDigitalAssistant(PDA)system

implementationinhospitalenvironments. InvestigatetheareasPracticeNursescanassistwithinformationregarding

pathologytestingandpatienteducation. Assesstheviabilityofre-establishingtheQualityUseofPathologyServices

EducationProgram(onpage109)inruralmedicalschools. Reviewtheformatandcontentofpathologyrequestforms. Investigateimplementinganeducationprogramwhichtargetsthemost

importanterrorsoromissionsonrequestforms. Possibledevelopmentofatrainingprogram/modulestobeprovidedto

GeneralPractitioner(GP)RegistrarsandInternationalMedicalGraduates(IMGs),andtheneedforatrainingmodule/s.

Producefactsheetscoveringthearea’shighlightedinrecommendationno.6ofthereportEnhancingtheQualityUseofPathologyforGPRegistrarsandInternationalMedicalGraduates–AssessingtheNeedonpage113.


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Produceafactsheetonantibioticuseandbacteriuriaforalllevelsofmedicalstaff,includingnurses,toempowerthemtodevelopconfidenceinwithholdingantibioticsforasymptomaticpatients.

IdentifyfurtherpotentialusersforiNvestigate. Developastandardnationaldefinitionof‘appropriate’pathologyuse.[alt=“ThefollowingtableliststheseventeenprojectnamesandgrantrecipientsunderthePathologyRequestingandReporting–RequesterandConsumerFocustheme”] Project Name Grant Recipient/s 1 GuidelinesforPatient/ConsumerAccesstoPathology

TestReports(2001)QualityUseofPathologyCommittee(QUPC)

2 AUSLABRetestIntervalTrialProject(2003) QueenslandHealthPathology&ScientificServices

3 AUSLABRetestIntervalProject(2004) QueenslandHealthPathology&ScientificServices

4 HomeMonitoringofWarfarinTherapyinChildrenusingtheCoaguchekTMPointofCareINRMonitor(2003)

TheRoyalWomen’sHospitalandtheRoyalChildren’sHospital

5 FacilitatingBestPracticePathologyUtilisationbytheUseofHand-HeldDecisionSupportDevices(2004)

FlindersMedicalCentre

6 ImprovingGPAccesstoandUseofRetrospectiveandCurrentPathologyDatatoIncreaseDetectionofEarlyDiabetes(IGTandIFG)inGeneralPractice(2005)

FremantleRegionalGPNetwork

7 QualityUseofPathologyServicesEducationProgram(2006)

UniversityofSydney

8 InvestigationintotheReasonsforIncorrectorIncompletePathologyRequestForms(2008)

RoyalNorthShoreHospital

9 EnhancingtheQualityUseofPathologyforGPRegistrarsandInternationalMedicalGraduates–AssessingtheNeed(2009)

UniversityofAdelaide

10 EffectofaStructuredMicrobiologyLaboratoryReportonAntimicrobialPrescribingforAsymptomaticBacteriuriainElderlyFemales(2010)

FlindersMedicalCentre;SouthAustraliaPathology

11 IdentifyinghowElectronicDecisionSupport(EDS)inComputerisedPathologyOrderEntrySystemscanImprovePathologyPractice,RationalOrderingandPatientOutcomes(2010)

UniversityofSydney

12 TheImpactoftheImplementationofElectronicOrderingofPathologyRequestingandtheQualityandEffectivenessofHospitalPathologyServices–BuildingaRobustEvidenceBaseandBenefitsFrameworkforSuccessfule-HealthDiffusions(Current)

UniversityofNewSouthWales

13 ComputerAssistedPatientSimulationsforEducationintheRationalUseofInvestigations–FinalReportforPhase1(iNvestigateProject)(2010)


14 iNvestigate:OnlinePatientSimulationsforEducationintheRationalUseofInvestigations–FinalReportforPhase2(2011)


15 iNvestigate:OnlinePatientSimulationsforEducationintheRationalUseofInvestigations(Current)


16 EncouragingQualityPathologyOrderinginAustralia’sPublicHospitals(2011)

NationalCoalitionofPublicPathology(NCOPP)


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17 EffectiveCommunicationofPathologyResultsinRequestingPractitionersandConsumers(Current)

UniversityofMelbourne;DianellaCommunityHealth;RoyalCollegeofPathologistsofAustralasia(RCPA)

Table 6: Reports summarised for Pathology Requesting and Reporting – Requester and Consumer Focus

Guidelines for Patient/Consumer Access to Pathology Test Reports (2001)

Description Thispapersetsoutguidelinesforpathologistswhereaconsumer/patientdecidestoseekaccesstopathologytestreportsdirectlyfromthepathologyprovider.TheywerewritteninresponsetoamendmentstotheCommonwealthPrivacy Act 1988whichcameintoforceon21December2001.TheseamendmentsallowedaCommonwealthstatutorybasisforpatients/consumerstorequestandobtainaccesstohealthinformationbythemselvesthatisheldbyorganisations,includingfrompathologists.TheyextendedthistotheprivatesectoraslegislationwasalreadyinplaceinsomeStatesandTerritoriesforprovidingaccesstomedicalrecords.Eachorganisationholdingpersonalinformationwasthereforerequiredunderthelegislationtohaveproceduresinplacetoaccommodatethesenewrequirements.

Grant Recipient QualityUseofPathologyCommittee(QUPC)

Aim

toprovideguidelinesforpathologistswhereaconsumer/patientdecidestoseekaccesstopathologytestreportsdirectlyfromthepathologyprovider.


Findings

TheQUPCsupportsthegeneralprinciplethatpatients/consumersshouldconsultwiththeirtreatingpractitionerbeforedirectlyapproachingthepathologyproviderforaccesstopathologytestreports.

TheQUPCrecognisesthattheprimaryadvicerelationshipisbetweenthepatient/consumerandtherequestingpractitionerwhoisinthebestpositiontointerpretthepathologytestreportswithinthecontextofthepatient’s/consumer’shistory,andallotherinformationincludingotherdiagnosticprocedures.

Incircumstanceswherethepatient/consumerdecidestoseek(obtain)directaccesstopathologytestreports,theQUPCencouragespathologyprovidersandrequesterstofollowtheprocesssetoutinrecommendationstwotofivebelow.

Recommendations 1. Thepatient/consumershouldalways,inthefirstinstance,approachthe

requestingpractitionerforaccesstotheirpathologytestreport.


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2. Subjecttothepolicyandprocedureswhichithasputinplacetodealwiththenewlegislativerequirements,wherethepatient/consumercontactsthepathologyproviderdirectlyforaccesstothepathologytestreport,thepathologyprovidershouldrecommendthatthepatient/consumercontacttherequestingpractitioner.Inmostinstances,therequestingpractitionerwillprovideacopyofthepathologytestreporttothepatient/consumerwithanappropriateinterpretation.

3. Ifthepatient/consumerrequestsaccesstothepathologytestreportfromthepathologyprovider,thenthepathologyprovidershouldconsultwiththerequestingpractitionertoascertainwhetherornotacopyofthepathologytestreportshouldbeprovidedbythepathologyproviderdirectly. Iftherequestingpractitioneragreesthatthepathologyprovidershould

provideacopyofthereport,thenitisrecommendedthatthepathologistgivesaprintedcopyofthereporttothepatient/consumerandsendsacopytotherequestingpractitionerwithadatednotationthatacopyofthereporthasbeenprovidedtothepatient/consumer.

Thepathologistshouldkeepdocumentationofthediscussionwiththepatient/consumer.Ifthepatienthasanyquestionsconcerningtheirtestresults,thepathologistshoulddirectthepatient/consumertoraisetheseissueswiththerequestingpractitioner.

If,afterdiscussionwiththerequestingpractitioner,thepathologistdeterminestheresultsshouldnotbeprovided,thenthepathologistshouldadvisethepatient/consumerthattheresultsarebeingwithheld.Thereasonsfornotprovidingthepathologytestreportdirectlytothepatient/consumershouldbeconveyedtothepatient/consumer,preferablyinwritingandsignedbythepathologist.Reasonsforwithholdinghealthinformation,includingpathologyresults,asprovidedforinthePrivacyAct,include:

o aseriousrisktothelifeorhealthoftheindividualo thattheprivacyofothersmaybeaffectedo thattherequestisfrivolousorvexedo existingoranticipatedlegalproceedingso thataccesswouldbeunlawfulo thatdenyingaccessisrequiredorauthorisedbyorunderthelawo lawenforcementandnationalsecurityreasonso commerciallysensitiveevaluativeinformation.

4. Ifthepathologyproviderdeterminesthatthepathologytestreportshouldnotbereleaseddirectlytothepatient/consumer,forreasonsthepathologyproviderconsiderstobeinaccordwiththePrivacyActandanyotherrelevantlegislation,andthepatient/consumerstilldesiresacopyofthetestresults,thenthepathologistshouldadvisethepatient/consumertosubmitawrittenrequesttotherequestingpractitioner.(Thisisrecommendedonthebasisthattherequestingpractitionerislikelytobethebestpersontodeterminewhethertheprovisionofthepathologytestreporttothepatient/consumerwouldconstituteaseriousthreattothelifeorhealthoftheindividual).

5. Ifthepathologyproviderandtherequestingpractitionerrefusetoprovideacopyofthepathologytestreporttothepatient/consumer,thepatient/consumercanseekredressthroughtheHealthCareComplaints


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Commissionorthecomplaintmechanismprovidedunderthenewprivacylegislation.

AUSLAB Retest Interval Trial Project (2003)

Description TheAUSLABlaboratoryinformationsystemisimplementedin34publicpathologylaboratoriesacrossQueensland.Over20,000testsareorderedperdayonthissystem.Certaintestsarefrequentlyrepeatedonthesamepatientwithinaninappropriatelyshorttimeperiod,mostlybecausetherequestingdoctordoesnotrealisethetesthasalreadybeenrequested/performed.TheRetestIntervalfunctionalityinAUSLABwastrialedandactivatedforthreemonthsatRockhamptonBaseHospitalandLoganBaseHospitalforthefollowingtestsjudgedtobethemostsuitableforthisintervention: antinuclearantibodies(ANA) folate glycosylatedhaemoglobin(HbA1c) HepatitisCantibody(HCVAb) ironstudies lipids(cholesterol,triglycerides,+/-HDL) syphilisserology(RPR,TPHA) thombophiliascreen Thyroidfunctiontests(TFTs) VitaminB12.

Grant Recipient QueenslandHealthPathology&ScientificServices(QHPSS)

Aims

toimplementtheretestintervalfunctionalityinAUSLABtopreventoverorderingofpathologyrequests

tonotifymedicalstaffiftheirpathologyrequestincontraindicatedduetorecentprevioustest.

The first aim was achieved by this project although the report did not specifically state if medical staff were notified if their pathology request was contraindicated.

Outcomes

Theprojectsaved$4,494.90overthreemonthsbyrejectingpathologyteststhathadalreadybeenordered.

Theprojectwasverysuccessfulinstoppingpathologyre-orderingfortestsalreadyorderedwithinapre-determinedtimeframe.

Themostcommonpathologytestsrejectedusingtheintervalwere:o TFTs 5.8%o HbA1c 12.0%o lipidprofiles 8.9%.

Thebenefitsrealisedwere:o a6.2%decreaseintheamountofinappropriateorderingofthe

pathologytestsselectedinthetrial


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o improvedcommunicationresultinginincreasedawarenessbetweenrequestorsandpathologists

o changestopathologyorderingpatternsbyseniorclinicianso alterationtochemistrypathologyorderingcriteriaofrenalpatientsat

RockhamptonBaseHospital.o significantadditionalrequestsforsupplementaryteststobeaddedto

theintervals. Thenumberof“Retests”decreasedoverthethreemonthsofthetrialatboth

LoganBaseHospitalandRockhamptonBaseHospital. Thereweretworeportedcasesofmedicalstaffphoningthelaboratoryand

requestingadditionaltestingonasamplethathadoriginallybeenrejectedbytheretestalgorithmatLogan.

Findings

Usingthecurrenttestcodesintheretestprojectwouldsaveanestimated$18,000peryearinunnecessarypathologyorderingatRockhamptonandLogandistricthealthservicesin2003.Anestimated$360,000peryearwouldbesavedinunnecessarypathologyorderingifthesewereexpandedtothewholeofQueenslandHealth.Ifextratestcodeintervalswereaddedthepotentialsavingcouldbegreaterthan$500,000peryear.

Thereasonstestswerere-orderedcanbesummarisedinthreemainareas:o medicalstaffwereunawarethetesthadalreadybeenorderedby

anotherclinicianduetonothavingaccesstoAUSLABterminals,theinformationwasnotrecordedinthepatient’schartandthelackofclinicalinformationsystemorwardorderingsystem

o juniormedicalstaffattemptingtobesuretheyhadorderedALLtestsrequiredbytheirconsultant.Thismaybeduetoacultureinsomeclinicalenvironmentswerejuniormedicalstaffarereprimandedfornotorderingtheappropriatepathologytests

o clinicalpracticesthatorder“defaultordering”incertainareas.Forexample,renalpatientshavelipidsorderedwhenanyotherchemistrytestisordered.

Recommendations 1. AsubsequentprojectissupportedtoimplementtheAUSLABRetestInterval

functionalityatallQHPSSlaboratories.2. Investigatetheoptionofexpandingtherangeoftests.3. AreviewoftheprojectatLoganBaseHospitalidentifiedthefollowing

requests(subjecttofindingforaprojectofficertoexpandtheretestalgorithm)bymedicalstaff:

a. additionaltestinglength’sbeaddedtothetestcodesusedinthetrialb. additionaltestsbeaddedtotheAUSLABalgorithmc. acentralcontactbeprovidedformanagingchangesandnewrequests.


SeniorclinicalstaffatRockhamptonandLoganapplaudedthetrial. Therewerefiverequestsbyotherdistrictstoimplementthisfunction. TherewasnosignificantimpactonotherQHPSSlaboratories.

Follow on Initiatives and Projects AUSLABRetestIntervalProject(2004).


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AUSLAB Retest Interval Project (2004)

Description ThisprojectextendedtheAUSLABretestintervaltrialprojectto33QueenslandHealthlaboratorieswithover25,000testsorderedperdayonthissystem.

Grant Recipient QueenslandHealthPathology&ScientificServices(QHPSS)

Aim

toimplementaprocessforinterceptinginappropriatepathology. This aim was achieved by this project.

Outcomes

QHPSSimplementedtheRETESTintervalsysteminall33laboratories,andasaresultallpublicQueenslandHealthrequestsforteststargetedbytheprojectweresubjectedtotheRETESTalgorithm.

AdditionaltestscodestotheRETESTintervalalgorithmwereimplemented. Anacceptedandapprovedmethodfortheinterceptionofinappropriate

pathologyordershasbeenimplementedacrossQueenslandHealth. TheRETESTalgorithmisnowanacceptedbusinessprocessforQHPSSin

everyhospitalacrossQueenslandHealth. Developmentofabestpracticeprocessforselectionofpathologytestsby

medicalstaff. DevelopmentofalaboratoryprocedureforteststhataresubjecttoaRETEST

IntervalinAUSLABincludingaprocesstoassessandanalysetheteststhathaven’tbeenorderedwithintheacceptableretestinterval.

Developmentofasurveytooltomeasuretheextentofunnecessaryrepeatorderingacrossthestate.

AwarenessandtraininginappropriatepathologyorderingandtestingforQHPSSandmedicalstaff.

Extractionofdatathatmeasurestheutilisationofpublicpathologyservices. PresentationshavebeenmadetootherAUSLABsitesacrossAustraliaduring

annualAUSLABusergroupmeetings.

Findings

TheprojectwassavingconsiderableamountsofmoneyeachmonthforQueenslandHealth.Directsavingsatthetimeofthereportwerealmost$150,000,andabove$10,000permonth.

DatafromallsitesinvolvedintheprojectshowedtheretestfunctionalityhasseensomereductionintheoveralltestcodesorderingusedintheRETESTproject,althoughthiswasnotuniformacrossallsites.Manyexternalfactors,suchashospitalactivity,mustbeanalysedbeforemoreformalconclusionscouldbedetermined.

Analysisindicatedtheliverfunctiontest(LFT)wasover-ordered;8%ofallofthesetestsinQueenslandwereonthesamepatientonthesameday.


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However,theChemicalPathologyCommitteedidnotapproveofthistestcodebeingaddedtotheintervalalgorithm.

Thyroidfunctiontest(TFT),glycosylatedhaemoglobin(HbA1c)andcholesterol(lipids)werethemostcommonlyover-orderedorrepeatedtestsintheproject.Requestsforthesetestsweresuccessfullyinterceptedbythisproject.

AlmostallsitesexperiencedareductioninthenumberoftestsrejectedasaresultoftheRETESTprogram.IpswichexperiencedamarkedincreaseinthenumberofRETESTsorderedinthepathologydepartment,withnoexplanationabletobefoundforthisincrease.


TherewasoneformalcomplaintreceivedbytheprojectstafffromaseniormedicalconsultantwhichwashandledbytheDirectoroftheDivisionthetestcameunder.AconfigurationchangewasmadetothetestreporttoindicatethetestwassubjectedtoaRETESTinterval,eventhoughthisisalsoindicatedonrejectedreports.

ThereweredifficultiesexperiencedinengagingsomeareasofQHPSS,includingadditionalnewtestsforconsideration.

TheprojectwasperceivedtobeapoorbusinessdecisioncostingincomefromareaswithQHPSS.

ShortagesinqualifiedAUSLABconfigurationstaffimpactedonthespeedthatnewtestscouldbeimplemented.

Aprojectofthistypemustbedrivenbytheclientsofthepathologyservice(i.e.doctors)notbusinessmanagers,accountantsorpathologists.

Itwasthesupportoftheseniorcliniciansateachsitethatencouragedalmostallotherclinicianstoacceptthechangestothepathologyorderingprocess.

Complaintsandeducationmustbehandledcorrectlyandpromptlytoensuresmoothacceptanceduringtheimplementationphase.

GettingengagementfromthelargestfacilityinQueenslandHealth(RoyalBrisbaneandRoyalChildren’sHospitals)foranimplementationmeetingwasdifficultduetoconstantchangeindistrictmanagementandmedicaladministration.

Whentheprogramwasacceptedinsomeofthemajorhospitalsites(e.g.ThePrinceCharlesHospitalandThePrincessAlexandraHospital)thenothersitesaroundQueenslandbecameverywillingparticipantsintheproject.

Difficultieswereexperiencedingainingapprovalfornewtestsforthealgorithmfromchemicalpathologyandhaematology.ThereductionintheRETESTIntervalforTFTandHbA1cwasunfortunatebutacceptedasthedecisionwasmadebythecommitteewithinQHPSSforexpertadviceonchemicalpathologytesting.

TheimplementationoftheNewTests–MicrobiologyTestcodeURINE-requiredmodificationtoworkpracticeinthelaboratories.

Area for Future Consideration

ReviewtheAUSLABprojectwithaviewtoimplementingitinotherstates.


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Home Monitoring of Warfarin Therapy in Children using the CoaguchekTM Point of Care INR Monitor (2003)

Description PreviousresearchperformedbytheRoyalChildren’sHospital(RCH)hadshowntheCoaguchekTMINR(internationalnormalisedratio) monitorwasreliableandaccuratewhenusedtomonitorchildrenwithinthehospitalenvironment.Thisstudyaimedtodetermineifthisoutcomewasachievableinthehomeenvironment.AllchildrenreceivingwarfarintherapymanagedbytheHaematologyDepartmentoftheRCHwereinvitedtoparticipate.Sixteenfamiliesrespondedandallwereacceptedintothestudyasfundswereavailableforuptotwentychildren.Fourteenfamiliescompletedalloftherequirements.

Grant Recipients TheRoyalWomen’sHospitalandtheRoyalChildren’sHospital

Aim

todeterminethesafetyandefficacyofahomemonitoringprogramfacilitatedbyacomprehensiveeducationpackagetofamilies.


Outcomes

INRsperformedbyparentsathomecorrelatedverywellwithINRsperformedinthehospitalbydedicatedpathologycollectionstaff.

ThehomeINR(H-INR)resultswouldhaveproducedadifferentmanagementplanthanthecontrolINR(C-INR),takenateverysecondtestpoint,onthreetest-pointsoutofthetotalnumberperformed.

Allparentscompletedtheeducationandtrainingprogramassociatedwiththisprogram.

Findings

28%ofparentsunderstoodtheirchild’sindicationforwarfarintherapyatthecommencementoftheeducationprogram,whichincreasedto93%atthecompletionoftheprogram.85.7%maintainedthisknowledgeatthesix-monthreassessment.

Mostparentsratedtheprogram10outof10,andallstatedtheywouldliketocontinueperformingINRtestsontheirchildintheirhome.

TheestimatedtotalcostofperforminganINRathomeis$13.56plus10minutesofparentaltime.

TheestimatedtotalcostofperforminganINRinhospitalsettingsis$21.96plusaboutonehourormoreofparenttimeaswellascommunityimpacttime.

Homemonitoringofwarfarintherapyisassociatedwithreducedcostcomparedtohospital-basedmonitoring.

Thereisnoavenuetosupportthecostofongoinghomemonitoringofwarfarintherapyanditdoesnotreceiveanyformoffunding.

Homemonitoringofwarfarintherapyisunlikelytobewidelyused,despitethesignificantsavings,unlessinfrastructureisofferedtosupportthisactivity.


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Recommendation 1. Developa“self-monitoring”programwherepatientsofsufficientageare

taughttoperformtheirowntests.


SeveralparentsnotedtheyhadearlyproblemsgettingasufficientsizeddropofbloodtoperformtheINRtest.Thisproblemcanbeovercomethrougheducationabouttechnique.


FurthertestingofthesafeuseofPOCTdevicesaspartofthePointofCareTestinginGeneralPracticeTrialhttp://www.health.gov.au/internet/main/publishing.nsf/Content/health-pathology-poctt-index.htm.

Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)

Description Thisstudysoughttoprovethatthequalityuseoflaboratorytestingcouldbeimprovedbytheuseofanelectronicclinicaldecisionsupportsystemforrequestingdiagnosticlaboratorytestswhichprovidedtheuser,atthetimeofclinicaldecision-making,with:

o bestpracticetestselectionfortheclinicalproblemo relevantpasttestresults.

Grant Recipient FlindersMedicalCentre

Aims

toinvestigateiftheutilisationoflaboratorytestscouldbeimprovedbyrequestersusingwireless-enabledpersonaldigitalassistants(PDAs)that:

o providedpasttestresultso recommendedtestsandguidelinesonexcessivefrequencyofrepeat

testing‘atthebedside’o identifiedfeaturestoencouragetheaboveoutcome

toencouragetheuseofbestpracticetestutilisationbydevelopingsoftwarethat:

o utiliseswireless-enabledPDAstoprovidemedicalstaffwithelectronicsupportatthetimeofclinicaldecision-making

o integratesbestpracticetestselectionandrelevantprevioustestresultswithminimumre-testintervalsforeachselectedpatient

o downloadsthefinaltestselectiontolocallygenerateapathologyrequest.

These aims were achieved by this project.


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Objectives

toincreaseknowledgeaboutthedevelopmentandimplementationofintelligentelectroniccommunicationbetweenpathologyrequestersandproviders

toidentifythosefeaturesthatwillfacilitatebroadapplicationanduseracceptanceofthemodeltoimprovepathologyutilisation

Path-Pilot System toidentifysuitablewirelesstransmitterandPDAdevices toidentifysuitablecommercialsoftwaretoestablishcommunication

betweenhospitalserversandPDAs todesignPDAscreenstofacilitateuserrequirementsandworkflow tocreatesoftwaretogeneratePDAscreens,captureanddisplaypatientand

pathologydatafromhospitalserversandrecorduseractivityTrials todesignclinicalcondition‘trees’andassociatedrecommendedtests toobtainclinical/laboratoryconsensusfortestminimumre-testintervals toobtainparticipationinpilottrialsbymedicalstaffinageneralmedicine

unit tocollecttestrequestingactivitydatawith/withoutthePath-Pilotsystem.These objectives were achieved by this project although wireless reliability problems, thought to be associated with mandatory encryption requirements, precluded more extensive test utilisation data within the project timeframe.

Outcomes Implementation PDAswereprovidedtogeneralmedicineinterns,residentmedicalofficers

(RMOs)andregistrarsworkinginoneormoreofthewardswithwirelesscoverage.UsersweretrainedintheuseofthePDAandtheprojectsoftwaresystem(Path-Pilot).ThesoftwarewasupdatedwiththenamesofnewuserssothePDAwas‘personalised’foreachuser.Intheeventofhardware/softwareproblems,usershadaccesstotechnicalsupportfromaprojectteammemberviaadedicatedpager.

Theuserselectsthepatientofinterestbyasinglestylustaponthescreentoviewthetestresultsuploadedfortheselectedpatient.Anupperscrollablepaneldisplayedthedatesandtestmnemonicsofresultsavailableforviewing.Theselectedtestdatawasdisplayedonscreeninacumulativeformat,withreferencevaluesalsodisplayedandabnormalvaluesdisplayedinred.

Biochemistry,haematology,immunology,pharmacologyandmicrobiologyresultswereincludedinthetrial,whiletransfusionmedicineandhistopathologywerenotincludedinthesystem.

Teststoassistwithaninitialdiagnosticinvestigationcouldberequestedviaascreen(called?Diagnosis)thatdisplayeda‘tree’ofclinicalproblems/conditionsrelevanttothegeneralmedicineunit.Eachclinicalproblem/conditionwasassociatedwithalistoftestsjointlyrecommendedbytheheadofgeneralmedicineandthepathologyservice.

TherewasaRoutine Managementoptionforpatientswhorequiredon-goingmanagement.

ByApril2004,thebasicsystemdevelopedhadthecapabilityto:


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o utilisewirelesstechnologytodownloadthebasicidentificationdetailsofgeneralmedicalinpatientsallocatedtoaselectedwardorclinicalunit(surname,givenname,unitrecordnumberandbednumber)toPDAs

o downloadanddisplayrecentpathologytestresultsforaselectedpatient

o providerecommendedbestpracticetestingforclinicalconditionsselectedfromclinicalconditiontrees

o allowfurtherteststobeselectedfromthelaboratorymenuo suppressrecommendedoraddedtestsiftherewereconflictswith

minimumre-testintervalso localprintoftestrequestformswirelessly.

Anydeficitsinthesystem,suchastestsmissingfromthemenu,couldbeovercomebywritingonthegeneratedrequestforms.

Eachtrialperiodlastedtwotofourweeks,dependingontheleveloftechnicalproblemsandusercooperation,withfeedbackobtainedbyface-to-facedebriefsbasedonaquestionnaire.Thiswasfollowed,wheretechnicallyfeasible,byanupgradeoffeaturesforwhichtherewasareasonablelevelofuserconsensus.ThreeofthesedevelopmentcycleswerecompletedintheperiodMay-December2004involvingatotalofapproximately20medicalstaff.

ThemajorityoftestsinthePath-Pilotsystemwereassociatedwith‘minimumre-testintervals’(MRI)whichweredefinedasthetimeperiodwithinwhicharepeattestwasveryunlikelytobeofclinicalordiagnosticvalue.

Ofalltheuserselectedanduseraddedtests/panels(2835),170(6%)didnotproceedtoalaboratoryrequestduetoMRIguidelines,andafurther147(5.2%)didnotproceedtoalaboratoryrequestduetotheuserde-selectingthetest.Thetotalnumberoftests/panelsreinstatedbyuserswas246(8.7%).

ThelimiteddatasuggestedthatPDAswereusedtoviewtestresults(62%)moreoftenthattorequesttests(38%).

Costs Evenaminimumreductionof5-6%oftestrequestingrepresentsa

significantmarginalcostsavingformediumtolargelaboratories,andforMedicarepathologyservicerebates.

Issues ThePath-Pilotsystemincorporatedaclinicalconditionstreedesignedbyan

EmergencyDepartmentconsultant,buttodateorganisationalfactorshaveprecludedatrial.

Thelevelof‘inappropriate’repeattestingwassmallrelativetolevelscommonlyreportedinlargestudieswhichmaybedueto:

o theuserswerewell-versedinappropriatetestutilisationo participationinthetrialscausedachangeinusualrequesting

behaviour.Thiswillbeexploredwhentheoriginalpre-andPath-Pilotinterventionisundertakenwhentheconnectivityproblemsareresolved.

Feedback


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Feedbackindicatedthat?Diagnosiswasmostusedwhenpatientswereintheadmissionwardandbeingworkedup,whiletheRoutine Managementoptionwasusedfortheongoingmanagementofalreadydiagnosedpatients.

AlltrialuserswerepositiveabouttheusabilityofPDAsandgenerallyconsideredtheirusewouldberoutineinthenearfuture.

Allusersfoundthealertsforminimumretestintervalsuseful.Severaluserssuggesteditwouldbeusefultohaveselectablepop-upstoprovidemoredetailedinformationabouttestMRIs.

Therewasamarkedcontrastinuserhabits.Someinternsusedthemonwardroundswhilesomebatchedrequestsattheendoftheday.

Allusersfoundflaggingofunnecessaryrepeattestshelpful(MRIs). Bothspecimencollectionnursesandlaboratoryspecimenreceptionstaff

reportedthattheyfoundtheprintedrequestformstobeasignificantimprovementtotheirregularforms,citinglegibilityoftherequester’sidentity,100%completionofwardlocation,dateofrequest,dateofrequiredcollectionandtestsrequested.Aformalsurveywasnotundertaken.

AwardpharmacistexpressedinterestintriallingaPath-PilotPDAtoaccesspathologyresultsatthebedsidewhenprescribing.

Findings

Valuableinformationwasobtainedconcerninguserprofiles,pathologydecisionsupportpreferencesandpathsforfurtherdevelopment.

Thebasicconceptofprovidingmobilitywiththeabilitytoaccesstestresultsandrequestlaboratorytestswaswellreceivedandviewedasbecominganadditionalworktoolinthenearfuture.

LimiteddatacapturedduringtrialsindicatedthePath-Pilotsystemcanimprovetestutilisation.

Thedegreeofvalueofthesystemdependedontheuserroleintheclinicalunitsandtheworkpatternoftheuser/unit.

ThemajorityofuserscitedthefollowingadvantageswiththePath-Pilotsystem’sabilitytoviewresults:

o rapidaccesstoresultsduringwardroundso noneedtoleavewardroundstoaccessthelatestresultsfrom

desktopsinthewardstation/officeo theabilitytoreviewpatientresultsattheendoftheshiftwithout

waitingtoaccesswarddesktopso theabilitytocheckurgenttestresultswhenabsentfromthepatient’s

ward. Therewasaclearpositiveimpactontestutilisationthroughtheuseofthe

Path-Pilotsystem,althoughitwasnotclearifthiseffectwouldbesustainedinthelongterm.

UptakeofthePath-Pilotwillbegradual,andgenerallyparallelincreasingsystemreliabilityandpeeruse.

Userfeedbackclearlyidentifiedthatacriticalfactortouptakebymedicalstaffinahospitalenvironmentistheextenttowhichconvergenceofbothinformationsourcesandcommunicationcanbeachieved(asoutlinedintherecommendationsbelow).MostusersviewedthePDAasafuturemulti-functiontoolthatwouldcontributetoimprovingtheireffectivenessandefficiencyinclinicalwork.


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Thefrequencyofuseclearlyreflectedthehierarchyoftheclinicalusers,withjuniorstaffbeingtherelativelyhighusers,andregistrarsbeinginfrequent‘one-off’users.Thelattergroupreportedthisfunctionwasofpositivevalue.

DifferentviewswereexpressedintermsofthePDA’svalueforworkactivities.

Recommendations 1. Suggestionsforfurtherdevelopmentofthepathologymoduleinclude:

a. theabilitytoentertestrequestsforspecifiedpatientsduringwardrounds,andholdpendingreviewandorderingattheendofashift

b. expandrequestingcapabilitytootherspecimentypese.g.faeces,pleuralfluids

c. includemorediagnosticallytargetedtestpanelsintheRoutineManagementoption,e.g.‘bone’,‘stroke’,‘pneumonia’,‘septic’,‘diabetic’

d. theabilitytocustomiseclinicalproblemsliststoprofiletheuser’sclinicalunitsuchason-goingmanagementtestingforclinicalproblemsasopposedtodiagnosticwork-uptestingasdoneforanadmissionwork-up

e. theoptiontoincreasecumulativeresultsdisplaybyhavingreferencevaluesas‘pop-ups’,orL/Rscrolling

f. accesstoelectroniclaboratoryhandbookg. a‘pop-up’optiontoviewspecimencollectionrequirementsh. afieldforprovidingtimesfordynamicfunctiontestingi. afieldforprovidingpatientstatuse.g.fasting.j. increasetestmenuentriestocaterforcommonnamevariantse.g.

FBE/CBP,ammonia/NH3etc.k. theoptiontocustomisethetestmenue.g.commonesttestsattop,

alphabetic,commonestofeachlabattopetc.l. providediagnosticpathwaysforinvestigatingspecificconditionsm. providelistsofcausesofabnormaltestsaccessibleselectablefroma

pop-uplistfromtestresult.2. SuggestionsforfurtherdevelopmentofPDAfunctionalityinclude:

a. accesstoradiologyreportsanddischargesummariesb. accesstoclinicalpathwayprotocolsc. accesstoPath-PilotmoduleonownPDAsd. convergehospitalpagersystemtoPDAe. accesstocommonlyusedriskpredictorsoftwaref. accesstopersonalsubscriptionclinicalinformationdatabasesg. accesstohospitalintranet,staffdirectory,medicalofficershandbook

etc.3. ThereisaneedtoupgradetheactivityauditfunctionwithinthePath-Pilot

softwaretoenablediscriminationbetweenuseofclinicalconditiontreesandroutinemanagementoption.

4. ThereisaneedtoautomaticallycapturemoredataonthetestscapturedbyMRIguidelines,particularlybywhichoptiontheywerepresentedforuserreview.

5. Manyuserssuggestedthatadditionalsupporttoolsthatprovidedpathologyinformation,suchasdiagnosticpathwaysandcausesofabnormaltests,wouldbevalued.


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Key Project Learnings Users Nearlyallclinicalparticipantswerepositiveabouttheconceptofcombining

pathologydecisionsupportwithmobility,andfoundtestrecommendationsandminimumre-testintervalalertstobeofvalue.

Themajorityofusersconsideredthepersonaldigitalassistantswillincreasinglybecomeroutinemulti-purposetoolsintheirclinicalworkenvironment.

InternsandRMOsarerotatedthroughclinicalunitseveryeighttotenweeksatFlindersMedicalCentre.ItwasfoundtobeimportanttointroducethePath-Pilotsystemtomedicalstaffatthecommencementofarotationotherwisetheylearnedtousethenormalpaper-basedtestrequestingsystemandweregenerallyreluctanttochangetheirworkpracticespart-waythroughtheirclinicalattachmenttotheunit.

Severalparticipantsfelttheirworkloadsprecludedfullparticipationinthetrial.

Thedevicewasdifficulttocarrycomfortably,especiallyforfemalesiftheydidn’thavepocketsand/orbelts.

Information Technology (IT) Wirelessreliabilityproblems,thoughttobeassociatedwithmandatory

privacyencryptionrequirements,precludedmoreextensivetestutilisationdatacollectionwithintheprojecttimeframe.

Thedebriefingsrevealedageneraldislikeof“computing/ITgadgets.” Bringingtogetheravarietyofcomputingsystemsandsoftwarecoveringthe

PDAitself,wirelesstransmissionandcoverage,hospitalserversandinformationsystems,andprivacyrequirementsinvolvingoff-siteDepartmentofHealthserversposedproblemsthattooksignificantlylongertoresolvethanexpected.

Therewereproblemswithfirst-trywirelessconnectionbyPDAs. Thetechnicalproblems,particularlyrelatedtoconnectionreliability,

stretchedthegoodwillofbusyjuniormedicalstaffforalargepartoftheproject.

WirelessusesignificantlydrainsPDAbatterypowerandconnectionisgenerallylostwhenpowerfallsbelow30%.Thiswasaproblemforsomeusers,butnotforothers.

Project Design and Implementation Itwasclearintheearlyphaseoftheprojectthattwotothreemedicalstaff

andabout20inpatientsinthegeneralmedicineunitco-locatedwiththeRenalUnitwouldprovideinadequatedataexposurefordevelopingthepilotsystem.Itwasthereforeexpandedtoengageallinterns,RMOsandregistrarsinthegeneralmedicineunitworkingacrossthreeinpatientwards.

FlindersMedicalCentrealsounderwentacontinuousperiodofchangein2004whichcauseddisruptiontothePath-Pilottrialsanddatacollectionwhenmedicalstaffandpatientsmovedtoareasnecessitatingthere-locationofthewirelesstransmitter.

ThereturnrateoffeedbackquestionnairesaboutthePath-Pilotsystemwasverylowatthebeginningofthetrial,sofeedbackwaschangedtoaface-to-faceinterviewbasedaroundthequestionnaire.


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Thestudyoriginallyaimedtocomparetestutilisation(choiceandvolume)bymedicalstaffusingboththenormalpapertestrequestsystemandPath-Pilot.Thisapproachwasconfoundedby:

o lessthan100%reliabilityofPDAwirelessconnectivityatfirstattempt,andtimetakentore-establishconnectivity,causedsomeuserstonotfullyparticipateinthetrials

o workpressuresofjuniormedicalstaffcausedsomeuserstoparticipateirregularly

o re-structuringofward/clinicalunitlocationsandpatientprofileso personaldislikeofelectronic‘gadgets’byseveralusers.

ThecombinedeffectofthesefactorswastopreventactiveusersbeinglocatedinthesameclinicalunitforsufficienttimewithsatisfactorilyoperationalPDAstoenablesufficientcollectionofdatatoallowmeaningfulstatisticalcomparisons.ItwasthereforedecidedtocollectallactivitydatageneratedbyuserswhenutilisingPath-Pilotregardlessofwardlocationandperiodofactivity.


PossiblefurtherfocusonelectronicdecisionsupportwilloccurunderthePathologyFundingAgreement.

Area for Future Consideration

ExploretheoptionsforPDAsystemimplementationinhospitalenvironments.

Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005)

Description Thisprojectsoughttolookateducationstrategiesforimprovingthedetectionandmanagementofpre-diabetesingeneralpractice.

Grant Recipient FremantleRegionalGPNetwork

Aims and Objectives

establishcurrentandbestpracticeRequest-Test-Reportpracticeandidentifygapsfromboththepathologylaboratoryandthegeneralpractitioner(GP)

establishthebasisforGPlearningwhichwillenablethemtoimprovetheirroleandperformanceintheRequest-Test-Reportcycle

establishcurrentpracticeandprepareGPsforimprovedknowledgeandpractice

provideopportunityforGPstobuildontheirimprovedknowledgeandchangestocommunicationsystemsinordertoimprovecompliancewithexistingguidelinesandtheuseofdiseaseregistersandrecallsystems.



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Outcomes

Detailedmappingofcurrentpracticeindetectionandmanagementofpre-diabetesthroughfocusgroups,GPclinicalauditactivityandretrospectivepathologyreports.Bestpracticewasestablishedthroughaliteraturereviewandconsultationwithdiabetesorganisationsandexpertsinthefield.Gapswerethenidentifiedandaneducationplandevelopedandimplemented.

KeyrecommendationsarisingfromtheoutcomesofthemappingofcurrentpracticeweredevelopedandsenttoallmajorpathologylaboratoriesoperatingintheFremantleDivisionboundariesinFebruary2005.

DevelopmentandimplementationofarangeofeducationopportunitiesforGPsandPracticeNurses(PNs)onthepreventionofdiabetes.

GPswerepreparedforimprovedknowledgeandpracticebycompletingPhase1oftheclinicalaudit,receivinganindividualandgroupreportoftheirresultsfromtheclinicalaudit,andreflectingontheircurrentpracticebycompletingareflectionandactionplan.

EducationopportunitiesforGPsincluded:o registerandrecalleducationo workshopso phase2oftheclinicalaudito receiptofregularretrospectivepathologyreportso bestpracticeguidelinesandpatientresources.

Development,distributionandevaluationofbestpracticeguidelinesonthedetectionandmanagementofpre-diabetesforgeneralpractice.

Development,implementationandrolloutnationallyofafivestageclinicalauditforGPsonthedetectionandmanagementofpre-diabetes.

Presentationofprojectresourcesatthe2004AustralianDiabetesSociety(ADS)–AustralianDiabetesEducatorsAssociation(ADEA)NationalConferenceinSydney.

“ThePracticalManagementofPre-diabetes–AGuideforGeneralPractice”wascompletedinmid-June2004with803copiesdistributedthroughoutAustraliaasof29April2005.

ApatientinformationleafletwasdevelopedinJuly2004with4,892copiesorderedbyGPs,PNsandDivisionsofGeneralPracticeby19April2005.

Samplecopiesofthepre-diabetesresources,alongwithanorderform,weresenttoallDivisionsofGeneralPracticeinAustraliainOctober2005,withordersformultiplecopiesreceivedfromninedivisions.

TheclinicalauditwasredesignedandsubmittedtotheRoyalAustralianCollegeofGeneralPractitioners(RACGP)foraccreditationtoberunnationally.

TheclinicalauditwasofferedtoallDivisionsofGeneralPracticeinAustraliainMarch2005with65divisionsorderingcopiesasof29April2005.

Findings

Thispilotprojectdemonstratedthesuccessfulimplementationofawhole-of-practiceapproachtoimprovingthedetectionandmanagementofpre-diabetesingeneralpractice.

ParticipantGPschangedtheirclinicalpracticeinrelationtomeasurementofweight,BodyMassIndex(BMI)andwaistcircumferenceinpatientsatriskofdiabetes.


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Over50%ofGPsstatedtheyhadchangedtheirpracticeasaresultofparticipatingintheclinicalaudit.

Datafromentryandexitquestionnairesshow67%ofGPshadaregisterandrecallsystemforpre-diabetesascomparedto42%priortotheclinicalaudit.

Morepracticeshaveaneffectiveregisterandrecallsysteminplaceforpatientswithimpairedfastingglucose(IFG)/impairedglucosetolerance(IGT)toensuretheyaretestedregularlyfortheonsetofType2diabetes.

Recommendations 1. AllDivisionprogramsshouldadoptawholeofpracticeapproachinall

projectsinordertoaddressallstakeholdersingeneralpracticeratherthanjustfocusingonthegeneralpractitioner.

2. OfferfutureclinicalauditsduringthefirstorsecondyearoftheRACGPQualityImprovement&ContinuingProfessionalDevelopmentProgram(QA&CPD)triennium.

3. GPswhoenrollintheQA&CPDshouldberequiredtocompletePhase1andPhase2oftheclinicalaudit,asthereissignificanteducationalvalueincompletingPhase2.

4. Ensurethereisaclearunderstandingwithprojectstakeholdersofthetimeframewhenputtinginafundingsubmissiontoensurethatcircumstancesdonotchangesignificantlybetweenprojectplanningandprojectimplementation.

5. Continuetoreviewcurrentliteratureonbestpracticeforthemanagementofpre-diabetestoensureresourcesremainuptodateandrelevant.

6. OffertheclinicalaudittoGPseverythreeyears.ThiswillensuretheGPNetworkhasacurrentandaccuratepictureofgapsinthemanagementofpre-diabetes.Asthetoolsarealreadydevelopedthiswouldnotbeatimeconsumingexercise.

7. Continuetoidentifymethodstoovercomethebarriersidentifiedbygeneralpracticeinthedetectionandmanagementofpre-diabetes.

8. Continuetopromotethe‘PracticalManagementofPre-diabetes–AGuideforGeneralPractice’togeneralpracticeasaresource.

9. JointGuidelinesfromtheAustralianDiabetesSociety–AustralianDiabetesEducatorsAssociationareduetobeformalisedshortly.Theseshouldbeincorporatedintothecurrentresourceasatearoutpage.

10. Offeravarietyofregulareducationandupskillingactivitiestogeneralpracticeonthedetectionandmanagementofdiabetes

11. OfferfundstoDivisionsofGeneralPracticeacrossAustraliatoimplementtheclinicalauditandassociatededucationalactivities.

12. Pathologylaboratoriesoffer,aspartoftheirservicetogeneralpractice,theregularprovisionofpracticeleveldataontestresultsofalltypes.

13. Alltrainingprovidedtopracticesondevelopingeffectiveregistersandrecallsystemsfordiabetesshouldalsoincludepre-diabetes.

14. GPNetworkshouldcontinuetoadvocateforandsupportpreventativehealthinitiativesthatutilisetheprofessionalexpertiseofthepracticenurse.

15. PracticevisitsshouldbeofferedtoallGPNetworkpracticesonanannualbasistooffersupportfortheirdiabetesandpre-diabetesregisterandrecallsystemstoensuretheyareuptodateandbeingmaintained.

16. Allpracticeshaveinplaceaprotocoltoupdateandmaintaintheirregisterandrecallsystems.GPNetworkstaffcanassistpracticestodevelopthis.


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17. GPscodepatientswithIFG/IGTprospectivelyastheyarediagnosedtoensuretheyareincludedintheregisterandrecallsystemsandpracticeshaveanaccuratepictureoftheirat-riskpatientpopulation.

18. Continuetopromotethepre-diabetesresourcesandeducationactivitiesdevelopedthroughthisprojecttogeneralpractice.

19. Runeducationeventseverytrienniumonthepreventionofdiabetes.


Twenty-oneGPsenrolledtoparticipateintheclinicalaudit“ImprovingGPaccesstoanduseofretrospectiveandcurrentpathologydatatoincreasedetectionofpre-diabetes(IGTandIFG)ingeneralpractice”.SixteenGPscompleteddatacollectionforSteps1-4.EightGPsenrolledinStep5oftheclinicalauditandfivecompletedthedatacollection.Theattritionratewasduetoseveralreasonsincludingcompetingtimecommitments,involvementinotherDivisionalprojectsand2004beingthefinalyearoftheRACGPQA&CPDtriennium.

OneoftheaimsofthisprojectwastodevelopcommunicationsystemsbetweengeneralpracticesandpathologylaboratoriesthroughtriallingaformatforfeedbacktoGPs.Duetothetimedelaybetweenprojectplanningandprojectimplementation,GeneralPathologyLaboratories(GPL)hadalreadyputthisinitiativeintooperationanditwasnotincludedasaninterventioninthisproject.Theuseofretrospectivepathologyreportsprovidedbythepathologylaboratorytothegeneralpracticeastheinterventiontoimprovecommunicationsystemsbecamethefocusinstead.

Amultifacetedapproachtoimprovingthedetectionandmanagementofpre-diabetesprovedtobeaneffectivestrategythattargetedallthestakeholdersingeneralpractice.ThisapproachincludedthedevelopmentoflinkededucationandresourcesforGPs,PNsandpatients.

ThepathologylaboratoriesandinformationmanagementsystemsingeneralpracticewerealsotargetedtoensuretheinfrastructurewasinplacetosupportGPsandPNstoimprovethemanagementofpre-diabetes.Thisstrategyalsoensuredthatallcareprovidersandpatientswereprovidedwithconsistentinformation.

CombiningeducationaloutreachforGPs,PNsandpatients,auditandfeedback,alongwithprovisionofresourcesandinformationmanagementsupportwaseffectiveinpromotingbehaviourchangeamonghealthprofessionals.

InvolvingPNsinallaspectsofthisprojectwasasuccessfulstrategy.TheroleofthePNingeneralpracticeisrelativelynewandtheirrolesanddutiesarecontinuallyevolving.ByprovidingeducationforPNsandlinkingittoGPeducation,GPscouldunderstandandutilisethepotentialofthePNtoprovideeducation,distributeresourcesandassesslifestyleriskfactorsinpatients.

Thestrategyofprovidingcontinuingmedicaleducationlinkedtotheworkplace,plannedtomeetGPsneedsandbasedonself-assessmentandpeerreviewprovedtobeeffectiveinthisproject.ThebaselinedataprovidedbytheclinicalauditinformedthedevelopmentoftheeducationalactivitiesandresultedinparticipantGPstakingpartineducationdesignedtomeetneedsidentifiedthroughtheclinicalaudit.


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Thevaryingeducationalactivities,rangingfromclinicalaudittoeducationworkshops,wereeffectiveinaddressingthebroadeducationalneedsofGPs.Italsoallowedtheknowledgegainedfromthiseducationtoleadtosustainablechangesinpracticethroughtheincorporationofinformationmanagementstrategiesandprovisionofresourcesforpatients,GPsandPNs.

Undertakingarangeofactivitiesenabledadetailedpictureofcurrentpracticetobedeveloped.Thishelpedinthedevelopmentandimplementationofacomprehensiveeducationplanthataddressedallaspectsofgeneralpractice.Asaresult,allplannededucationalactivitieswerewellattendedandreceivedandresultedinrealchangesinpracticebyGPsandPNs.

Theinvolvementoflocalpathologylaboratoriesatbothasteeringcommitteeandprojectimplementationlevelenabledgeneralpracticeandpathologylaboratoriestofurthertheirknowledgeabouttheserviceseachprovides,andhowtoimprovethelinkagesbetweenthem.


InvestigatetheareasPracticeNursescanassistwithinformationregardingpathologytestingandpatienteducation.

Quality Use of Pathology Services Education Program (2006)

Description AstructuredprogramforteachingdiagnosticpathologybypathologistsandscientificstaffwasdevelopedanddeliveredtoyearthreemedicalstudentsattheUniversityofSydney’sSchoolofRuralHealth(formallyDubboClinicalSchool)overafour-yearperiod(2003-2006).


Aims and Objectives

toachieveimprovementinthehealthandeconomicoutcomesoftheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequestersandprovidersofpathologyservices

toproduceagreaterunderstandingofpathologytestsbymedicalstudents toequipmedicalstudentswiththecapacitytoactmoreconfidentlyinclinical

situationsinwhichpathologyservicesmaynotbereadilyavailable toprovidemedicalstudentswithabetterunderstandingofthepathological

processofdiseaseandtherealisticroleofthepathologylaboratory. These aims and objectives were achieved by this project.

Outcomes

AprogramtoprovideastructuredprogramfortheteachingofdiagnosticpathologybypathologistsandscientistswasdevelopedforstudentsatTheSchoolofRuralHealth.


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Pathologyteachingwasincorporatedintotheyearthreemedicalstudents’academictimetabletomakeitanintegratedpartofmedicaltrainingatTheSchoolofRuralHealth.

Partofthecoursedemonstratedthatacliniciancanmakeanaccuratediagnosisinrural/remotepracticewithsimpleequipmentandbasicpointofcaretechnology.

Thestudentsspenteighthalfdayscoveringthemajordisciplinesofpathology,andwereinvolvedinautopsiesandformaltutorials.

Independentevaluationsofthecourseweresubmitted.

Findings

TheSchoolofRuralHealthnotedthevalueofteachingpathology,andstudentopinionwasinfavourofpathologyteaching.

Pathologydepartmentsatbothsitesacknowledgethebenefitsoftheprojectandindicatedthatteachingwouldcontinueintheshortterm.

Aindependentexternalreviewernotedthefollowingstrengthsoftheprogram:

o ithadastrongcorrelationwithclinicalpracticeo theinvolvementofabroadrangeofstakeholders(scientists,

technicians,pathologistsandphysicians)todelivertheprogramobjectives

o enthusiastic,engagingandcommittedstaffatbothcampuseso thegoodrelationshipbetweenthepathologylaboratoriesandThe

SchoolofRuralHealth,UniversityofSydneyo thecloselocationbetweenTheSchoolofRuralHealth,thehospitals

andthehospitalpathologylaboratorieso goodphysicalteachingfacilitieso positivefeedbackabouttheprogramfromthemedicalstudentso willingnessofstafftoimprovetheprogram.

Asecondindependentexternalreviewernoted:o theprogramhadthepotentialtoprovideamodelforteaching

laboratorymedicineinthesenioryearsofmedicalcourseso theinitialfundinghadbeenwell-utilisedtobuildanexcellentteaching

programwithgreatpotentialasamodeltoadvancethebetteruseofpathologyinhealthcare.

Recommendations 1. TheSchoolofRuralHealthwillconsideranothersubmissioninconsultation

withtheAustralianGovernmentDepartmentofHealthandAgeing.Independent external reviews recommended: 2. Developstrategiestoensurethatstudentscanparticipateinallaspectsofthe

programsuchasensuringthestudent’stimetablesarecompatiblewiththepathologysessionsorintroducingapathologyprize.

3. Ensuremoreconsistencyinthedeliveryoftheprogrambetweenthecampuses.

4. Greaterclarityforstudentsandsomestaffregardingthelearningobjectivesandoutcomesoftheprogramsuchasthelearningstandardsrequired.

5. Moredetailedplanningonhowthemedicalschoolwillmanagethedeliveryoftheprogramifpathologistnumbersarereducedfurther,includingpossibly


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developinglinksbetweentheprivatepathologyservicesandTheSchoolofRuralHealth.

6. DevelopmentofformalassessmentprocessestoalignwiththelearningobjectivesinvolvingtheUniversityofSydneyMedicalEducationUnit.

7. Moreaccesstostaffdevelopmentprogramstohelpwiththeprogramdevelopmentanddelivery.

8. TheUniversityofSydneyandtheAreaHealthServicemustprovidemoreacademicteachingstaffforthisteachingprogramtocontinueanddevelopsuccessfully.

9. Secure,long-termfundingarrangements,probablyinvolvingtheAustralianGovernmentDepartmentofHealthandAgeing,mustbenegotiatedtoensurecontinuationoftheteachingprogram.

10. Considernetworkingwithsimilarprogramsinothermedicalschools.11. Furthersupportofthisprogramisstronglyrecommended.


ThetimeandresourcesspentbyacademicsandsupportstaffwasnotfactoredintotheagreementwiththeAustralianGovernmentDepartmentofHealthandAgeing.

TheSchoolofRuralHealthidentifiedalackofadministrativesupportandformalcoordinationbetweentheircampusesinOrangeandDubboandthepathologytutorsasasmallbarriertothesuccessfuldeliveryoftheprogramtostudents.Thisfactormustbeaddressedtomaketheprogramsustainable.

Casebook/skillslogbooksweredevelopedandsuppliedtostudentsatbothcampuses,however,sincetheircompletionwasnotarequirementoftheUniversity’smedicalcoursetherewaslimitedsuccesswithstudentsfillingthemout.Newassessmentmethodswillneedtobestandardisedanddevelopedacrossbothcampuses.


Assesstheviabilityofre-establishingthisprograminruralmedicalschools.

Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008)

Description ThisprogramsoughttodevelopaprogramtoidentifythereasonsforincompleteorincorrectpathologyrequestformssubmittedbymedicalstaffinalargeteachinghospitalinSydney.Thiswasdoneusingaquestionnaire,focusgroupinterviewsandauditsofpathologyrequestforms.

Grant Recipient RoyalNorthShoreHospital

Aims

todeterminethetypeoferrorsthatcanoccurinthecompletionofpathologyrequestforms

todeterminethereasonsfortheseerrors todeterminetherelativeimportanceoftheseerrors


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todeterminetheimpactoftheseerrorsonlaboratorystaff. These aims were achieved by this project.

Outcomes

Onehundredandfourquestionnaireswerecompletedbyinterns,residentofficers,registrarsandconsultants(342weresentout).

Anauditof236randomlyselectedpathologyrequestformsoveraperiodofonemonthtodeterminethetypeoferrorsandomissionsandtheirfrequency.

Anadditional179requestformscompletedbyinternswerealsoaudited.Thisconsistedoftwoseparateauditsthreemonthsaparttodeterminetheeffectoftheworkenvironmentonthecompletionofrequestforms.

Anauditoftimespentseekinginformationfromclinicalstaffduetoincompleteorinadequaterequestforms.

Findings Staff Attitude Theclinicalstaffdidnotconsideritnecessarytocompleteapathology

requestform,particularlyclinicalandmedicationdetails,whichshowedamajorproblemwiththeattitudeoftheclinicalstafftowardsthepathologyrequestform.

Clinicalstaffdidnotunderstandtheimpactofincompleteorincorrectpathologyrequestformsonlaboratorystaffincludingtheextraworkrequiredbylaboratorystafftofindthemissinginformation.Therewasalsocorrespondingresentmentamongstlaboratorystaffwhichadverselyaffectedcommunicationbetweenthetwostaffgroups.

Time Issues Onereasonforincompletedocumentationonthepathologyrequestform

wastoomaysectionstobecompletedwhichtooktimetofillin. Theamountoftimewastedandthereforecosttothelaboratorybecauseof

errorsinrequestformsisconsiderable.OmissionofIDoftherequestorandrequestorcontactdetailsarethesectionsthatcausethemostwasteoftimeforcollectorsandlaboratorystaff.

Laboratorystaffspentaconsiderableamountoftimetofindthemissingorincorrectinformationonthepathologyrequestform.Thismeansthatanyimprovementinthecompletionrateandaccuracyofpathologyrequestformswillimprovelaboratoryproductivity.

Errors Theauditshowedsixsectionsonthepathologyrequestformaccountedfor

about80%oftheerrorsandcausedsignificantproblemsforlaboratorystaff.Thesewere:

1. clinicaldetails2. medicationdetails3. requestorcontactdetails4. IDoftherequestor5. IDofthecollector6. collectiondetails.


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Ofthesesections,clinicalandmedicationdetailswerethemostfrequentlyomittedwhichhaveasignificantimpactontheinterpretationandreportingoftheresult.

Education Internswereverygoodatcompletingpathologyrequestforms,withthe

exceptionofclinicalandmedicationdetails,atthestartoftheircareer.However,theirerrorrateincreasesovertimewhichindicatesthateducationandfeedbackareessentialtomaintaingoodclinicalpractice.

Medicalstaffhaveagoodunderstandingofthemedico-legalaspectsofthepathologyrequestform.

Educationshouldtargetafewkeyareasratherthancoverallsectionsoftherequestform.

Theworkenvironmentdoesnotencouragejuniormedicalstafftocorrectlycompletepathologyrequestforms.Theyaregivenlittlefeedbackabouttheirperformanceinthecompletionofrequestforms.

Recommendations 1. Developaneducationprogramthattargetsthemostimportanterrorsor

omissionsonrequestforms.2. Aneducationprogram,whichincludeslaboratorystaff,mustbegiventoall

medicalstaff.Theerrorrateinconsultantsissufficientlyhightowarrantprovidingfurthereducation.

3. Reviewthecontentandformatofpathologyrequestformsanddecidewhichsectionsdonotrequirecompletionbymedicalstaff.Removingnon-essentialsectionswillallowmoretimeforcompletionofessentialsections.

4. Reviewtheformatofthepathologyrequestformtofacilitatecompletionofthemostessentialsections.

5. Movetoelectronicrequestformswhichwillallowtheimplementationofmandatoryfields.


ABestPracticeinPathologyRequestingandReportingWorkshop(2009)onpage175wasconvenedbytheAustralianGovernmentDepartmentofHealthandAgeingtofurtherexplorerequestingissueswithkeystakeholders.


Reviewtheformatandcontentofpathologyrequestforms. Investigateimplementinganeducationprogramwhichtargetsthemost

importanterrorsoromissionsonrequestforms.

Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009)

Description Thisprojectsoughttoundertakeaneedsassessmenttoinformthedevelopmentofatrainingprogramandseriesoftrainingmodulesfocusedonmaximisingtheuptakeofeducationandtraininginthequalityuseofpathologybygeneralpractice(GP)RegistrarsandInternationalMedicalGraduates(IMGs).Itadopted


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theviewthatimprovedvocationaltrainingintheappropriateuseofpathologywillassistinaddressingtheissuesfacedbyGPRegistrarsinmovingfromahospitalbasedtrainingsettingtocommunitybasedgeneralpractice,especiallysinceregistrarsindicatedthatitwaseasiertoseekadviceandfeedbackregardingpathologyuseinthegeneralpracticeenvironment.

Grant Recipient UniversityofAdelaide

Aim

toidentifythepathologytrainingneedsofGPRegistrarsandIMGstoinformthedevelopmentofatrainingmodule/sfocusedonmaximisingqualityuseofpathology

Objectives

toundertakeaneedsassessmenttoinformthedevelopmentofatrainingmodulefocusedonmaximisingtheuptakeofeducationandtraininginthequalityuseofpathologybyGPRegistrarsandIMGs

toinvestigatetheworkundertakentoassesstheeducationalneedsofGPRegistrarsandIMGsinrelationtopathologytesting

togaininsightintoGPRegistrars’andIMGs’knowledgeofpathologytesting,theirtrainingexperienceandtoidentifygapsintheirtrainingtoassistindesigningtheNeedsAssessmentSurveytobedisseminatedtoawidergroupofGPRegistrarsandIMGs

togaintheperspectiveofpathologyprovidersonthecurrenttrainingneedsforGPsandIMGs

togainanunderstandingofGPRegistrars’andIMGs’knowledgeofpathologytesting,theirpathologytrainingexperienceandtoidentifygapsintheirtraining.

The aim and all objectives were achieved by this project.

Outcomes

Aliteraturereviewwasconductedtoinformtheconductoffocusgroups,pathologyproviderinterviewsandthedevelopmentofaneedsassessmentsurvey.

AqualitativeanalysisviafocusgroupswithGPRegistrarsandIMGstogaininsightintotheirknowledgeofpathologytesting,theirpathologytrainingexperiencesandtoidentifygapsintheirtraining.

AqualitativeanalysisviainterviewswithpathologyproviderstogaintheirperspectiveonthecurrenttrainingneedsforGPRegistrarsandIMGs.

Informationfromthefocusgroupsandinterviewswasusedtodevelopaquestionnaire.

AquantitativeanalysisviaaNeedsAssessmentSurveydisseminatedtoabroadercohortofGPRegistrarsandIMGstogainanunderstandingoftheirknowledgeofpathologytesting,theirpathologytrainingexperiencesandtoidentifygapsintheirtraining.

Findings Literature Review


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ThisstudyconfirmedthereisalackofpathologytrainingbeingprovidedtoGPRegistrarsandIMGs.

TheliteraturereviewhighlightedalackoftrainingforGPRegistrarsandIMGsintheareaofpathologytesting.

Thereviewhighlightedanumberofareasrelatingtothequalityuseofpathologyingeneralpracticeincluding:

o EvidenceindicatesarelationshipbetweenGPs’characteristicsandpathologyutilisation.Forexample,femaleGPsandyoungerGPstendtoordermorelaboratorytests.

o Pathologyusageislinkedtoleveloftrainingandexperience.AstheconfidenceofGPRegistrarsandIMGsincreases,theirtestorderingbehavioursmayimprove.ForRegistrarsitwilldevelopwithknowledgeandexperience;forIMGsitwilldevelopastheygainabetterunderstandingoftheAustralianhealthcaresystem.Thisisalsorelatedtoconfidenceandknowledge.

o Additionally,knowledgeofclinicalguidelines,sizeofpracticeandutilisationofspecificallydesignedpathologyorderingformsimprovedqualityuseofpathology.

o PatientprofilecaninfluencepathologyorderingforGPs.Patientswithahigherlevelofeducationrequestedmorepathologytests.

o Anumberofinterventionswhichrangefromfeedback,educationandauditstoorderingprotocolshavebeenshowntoimprovepathologyordering.Themostsuccessfulapproachesutilisemultifacetedstrategies.

o ThereexistsalackofdesignatedpathologytrainingattheundergraduateandpostgraduatelevelsinAustraliaandparticularlyforGPRegistrarsandIMGs.

o Differentgroupshavedifferenttrainingneeds.Forexample,IMGsrequiretrainingintheAustralianhealthcaresystem,communicationskillsandclinicalmanagementwithintheAustraliansetting.Anytrainingmoduleneedstoensurethesedifferencesareaddressed,whileotherareaswillbesimilartotheneedsofGPsundergoingregistrartraining.

o AnationalsurveyonpathologyteachinginprevocationalandGPvocationaltrainingidentifiedtheneedforapathologyauditpackageforGPs.

Focus Groups Thefocusgroupparticipantsandinterviewsconfirmedtheexistenceofgaps

inthepathologytrainingbeingprovidedtoGPRegistrarsandIMGs. Mostpathologytrainingatundergraduatelevelwasreceivedthroughcase-

basedorconditioned-baseddiscussionsandproblem-basedlearning(PBL). Mosttrainingandexperienceatpostgraduatelevelwasgainedthrough

clinicalplacementsingeneralpracticeandthehospitalsetting. RuralGPRegistrarsindicatedtheywouldlikefurthertrainingoncollecting

andpreservingsamplesproperly. Thefocusgroupparticipantsidentifiedtheconditionswhichappearedto

causethemostdifficultiesinregardstotestorderingas:o rheumatologyo menopausalandinfertilityproblems


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o vagueillnessessuchastiredness. Thefocusgroupparticipantsidentifiedthetestsmostdifficulttointerpretas:

o rheumatologyresultso liverfunctiontests(LFTs)o lipidtestso hormoneso prostatespecificantigen(PSA)

Testresultsthatweremildlyelevatedandmoderatelyabnormalposedthemostproblems.

Thefocusgroupparticipantsidentifiedsupervisorsandcolleaguesasthepeopletheywouldmainlyapproachforassistancewithtestorderingandtestinterpretationdifficulties.Theyoftensoughtadvicefrompathologyproviders,butmostlyinregardstotestinterpretation.

Pathology Provider Interviews ThepathologyprovidershighlightedLFTs,fullbloodcounts,thyroidfunction

tests(TFTs)andreproductiveendocrinologyastheteststheyreceivethemostcallsinregardstoassistancewithtestinterpretation.

ThepathologyprovidersbelievedthefollowingtestswereoverusedbyGPs:o TFTso PSAo glycatedhaemoglobin(HbA1c)o lipidso tumourmarkerso vitaminB12o folatetests.

Situationstheymightreceiveacallaboutatestresultincluded:o atestresultislateo atestresultforapatientwhohasbeenseenbyaGPorspecialist

outsidethepracticeo atestresultforaGPwhosepracticeisnotcomputerised.

TheyreceivedthemostenquiriesfromGPsinruralandremoteareas,IMGsandolderGPs.

TheyreceivedmorecallsfromGPstohelpinterpretatestresultthanforadviceonthemostappropriatetesttoorder.

Theneedtohavesufficientinformationontherequestingform,includinggoodcontactdetailsfortheGP,washighlightedasveryimportant.

Allintervieweesbelievedtherearegapsinthecurrentmedicaltrainingregardingpathologyincludingpracticalaspectssuchas:

o howspecimensarecollectedo thetimingofspecimencollectiono thedifferencebetweenthefirstpassedspecimenofurineandamid-

streamurineo bestpracticetocultureawound.

PathologyprovidersindentifiedthefollowingareasforinclusioninpathologytrainingforGPs:

o practicalsessionsonspecimencollectionandtypesofspecimenso moreeducationaboutcommontestsandtheiruseinscreeningo theimportanceofprovidingappropriateandsufficientclinicalnotes

onrequestforms


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o specificinformationabouttests/conditionsthatareapplicabletotheareainwhichtheGPisworking.

Youngerdoctorsandfemaledoctorstendedtoordermorepathologyasagroup.

Needs Assessment Survey Pathologytrainingdiminishesasparticipantsmovethroughtheirlevelsof

medicaltraining. IMGsreportedlesstestinterpretationproblems.Asthiscohortwereolder

andgraduatedearlierthantheGPRegistrars,thiswasthoughttobeassociatedwiththeiryearsofexperience.

Bothgroupsrequestedfurthertraining,particularlyforreproductivehormonesincludingtheinfertility/pregnancytestsaswellashepatitisserologytests,andmoreinformationaboutnewtestsandadvancesinpathologytesting.

Thecasescenarioalsoidentifiedseveralteststhatmaybeinappropriatelyusedincludingferritin,creatinekinase,erythrocyte sedimentationrate(ESR)andc-reactiveprotein(CRP)tests.Itisunclearifthisisduetoalackofunderstandingontheuseofthesetestsoraresultofpanelordering.

Theparticipantsidentifiedseveralconditions/symptomswhichcausedthemthemostproblemsinregardstopathologytesting.Participantshadthegreatestdifficultywithtestorderingandtestinterpretationsforconditions/symptomsthatarevagueand/orwheretherewerenoguidelinesordecisionsupportsystemsavailable.Incontrast,theleastdifficultywasreportedforconditionssuchasdiabetes,lipidsandurinarytractinfectionswhereclearmanagementguidelinesareavailable.

Presentationsofweakness/tirednessandmenopausalsymptoms/complaintswerereportedasconditionscausingthemostproblems.

Theformatinwhichparticipantswouldliketoreceivefurthertrainingincludedcasestudies,shortseminarsorconferencesandon-linelearningresources,withcasestudiesbeingmostfavouredbyIMGs.

Recommendations 1. Atrainingmodule/stoincludeinformationontheapplicationofthetests

identifiedascausingthemostdifficulties.2. Atrainingmodule/stoincludestrategiesandavailableevidence-based

resourcestomanageconditions/symptomswherenoguidelinescurrentlyexist.ThemodulealsoneedstoincludeinformationtohelpraiseawarenessaboutthedifferencesbetweenpathologytestinginthehospitalandGPsetting.Thiscouldincludeuntilising‘awaitandsee’approach,communicatingeffectivelywithpatientsandadvocatingtheimportanceoftakingadetailedhistory.

3. Thetrainingmodule/sbeprovidedinmultipleformatsanddesignedtosuittheeducationmaterialbeingprovided.

4. GPSupervisorsadvisedofthepathologytrainingneedsforGPRegistrarsandIMGS,andprovidethemwiththeeducationandresourcestoassisttheminthisknowledgetransfer.

5. Establishaworkingparty,includingaGPSupervisorandapathologyprovider,todevelopthetrainingmodule/sforimplementationthroughGPtrainingproviders.Itisimportantthatthemodule/sbecontinuallyupdated


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toreflectthebestevidence-basedresourcesavailable,andthattheparticipant’spathologytrainingneedsareperiodicallyevaluated.

6. Areas/topicssuggestedbythisproject’sfocusgroupandintervieweesforfurtherpathologytraininginclude:

a. practicalsessionsoncollectingandpreservingsamplesb. commontestsandtheiruseinscreeningc. whatiscoveredundertheMedicareBenefitsSchedule(MBS)d. howtofindpathologyinformationallinonespote. informationonspecifictests/conditionsthatareapplicabletothearea

inwhichtheGPisworking.7. Pathologyproviderswouldlikeasessiononprovidingappropriateand

sufficientclinicalnotesonrequestforms.8. Supervisorscanplayakeyroleinprovidingfurtherpathologytraining.


ProjectoutcomeswerepromotedattheBestPracticeinPathologyRequestingandReportingWorkshoponpage175.


Possibledevelopmentofatrainingprogram/modulestobeprovidedtoGPRegistrarsandIMGs,andtheneedforatrainingmodule/s.

Developfactsheetscoveringthearea’shighlightedinrecommendationno.6above.

Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010)

Description Thisprojectsoughttotestthehypothesisthat‘withholding’ofantimicrobialsensitivityreportinginconjunctionwithaselectiveevidence-basedinformativecommentwillresultin: lessongoingantibioticusageinelderlyfemalepatients fewerantibioticsideeffects improvedpatientcare improvedoutcomes significantcostsavings.

Grant Recipients FlindersMedicalCentreandSouthAustraliaPathology

Aim

totestthehypothesisthatthe‘unjustified’antimicrobialtreatmentofasymptomaticbacteriuriainelderlyfemalescouldbereducedbyutilisingamodifiedmicrobiologyreportinwhichfullmicrobialspeciationwasnotperformed,antimicrobialsensitivitydatawasnotreportedandashorteducationalcommentregardingthelikely(orlackof)clinicalsignificanceoftheresultwasincludedinthepathologyreport.


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Outcomes

Urinesamplesreceivedintheroutinediagnosticmicrobiologylaboratoryfromfemalesaged70yrsandoverwithdetectedbacteriuria(>105cfu/ml)wereconsideredforrandomisationtoeither:

o fullreportingofisolateatthespecieslevelwithan‘appropriate’choiceoforalandintravenousantibioticsreported.Asaminimum,sensitivitytoampicillan,cephazolin,timethoprimandgentamicinwasreported,withadditionalantibioticsiffirst-linedrugresistancewaspresentOR

o generalreportingofthemicrobiologyresultwithoutprovisionofanymicrobialsensitivitydata,butinclusionofthefollowingcomment:‘Asymptomatic bacteriuria in elderly women does not usually require antibiotic treatment. Sensitivities are available upon request.’

Womenwereexcludedfromthetrialif:o therewasanindicationfromclinicalnotestosuggesttheirbacteriuria

wassymptomaticorthatantimicrobialsmightbeindicatedo theywerereceivingantimicrobialsforanotherclinicalindication

whichhadactivityagainsttheurinaryisolate.

Findings

Ratesofantimicrobialprescribingforurinarytractinfection(UTI)were202of272(74%)inthereportedgroup,and205of293(70%)inthesensitivitiesmaskedgroup.

Thesubsequentanalysiswasperformedin470subjectsafterexclusionof95subjectsforreasonsnotavailabletothelaboratoryatthetimeofrandomisation.

TheinterventionofmaskingantimicrobialsensitivitiesandprovidingeducationalcommenthadasmalleffectonantimicrobialuseforUTI.

Sensitivitieswereonlyrequestedin45%ofcasesofthegroupreceivingmaskedreportswhowereprescribedantibiotics.Thisfindingindicatedthepracticeofnotconfirmingantibioticsensitivitiesdespiteprescribingantibioticswascommon.

Therewasconsiderablevariationinthedurationofantimicrobialuse. Antimicrobialswerewidelyused‘unnecessarily’inbothgroupswhich

highlightstheimportanceoftargetededucationalprograms. Alimitationofthestudywastheconsiderablenumberofsubjectswhere

antimicrobialswereinitiatedempirically,eitherforpresumptivesymptomaticUTI(withnoindicationofthisonthepathologyrequestform)oronthebasisofimmediatedipsticktestscollectedonadmission.

Therewasnoapparentadverseclinicaleffectassociatedwithmaskingantimicrobialsensitivityresults.

Themeanlengthofstayforthemaskedversusreportedgroupwere13.3daysand14.2daysrespectively.

Follow-upurinespecimenswerecollectedwithsimilarfrequencyinbothgroups.


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Educationalinterventionsarebeneficialbutrequiresignificantresourcestoinstigate,mayloseeffectovertimeandmaynotpreventantimicrobialprescribingoncea‘positive’urineresultisobtained.

Antimicrobialuseisassociatedwithadditionalcosts,toxicityandtheemergenceofresistance.

Recommendations 1. Strategiesforreducingunnecessaryprescribingforasymptomatic

bacteriuriacouldbedirectedatreducingthenumberofspecimensinitiallysentfromasymptomaticpatients,orprovidingeducationalinformationregardingthesignificanceoftheresult.

2. Providingonlylimitedinformationonthelaboratoryreport,andaddingabriefeducationalcommentinanattemptto‘downplay’thepotentialsignificanceofthepositiveurineculture,couldbeutilisedatessentiallynocostandbeeasilysustainedwithongoingresources.Incorporatingadditionalcomponents,suchascomprehensiveeducationalprograms,willproducethebestoutcomes.

3. Educationalprogramsshouldbetargetedtospecificgroupstoempowerthemtodevelopconfidenceinwithholdingantibioticsforasymptomaticpatients.

4. Educationalprogramsshouldalsotargetnursingandmedicalstafftoeducatethemonnotobtainingurineforanalysisunlessthepatientissymptomatic.

5. AutomaticstopordersafterthreeorfivedaysofantibioticuseforUTIcouldbeinitiatedinahospitalsetting.

6. Additionalcommentssuchas‘Recommended duration of antimicrobial therapy for symptomatic, uncomplicated UTI is 5 days for β-lactams and 3 days for trimethoprim/quinolones’couldbealsobeaddedasasupplementtolaboratoryreports.


Produceafactsheetonantibioticuseandbacteriuriaforalllevelsofmedicalstaff,includingnurses,toempowerthemtodevelopconfidenceinwithholdingantibioticsforasymptomaticpatients.

Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010)

Description Thisprojectsoughttoidentifywhethercomputerisedpathologyorderentry(CPOE)systemswithvaryinglevelsofelectronicdecisionsupport(EDS)canenhancetheefficiencyofpathologyservicesandleadtomoreeffectiveandrationalpathologyorderingandimprovedpatientoutcomes.WhileresearchhasshownthatCPOEhasthepotentialtosupportmoreefficientpathologyservices,itistheEDScomponentwhichholdsthepromiseformakingsubstantialimprovementsindeliveringmorerationalpathologyorderingandimprovementsinpatientsoutcomes.


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AmajorlimitingfactorinderivingbenefitfromCPOEwithEDSisthelackofresearchevidenceregardingwhichlevelofEDSisusefulandwhichspecificEDSfeatureswillimprovepathologypracticeandpatientoutcomes.ThisprojecttargetedthislargeknowledgegapbyundertakingadetailedanalysisofthreelevelsofEDS.


Aims and Objectives

toidentifyhowcomputerisedpathologyordersystemswithvaryinglevelsofelectronicdecisionsupportcanenhancetheefficiencyofpathologyservicesandleadtomoreeffectiveandrationalpathologyorderingwhichimprovespatientoutcomes

toundertakeamulti-sitestudywhichwill:a. undertakeaglobalassessmentoftheimpactofCPOEonpathology

practicemeasuringabroadrangeofeffectiveness(e.g.lengthofstay)andefficiency(e.g.turnaroundtime)indicators

b. measuretheimpactofdifferentlevelsofEDS(basic,intermediateandadvanced)onqualityofinformationprovidedtolaboratories,rationalpathologyorderingandpatientoutcomes.

These aims and objectives appeared to be partially achieved by this project as the report did not articulate the level of EDS for each outcome/finding, nor did it articulate the 39 measures across the spectrum of the pathology test processes (see outcomes).

Outcomes

Thereportednotedthereviewidentified39measuresclassifiedinto10impactareasacrossthespectrumofpathologytestprocesses(ordering,processingandreporting).Theseincludedmeasuresof:

o turnaroundtime(TAT)o testvolumeso redundanttestso costso guidelinecomplianceo workpracticeso communicationo patientmanagemento lengthofstayo adverseevents/safety.

Thisprojectresultedin13peer-reviewedpapersincludinganumberinhighimpactinternationaljournalsandconferenceproceedings.

Thisprojectalsoresultedin19presentationsincludinginvitedandkeynotepresentationsatmajornationalandinternationalfora.

Theproject’sresearchersalsoreceivedaninvitationbytheAmericanCollegeofPathologiststocontributeachapteronelectronicmedicalrecordstotheCollegetextbook,andaninvitationtooutlinetheirworkinthefoundingissueoftheJournal of Pathology Informatics.


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Findings

Turnaroundtime,testvolumes,redundanttests(testsreorderedwithinaninappropriatetimeframeprovidingnoadditionalinformation)andlengthofstay(thenumberofdaysapatientremainsinhospitalfromadmissiontodischarge)canprovidevaluableinformationtomonitortheimplementationofCPOEanddrivebenefitsrealisation.

Thereisvalueinusingastandardisedrecordlinkagetechniquetogenerateaqualitydatasetwithenrichedinformation.Analysesappliedtotheseenricheddatasetscanprovidevaluableinformationtohealthsystemplanners,cliniciansandpathologymanagersforuseinmanagingandevaluatingnewCPOEsystems.

ThevariousmeasuresofCPOEperformanceandimpactprovideaframeworktoassess:

a. efficiency–testvolumes,communicationb. effectiveness–testcosts,redundanttestrates,TAT,workpracticesc. quality–patientsafety,compliancewithguidelines,patient

management,lengthofstay,patientsafety. ThestudyfoundtheCPOEsystemproducedsustainedandcontinuing

improvementsinlaboratoryefficiencyoveratwo-yearperiod. AregressionanalysisdemonstratedthatTATwasasignificantfactor

contributingtopatient’slengthofstayintheemergencydepartment.ThisprovidedevidencethatreducingTATsviatheintroductionofaCPOEmayproduceimprovementsinthesepatients’outcomesintermsofreducedlengthsofstay.

Theratesofmissedtestresultswerelowerthanthosefromstudieswherepaperorderingandreportingsystemswereused.ThissuggeststheavailabilityofCPOEsystemsmayreducetheriskoftheseevents.Electronicresultdelivery,withelectronicendorsementtoallowdocumentationoffollow-uptestresults,mayprovideadditionalefficiencybenefitsandfurtherreducetheriskoftestresultswhicharenotfollowedup.

TherewasapositiveimpactofusingtheCPOEfornotifyingthehaematologylaboratoryaboutpatientsonheparinorwarfarintreatmentwhenorderingactivatedPartialThromboplastinTime(aPTT)orProthrombin(PT)/InternationalNormalisedRatio(INR).ThemedianTATalsodecreasedfrom28to21minutesforaPTTandfrom34to23minutesforPT/INR.DecreaseswerealsoshownforTATinnormaltestresults(30to22minutes)andabnormalrestresults(33to23minutes).

Recommendations 1. Associationsbetweenincreasedmortalityratesandtheintroductionofa

computerisedproviderorderentrysystemshouldbeinvestigatedcarefullytoascertainanylikelyassociation.

2. ConductresearchintothechangeinlengthsofstayinemergencydepartmentsfollowingtheintroductionofCPOE.


Continueddevelopmentasstage2intheprojectTheImpactoftheImplementationofElectronicOrderingofPathologyRequestingandtheQualityandEffectivenessofHospitalPathologyServices–BuildingaRobustEvidenceBaseandBenefitsFrameworkforSuccessfule-HealthDiffusions


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The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current)

Description Thisprojectisdevelopingperformanceindicatorstoevaluatethequalityandeffectivenessofelectronictestorderinginarangeofhospitalsinmetropolitan,regionalandruralsettings.Itisbeingconductedinthreestages,andtheevaluationwillexaminethequalityofpathologytestorders,laboratoryturnaroundtimes,re-testingandadd-ontesting.

Grant Recipient UniversityofNewSouthWales(UNSW)

Aim

toprovideresearchevidence,employingkeyindicatorsofpathologyorderingefficiencyandeffectiveness,oftheimpactofelectronictestorderingontheutilisationanddeliveryofhospitalpathologyservicesacrossfivehospitalsindifferentdemographicsettings(majormetropolitan,regional,country)withintheSouthEasternSydney(PrinceofWales,RoyalHospitalforWomanandStGeorge)andIllawarraShoalhaven(Wollongong,Shoalhaven)LocalHealthNetworks.

Objectives

providekeycomparative(acrosshospitals)andlongitudinal(overtime)evidenceabouttheeffectofelectronicorderingsystems

produceasuiteofbenefitsrealisationindicatorsthatcanbeusedtomonitorwhatworks(orwhatdoesn’twork),where,andinwhatcircumstances

utiliseasetofperformanceindicatorstoevaluatetheimpactofelectronicorderingonthequalityuseofpathologyacrossthefollowingareas:

o thelegibilityandcompletenessoflaboratorytestordersandtheimpactonCentralSpecimenReceptionworkprocesses(qualityoftestorders)

o thetimelinessofthepathologylaboratoryprocess(laboratoryturnaroundtimes)

o thevolumeandmixoftestsorderedexaminedbysuchfactorsasDiagnosisRelatedGroups,wardlocationordepartment,andadjustedforclinicalactivitywhereappropriate

o theimpactonre-testandadd-ontestrates.This project is current and the aim and objectives are in the process of being achieved.

Outcomes ByearlyDecember2011thefollowingactivitieshadbeenachieved: ethicsapprovalgranted


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extractionoffirstdataforanalysisconcentratedon:o LaboratoryInformationSystem(turnaroundtimes,testorder

volumes,re-testratesandadd-onrates)o CentralSpecimenReception

analysisofCentralSpecimenReceptionworkprocesseshavebeenundertakentoinvestigatetheeffectofelectronicmedicalrecordandincidentreportingonthelaboratorytestprocessingprocedures,suchasward/laboratorycommunicationandefficiency.

Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010)

Description Thisprojectsoughttodevelopasoftwareplatformforuseinpathologycasestudiesforjuniordoctors.TheiNvestigatewebsiteis:http://investigate.med.unsw.edu.au/


Aim

todevelopafullyfunctioningsoftwareplatformtouseasabaseforanon-lineeducationalprogramforjuniordoctors.


Outcomes

AnalphaversionofthesoftwareprogramwasdemonstratedtotheQualityUseofPathologyCommittee(QUPC)on24February2010.Sincethattimefirst-passtestingofallcomponentsofthesoftwarecommencedwithseniorundergraduatemedicalstudentsrecruitedtoevaluatetwobetaversions.Thisledtomajorchangestoselectedareasoftheprogram.

OnecycleoffeedbackfromacademicstaffinpathologyattheUNSWandfromDrWendyPryorattheRoyalCollegeofPathologistsofAustralasia(RCPA)identifiedissuessimilartothosenotedbystudents,aswellassuggestionsforenhancingthecontent.

FurtherfeedbackafterthesecondmajorrevisionofthebetaversionwasdeployedfromProfessorFredDee,theoriginatoroftheLabCAPSconcept,whichhighlightedfurtherchangesrequiredtotheinterfacefortheUserrole.

TheCaseBuilderinterfacewastestedwhichledtoiterativechangestocertaincapabilities.

ManualcodingforeachitemsolvedtheproblemsassociatedwithlinkingMedicareBenefitsSchedule(MBS)datatoindividualtestitems.

Theprocessofenteringresultswhenbuildingacasewassimplifiedbycreatingasetof‘default’normalvaluesforallofthetestsavailablewithiniNvestigate.

Acompletesystemofself-registrationofnewusershasbeenimplemented.


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Agraphicdesignerwasemployedtocreatealogo/bannerfortheiNvestigatewebsite.

Providingaconsistentuserinteractionforaggregatedtestitemsprovedtobeasignificantchallenge,mostlyduetotheseaggregatedtestsnotbeingconsistentlyrepresentedintheRCPAManual.Thiswassolvedbyanextensible,easy-to-usesystemavailabletouserswithAdministratorrightstoaggregatetestsasneeded.Thiscateredforexistinggroupingsandallowedthecreationofnewgroupeditemsasrequired.

AllotherRCPAManualitemshavebeenincludedinthefullydevelopediNvestigatewebsite.

Topromoteinterestinandtheuseofinvestigate,juniormedicalofficers(JMOs)wereengagedwithdirectlyandthedevelopershavesoughttoembediNvestigateintoJMOtraining.

Variouselementswhichenhancetheeducationvalueand/orfunctionalitynotenvisagedaspartoftheoriginaldesignhavebeenincorporatedintothesoftwarepackageincluding:

o arunningtallyofthecostoftestsorderedbasedonindicativedatafromtheMBS

o aneffectiveandvisuallypleasinguserinterfaceo arangeofvaluableadministrationtoolsincludinganovelandsimple

testaggregationtool.

Recommendations 1. TakestepstomakeiNvestigatearecommendedresourcedisseminated

nationallyviatheAustralianCurriculumFrameworkforJuniorDoctorsProject.

2. FundinghasbeenrequestedfromtheQualityUseofPathologyProgram(QUPP)tocreatealibraryof20-25educationallyrichcasescenarioswithinputfromaspecialistpathologistemployedontheproject.


AlloftheseniorstudentswhotestedthewebsitemadeitcleartheywouldnotreadahelpfileorclickthroughahelpsystemtolearnhowtouseiNvestigate.Theysuggestedanyrelevanthelpshouldbeprovidedonthepageitself.Thisledtotheoriginalplantoprovideacompletehyperlinkedhelpsystemtobeabandoned,andtheuserinterfacewasre-designedsothatcontext-relevanthelpwasprovidedatthetopofeachpage.

FeedbackaboutproblemswiththedatasetandomissionsidentifiedwereprovidedtoProfessorBrettDelahunt,ChairoftheRCPAManualEditorialCommittee.Infuturethisisanticipatedtoleadtoco-operativeinteractionandimprovementoftheRCPAdataset,whichwillinturnleadtotheimprovementoftestavailabilitywithiniNvestigate.

ItismoreappropriatetoaskJMOstoundertaketestingwhenalibraryofcaseshasbeendeveloped.


iNvestigate:OnlinePatientSimulationsforEducationintheRationalUseofInvestigations–FinalReportforPhase2(2011).


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iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011)

Description ThisprojectfollowsonfromPhase1andsoughttodevelop20to25authenticcasestudiesspanningallpost-graduationyearone(PGY1)relevantareasofclinicalpracticeandrelatedinvestigations.TheiNvestigatewebsiteis:http://investigate.med.unsw.edu.au/


Aims and Objectives

todevelop20to25authenticcasestudiesforiNvestigate toenhancethesoftwarevia:

o reviewandoptimisationofthe‘virtualuniverse’ofinvestigationsavailableforordering

o programmingofanimproveduserinterface.These aims and objectives were achieved by this project.

Outcomes

Twelvecaseshavebeendevelopedandafurther10areinvariousstagesofdevelopment.

Allcasesstudies,oncetheyarefullydeveloped,willundergoprogressiveexternalreviewandimprovementasappropriate.

Over30additionalinvestigationshavebeenaddedwhileatleastanother30investigationsnowhavesynonymsorabbreviationsincludedinthenamelabeltoimprovefulltextsearching.

Theinterfacewasupgradedtostreamlinetheuser’sinteractionwiththewebsite.

Thereisenhancedsearchingfortests. Thewebsitehasbeencontinuouslyavailablesinceitwaslaunchedwitha

demonstrationcaseon6June2010.RakeshKKumarfromtheDepartmentofPathologyatUNSW,andtheMedicineComputingSupportUnitatUNSW,sharetheresponsibilityforhostingthewebsiteandensuringitsavailability.

TherehasbeenasystematicefforttopubliciseiNvestigate,althoughthemostsignificantissuesinthelongertermistheimpactofexternalfactorsonthecapacityofthoseinvolvedwithiNvestigatetopromoteitsdisseminationandusebythetargetaudience.

ThelackoffundingfortheAustralianCurriculumFrameworkforJuniorDoctorsProjectwillinevitablyadverselyaffectthevisibilityofiNvestigate.

Otherapproachestodisseminatethisresourcearebeingexplored.Forexample,theRoyalCollegeofPathologistsofAustralasia(RCPA)haveprovidedalinkviaitsEducationPortaltotheiNvestigatewebsite.

RakeshKKumar,fromtheDepartmentofPathology,UNSW,incollaborationwithProfessorGaryVelanofUNSW,hascreatedaclonedsitecalled‘eDiagnostic’withaccesstothiswebsiterestrictedtostudentsenrolledintheMedicineprogramatUNSW.


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Finding

Thecriticalissuefortake-upispersuadingthePGY1graduatestomakethetimetouseiNvestigate,andnotthequalityoftheresourceitself.

Recommendations 1. ResearchavenuesforiNvestigatetobedeployedforothertargetaudiences

withthedevelopmentofsuitablecases.Forexample,createacloneofiNvestigatewithcasesformedialstudentssuchaseDiagnostic.

2. IdentifyfurtherrelevanttargetaudiencessuchastheTheRoyalAustralasianCollegeofPhysicians(RACP)ortheRoyalAustralasianCollegeofGeneralPractitioners(RACGP),anddevelopnewcases.


ChallengesassociatedwithreachingiNvestigate’sintendedtargetaudiencewerenottechnicalissues,butissuesrelatedtodisseminationandtake-up.OnepotentialbarriercontributingtothisissueisthatwhatiNvestigate offersmaynotbewhatthetargetaudiencewants.Toaddressthis,feedbackfromPGY1graduatesduringthedevelopmentalphasewasessentialbutdifficulttoobtain,mostlybecausethesegraduatesaresobusytheyhaveinsufficienttimetobeinvolvedinalloftheeducationalactivitiesavailabletothem.Considerableeffortshavebeenmadetorecruitgraduatestoprovidespecificcommentaryandfeedbackalthoughtherehavebeenfewactiveparticipantssoitwasnotpossibletogatheruserquestionnairedata.Thefewwhoofferedcommentarywereverycomplementary.

Alesserissuehasbeenrecruitingspecialistreviewersforthecasesandfindingtheyarenotascomputer-savvyastheirPGY1juniorcolleagues.

OtherissuesrelatetoinvestigationsmissingfromtheRCPAManualwhichthereforehavenoassociateddataiftheyareincluded.ThiswasresolvedbytakingadvantageofthehighlyflexibleadministratorinterfacedevelopedforiNvestigate.


iNvestigate:OnlinePatientSimulationsforEducationintheRationalUseofInvestigations(Current).


IdentifyfurtherpotentialusersforiNvestigate.

iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current)

Description ThisprojectisStagethreeoftheiNvestigateinitiativeandisrebuildingtheplatform,includingdatabasestructureanduserinterface,toallowmultipleaudienceandinterfaceextensibility,andtoalsoallowtheiNvestigatewebsiteto‘golive’forongoinggeneralpractitioner(GP)instruction.TheiNvestigatewebsiteis:http://investigate.med.unsw.edu.au/.



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Aims

todevelopafullyfunctioningsoftwareplatformtouseasabaseforanon-lineeducationalprogramforjuniordoctors

toallowmultiplecasesetsonthewebsitetobedevelopedinthisinstanceforthespecifictargetaudienceofgeneralpractitioners.

This project is current and these aims are in the process of being achieved.

Outcomes

Stageonewasapilotstudywhichdevelopedthesoftwareplatformandatestcasescenario.

Stagetworesultedinthedevelopmentof20-25casescenarioswithappropriateinstructionalvalueandallowedthewebsiteto‘golive’forprevocationalmedicaltrainees.

Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011)

Description Thisprojectinvolvedexploring,documentingandreviewingtheeffortsmadeinAustralia’spublichospitalstobettermanagethedemandforandappropriateuseofpathologytestinginthecareofpatients.Thiswasexploredinthreeparts:

1. Understandingthedifferentapproachestakentoconsideringappropriateandinappropriatepathologyorderinginthehospitalsetting.

2. Creatinga‘snapshot’ofcurrentandplannedstrategiesinpublicpathologyservicesacrossAustralia.

3. ExaminingtheavailableevidenceinrelationtothetypesofinterventionsanddemandmanagementstrategiesimplementedinAustraliaandoverseas,andtheirimpactonclinicians’testrequestingpatterns.

Thisprojectalsosoughttoredresssomeofthedeficienciesindefinitions,approachesusedandassociatedmeasuresofappropriateversusinappropriatetestordering.Amatrixforappropriatepathologytestorderingwasalsodevelopedwhichcombinesthedifferentpurposesofpathologytestingwiththebroadclinicalindicatorsforuse.

Grant Recipient NationalCoalitionofPublicPathology(NCOPP)

Aims and Objectives

todocumentandreviewtheknowledgeandexperienceinAustralianpublichospitalsinordertobettermanagethedemandforanduseofpathologytestinginpatientcare

toconsiderthelessonslearnt toestablishfuturedirectionsforachievingsustainablechange. These aims and objectives were achieved by this project.


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Outcomes

Asurveyofcurrentandplannedpracticesfoundthatmostpublicpathologyservices(75%)aredoingsomethingtosecureimprovementsinappropriatepathologyorderinganduseinthepublichospitalstheyserve,withtheseeffortsmostlyledbypathology.

Afundamentaldifficultytheprojectgrappledwithconcernsthelackofaconsistentdefinitionof‘appropriate’versus‘inappropriate’pathologytestordering.Toresolvethisproblemtheprojectdevelopedamatrixencapsulatingauniformnationaldefinitionthatcouldbeappliedtotheassessmentofwhetherarequestforanyoreverypathologytestwasappropriate.Thematrixrecognisesthatinthehospitalsystemandtheentirehealthcaresystemtherearemanydifferentcircumstanceswhenorderingofpathologyinvestigationsiswarranted.Thematrixthereforecombinesthedifferentpurposesofpathologytestingwithbroadclinicalindicationsforuse:

o ifnoneoftheboxesinthematrixcanbeticked,thetestshouldberegardedasinappropriate

o similarly,ifaccordingtothematrixthereisanindicationforatesttobedoneanditisnotordered,thiswouldsuggestinappropriateorderingofpathologyasaresultoffailuretoorderanindicatedtest.


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[alt=“Thefollowingtableisamatrix.TheYaxisshowsthePurposeofPathologyTestingandtheXaxisshowstheClinicalIndicationsforUse.”]AppropriatePathologyTestOrderingMatrix

Purpose of Pathology Testing

Clinical Indications for Use

Indicated for Acute/ Immediate Patient Care

Indicated as part of a Clinical Pathway/ Standard Care for patients with that condition

Indicated for Public Health Objective

Indicated to assist good Patient Flow

For Diagnosis

For Treatment

For Monitoring – disease or therapy

For Assessment of Possible Adverse Event or Side-effect

For Exclusion of a Possible Diagnosis

Required to Assess or Manage a Comorbidity

(separate to main diagnosis)

Screening*

©NCOPP2011*NOTE:Thiscoverstheuseoftestsforpurposesof‘diseasescreening’.Formalpopulationbasedscreeningprogramsarerecognisedindicatorsforpathologytests,butgenerallytheyarenotundertakenaspartofusualpatientmanagementinthepublichospitalsetting.However,patientsinpublichospitalsmayhavepathologytestsaspartofacomprehensiveassessmentoffactorspotentiallycontributingtoaproblemoraspartofahealthcheckstrategy.

Thisreview’sproposedapproachtoareaswherepublicpathologyservices

mightbestcontributeandaddvaluetobuildingtheevidencebaseandextendingtheefforttoimprovepathologyorderinganduseinAustralia’spublichospitalsectorisguidedbyfiveprinciples:

1. Actingonmajorgapswherepathologyservicescanaddvalue.2. Promotingacollaborativeeffortamongpublicpathologyservices

throughoutAustraliainordertoovercomecurrentfragmentation.3. Targetingeffortstoaddressareaswheretheyarelikelytohavean

impact.4. Identifyingfactorslikelytocontributetosustainability.5. Supportingthedevelopmentofaframeworkthatisusefulthroughout

thecountryandinavarietyofpublichospitalsettings.


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Findings

Numerousreasonshavebeenputforwardtoexplaintheincreaseduseandcostsofpathologyalthoughfewhavebeenexaminedwithanyrigour.Theyinclude:

o advancesintechnologyenablingmultipleteststobeperformedonthesamespecimenreliablyandinexpensively,andmorerapidturnaroundofservices

o theavailabilityofnewtestsgivingmorefromwhichtochooseo extendingtheclinicalapplicationsoftestingacrossthediagnosis,

monitoring,screeningandprognosisspectrumo changesinclinicalpracticeo over-relianceontestorderingtodealwithuncertaintyo ‘patientpower’–specificallytheincreaseinpatients’knowledge

throughinternetaccess,andgreaterpatientexpectationsoftheclinicalencounterandthehealthsystemgenerally

o theincreaseddemandforcareasaresultofanageingpopulationandgrowingnumbersofpeoplewithchronicdisease

o theteachingofpathology(laboratorymedicine)o theabsenceofpricesignalsatthepointofrequesto perceptionsofpotentialmedico-legalliabilityiftestsarenot

performedo ignoranceofthediagnosticsignificanceoftestsandtheirsensitivity,

specificityandpredictivevalueo fearofbeingcriticisedbyseniorcliniciansforfailingtoorderatesto research,habitandmerecuriosity.

Appropriatepathologytestrequestingiscentraltocost-effective,qualitypatientcareandhealthcaregenerally.

Therearemanystrategiesthatcanchangethefrequencyofpathologyorderingwhichfallintofivebroadcategories:1. Education,auditandfeedbackwhichconstituteaneffectivedemand

managementstrategy,althoughtheeffectgraduallydeclinesduringtheperiodaftertheintervention.

2. Rulesandagreementsaimedatrestrictingtestrequestswhereminimumre-testintervalsaresuccessfulineffectingandmaintainingareductioninunnecessaryrepeattestrequestsbyclinicians,asevidencedbythesustainabilityoftheinterventions.Traffic-lightsystemshavebeeneffectiveintargetingthetestrequestbehaviourofjuniordoctorsinemergencydepartmentsthroughimprovingthequalityofrequestingandreducingunnecessarytesting,includingrepeattesting.Theeffecthasbeensustained–betweenfourand11years–inthethreeStatesandTerritorieswherethissystemhasbeenimplemented.Whenclinicalguidelinesareimplemented,seniorcliniciansarelikelytorequestfewertestsiftheyhaveamoredirectinvolvementinplanningclinicalpathways,andintheearlystagesofthepatient’smanagement.

3. Re-designingtherequestformtoprovideguidancetorequestershasbeeneffectiveinreducingtheuseofpathologytests,regardlessofthepurpose.Overallthisappearstobeaneffectivemechanismforsupportinggoodclinicalpractice,especiallyamonginexperiencedjuniordoctors.Therearestillquestionsovertheimpactofpricesignalssuchasdisplayingtestcostsontherequestformontestrequesting.


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4. Computerisedphysicianorderentry(CPOE)systemshavebeeneffectiveinbringingreal-timeevidence-baseddecisionsupporttorequestingphysiciansandfacilitatingeffortstomanagethedemandforpathology.Tobesuccessful,CPOEtechnologyneedstobedevelopedtoalevelofutilityandefficiencythatisacceptabletousers,withstakeholdersacceptingtheinvestmentrequiredandtheneedtoadoptcoordinatedimplementationplans.Thedesignanddeploymentofsuchtoolsarestillintheirinfancy.

5. Reimbursementandfundingmodelsdesignedtomanagethedemandforpathologytestinghavenotbeenexaminedtoanygreatdegree.Onlyonestudywasfoundtoinformthispracticewherehospitallaboratorybudgetsweretransferredtorequesters,however,theobserveddecreaseintestorderingreturnedtoitsformerpatternafterafewyears.

Alloftheabovestrategieshavethecapacitytodeliverasuccessfuloutcome,althoughthereisnoconsensusonamodel(ormodels)forbroaderadoptioninthelongterm,andsustainabilityremainsproblematic.

Successinachievingsustainedimprovementinappropriateorderinganduseofpathologyinpublichospitalsappearstobeassociatedwiththeinterplayofanumberofcriticalfactors:

o targetingmultiplebehaviouralfactorso basingmodelsonprovenandrobustbehaviouralscienceprinciples

usingamultifacetedapproacho clinicalengagementandownershipataseniorlevelo clinical‘champions’orleadclinicianstopromotetheapproacho strategiesthataresimpleandeasilyintegratedintoeverydaypracticeo adaptingstrategiestomeetlocalneedsandcircumstances.

Theimportanceoftheculturalbehaviouraldeterminantsofpathologyrequestingisoftenunderestimated,anditisthesefactorsthatmostprobablyholdthekeytolong-termsuccess.

Virtuallyallinterventionsusuallyhaveanimmediateandsignificantimpactonorderingpatternswhichisoftenshort-lived.Thismightpartlyreflectthelimitedtimeframeofmostpublishedstudies(interventionsgenerallylastingfromseveralmonthstoayearortwo)andlackoffollow-uponlonger-termsustainability.

Australianpublichospitalsvaryintermsofsize,locationandtypesofservicesprovidedandarecomplexorganisations.Everyinterventionwouldrequireamultifacetedapproachwithdifferentelementsorareasofemphasisfordifferenthospitalsettings.

EffortstosecureimprovementsinappropriatepathologyorderinganduseinAustralianpublichospitalstendtobeadhocandfragmented.Whereinterventionshavebeensuccessfulinchangingpathologyorderingpatternsinjurisdictionsandinstitutionsthereislimitedevidenceofmovestoimplementtheinterventionsmorewidely.

Theprimarygapsidentifiedbythisreviewrelatetothefollowing:o lackofasingleorconsistentdefinitionof‘appropriate’versus

‘inappropriate’pathologyorderingo lackofconsistentmeasuresanddatacollectiontodeterminebaseline

levelsofpathologyorderingandtoassesstheimpactofinterventionsimplemented


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o lackofdatatoguidetheselectionofwhichareastotarget–particularlyacrossthediverserangeofpublichospitalsettingsinAustralia.

Recommendations 1. Developastandardnationaldefinitionof‘appropriate’pathologytest

ordering.2. Allfutureresearchandauditsshouldusethematrixtoreviewandassess

pathologytestorderingandtoevaluateinterventions.Itmayalsobeausefuleducationaltoolinaninterventionstrategyornationalguidelines.

3. DevelopstandarddatasetsonpathologyuseinAustralia’spublichospitalsfordatacollectionandbenchmarkingpurposeswithinitialeffortsfocusedonassessingthetop10to15diagnosisrelatedgroupsforpublichospitalsnationally,andthetop10to15pathologytestsusedinpublichospitals.

4. Monitorandparticipateindevelopingelectronichealthrecordsystemsandcomputerisedphysicianorderentrysystems.

5. Identifywhichchangesinthefrequencyofpathologyorderingwillminimisewastewithoutimpactingonpatients’healthcareoutcomesoraccessinAustralia’spublichospitals.


Itwaschallengingtoassembleevidencefromavarietyofsourcesandprovideaclearevidencebaseintermsofwhatisknownandunknownandtheassociatedlimitations.Studiesvaryintheirlevelofrigourandqualityandusedifferentmethodologiesandapproachestoreviewingoutcomes.Insomecasestheoutcomeswereunclear.Thisnecessitatedthedevelopmentofausefulgroupingofinterventionsandanassessmentframeworkthatdrewtogetherandexaminedtheevidenceavailableforsimilarinterventionsandallowedconclusionstobemade.


Developastandardnationaldefinitionof‘appropriate’pathologytestordering.

Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current)

Description Thethreeorganisationsinvolvedinthisprojectareundertakingprojectworktowardsmoreeffectiveandconsumer-friendlypathologyreporting.

Grant Recipients UniversityofMelbourne;DianellaCommunityHealth;RoyalCollegeofPathologistsofAustralasia(RCPA)

Aims

toidentifyacoresetofkeyvisualcommunicationtechniquesforreportingpathologytestresultsbothtorequestingpractitionersandconsumers(includingconsumerswithlimitedliteracy)


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toprepareandtestseveralformatsdesignedtomaximisecommunicationwiththespecifiedtargetgroups(e.g.treatingclinicians,consumersfromculturallyandlinguisticallydiversebackgrounds,consumerswithlowliteracylevels)totestwhichformatswillbestengagehealthconsumersintheirowncare

todevelopaGPpracticepilottotrialthenewreportingformatunderclinicalconditions.

This project is current and these aims are in the process of being achieved.

Outcomes

Thedraftreportingformatshavebeendevelopedusingeye-trackingexperimentsandtestedwithconsumerfocusgroups.

Itisexpectedtherewillbeopportunitieswithinstageonetocarryoutsomepre-testingofthedrafttemplatewithgeneralpractitioner(GP)focusgroups.

PathologyprovidersandGPsarenowbeingrecruitedforthepilotthatwillformaproposedstagetwoofthisproject,althoughnodecisionhasyetbeenmadetoproceedtothisstage.


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Workforce Capacity and Competence Therelative‘invisibility’ofthepathologyworkforcehashadanumberofflow-oneffectsonitscapacityandcompetence.Pathologyisnota‘highprofile’choiceofspecialtyformedicalgraduates,whileotherfactorssuchasanageinganddecliningspecialistworkforceandunclearcareerpathwaysforscientistshavecontributedtowhatisrecognisedasapathologyworkforcecrisis.ThissituationisnotuniquetoAustraliawithworkforceissuesregardedasathreattotheglobalpathologysectorandthereforetothedeliveryofqualitypathologyservices.TheQualityUseofPathologyProgram(QUPP)hasenabledtheexplorationoftheseissuesthroughsixprojects(Table7).Detailedanalysesofworkforceissueshavebeenidentifiedaccompaniedbyalonglistofrecommendationstoachieveasustainablepathologyworkforceforthefuture.Areasforfutureconsiderationmayinclude: Investigatebetterdatacapturingmethodsfortheassessingpathology

workforce. Devisestrategiestoincreasetheprofileofpathology. Continuetoaddresspathologyworkforceissues. Continuetomonitortheworkloadforpathologists. Investigatestrategiestopromotepathologyasanappealingcareerchoice. Investigatestrategiestoprovideincreasedaccesstopathologytopeoplein

ruralandregionalareas. InvestigateavenuestopromoteandutilisethePathologyAssociations

Council’ssetofcompetencystandardsusingtheeightpathwaysidentifiedinthereportCareerStructuresandPathwaysfortheScientificWorkforceinMedicalPathologyLaboratoriesonpage153.

ItisalsoimportanttonotethatsincethePathologyFundingAgreementwasimplementedon1July2011,muchoftheworkaddressingworkforceissueshasbeentakenoverbytheWorkforceAdvisoryCommittee(WAC)whichiscomprisedofrepresentativesfromtheAustralianGovernmentDepartmentofHealthandAgeing(DoHA),RoyalCollegeofPathologistsofAustralasia(RCPA),NationalCoalitionofPublicPathology(NCOPP),AustralianAssociationofPathologyPractices(AAPP),CatholicHealthAustralia,HealthWorkforceAustralia(HWA),PathologyAssociationsCouncil(PAC)andtheDepartmentofIndustry,Innovation,Science,ResearchandTertiaryEducation. Project Name Grant Recipient/s Page

No. 1 PathWay(2005) RoyalCollegeofPathologists

ofAustralasia(RCPA)136

2 TheAustralianPathologyWorkforceCrisis(2008)

MichaelLeggandAssociates 137

3 ReviewofPathologySpecialistDevelopmentPathways(2010)

RCPA 143

4 ImpactofWorkloadofAnatomicalPathologistsonQualityandSafety(2011)

RCPA 147

5 SurveyofthePathologyWorkforce(2011) URBIS 150


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6 CareerStructuresandPathwaysfortheScientificWorkforceinMedicalPathologyLaboratories(2011)

HumanCapitalAlliance(HCA) 153

Table7:ReportssummarisedforWorkforceCapacityandCompetence

PathWay (2005) Description TheRoyalCollegeofPathologistsofAustralasia(RCPA)identifiedaneedtostrengthenthepositionofthepathologyprofessioninboththemedicalandgeneralcommunitiesandconsequentlydevelopedastrategycalled“PathWay”.Thisincludedaquarterlylifestyleformatprintmagazine,Internetsite,print/electronicmaterialandmediaplacementaimedatenhancingthepathologyprofession’sstanding,perceivedrelevanceandcredibility.PathWayalsointegratedarangeofRCPAinformationproductsandcommunicationinitiatives,suchastheRCPAManual,CommonSensePathologyseriesandworkforceinitiatives,intoasustainedandcohesivecampaign.TheRCPArequestedandwasgrantedseedmoneyfromtheQualityUseofPathologyProgram(QUPP)toassistinfundingstage1ofthisproject.Grant Recipient RCPAAim enhancethepathologyprofession’sstanding,perceivedrelevanceand

credibility. Objectives topromotepathologyasavocationalchoiceamongnear/recentmedical

graduates topromoteevidence-basedpathologyorderingbymedicalpractitioners

(generalpractitioners[GPs]andrecentgraduates) topromotejointdecisionmakingwithconsumersinpathologyordering topromoteappropriatepathologyorderinghabitsamongnear/recent

medicalgraduates todevelopacampaignthatcanbesustainedwithoutgovernmentfunds. This aim and many of the objectives appeared to have been achieved although they were difficult to measure. Outcomes Stage1,2004–anintegrated12monthcampaignwhichfocusedonthe

productionofaquarterlylifestylemagazine(PathWay),Internetsite,print/electronicmaterialandmediaplacement.PathWayintegratedarangeofcurrentRCPAinformationproductsandcommunicationinitiatives,suchastheRCPAManual,CommonSensePathologyseriesandworkforceinitiatives,intoasustainedandcohesivecampaign.

Stage2,2005–developtargetsbasedontheobjectivesandachievementsofStage1.


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Stage2,2006onwards–assesstheachievementsandongoingviabilityofthecampaign.

PathWay wasdistributedtoallmedicalstudentsinAustraliaandNewZealand,andprovidedtojuniormedicalstaffinhospitalsinAustralia.

TherewaspositivefeedbackfrommedicalstudentsinAustraliaandNewZealand,andfromjuniormedicalstaffinhospitalsinAustralia,aboutthevalueofthemagazineinraisingawarenessofpathologyasacareerchoice.ThisissuewasdiscussedattheRCPA’sTraineeAdvisoryCommittee,whoreportedaconsiderablenumberofjuniormedicalstaffapproachingthemaboutacareerinpathologyfollowingneweditionsofPathWay.

Medicalstudentsandrecentgraduatesalsoprovidedpositivefeedbackinrelationtothecontentofthearticles,particularlyeducatingthemabouthowapathologistcanbeusedinadvisingonappropriateusageofpathologytestingandtheinterpretationofresults.

AnevaluationformsentoutwiththethirdeditionofPathWayprovidedpositivefeedbackandsupportfortheusefulnessofthemagazineineducatingGPsandrecentgraduatesonappropriatepathologyordering.

ThePathWaymagazineswereavailableinpathologycollectioncentresanddoctors’rooms.TheRCPAalsosoldavaluablenumberofsubscriptions.

ThearticlesinPathWaywerealsoavailableonthePathWaywebsiteathttp://www.rcpa.edu.au/pathway.

Finding ThePathWayprojectwasdeemedsuccessful,withPathWaymagazinea

particularlyusefultoolforpromotingpathologyandpathologiststothemedicalandgeneralcommunity.

Recommendation 1. PublishPathWayonanongoingbasis.Key Project Learning ThesaleofadvertisingspaceinPathWaywasdifficult,althoughtheRCPAhad

soldsufficientatthetimeoftheirreportforcontinuedproduction.Follow on Initiatives and Projects TheRCPAinitiatedanonlineversionofPathWay,titledePathWay,in2011.

The Australian Pathology Workforce Crisis (2008) Description Thisreportrepresentedthefirstnationaloverviewoftheissuesfacingthecomprehensivepathologyworkforce.Itsetsoutthescopeandstructureforthepathologyindustryworkforce,anddrawstogetherasummaryofthekeyissues,gapsandopportunitiesforfurtherworkassuggestedbypathologystakeholders.Grant Recipient MichaelLegg&Associates


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Aim toassisttheAustralianGovernmentDepartmentofHealthandAgeing

(DoHA)toprepareabackgrounddiscussionpaperwhichsetsoutthescopeandstructureofthepathologyindustryworkforce,anddrawstogetherasummaryofthekeyissues,gapsandopportunitiesforfurtherworktobeundertakenonthisissue.

This aim was achieved by this project. Outcomes Aseriesofconsultationswereundertakenincludingmeetingsincitiesinfour

States/Territories(Canberra,Sydney,MelbourneandBrisbane) Relevantreportsandsubmissionswereidentifiedandreviewed,and

submissionswereinvitedfromrelevantorganisations. TheProductivityCommissionReportonAustralia’shealthworkforce

identifiedthefollowingsystemicproblems:o fragmentedrolesandresponsibilitieswithhealthworkforcepolicy

‘compartmentalised’byprofessions,evenincircumstanceswhereanintegrated‘cross-profession’approachisclearlycalledfor

o inadequateco-ordinationmechanisms,inflexibleandinconsistentregulationwithalackofcollaborativepolicyeffortstoimproveco-ordinationacrossthevariouspartsofthesystem

o inflexibleandinconsistentregulationthatissubjecttoconsiderableinfluencefromtheprofessionalgroupsconcerned,andwidelyperceivedasinhibitingchangestoscopesofpracticeandthedevelopmentofnewcompetenciesthatcouldmeetchanginghealthcareneeds

o perversefundingandpaymentincentivesthatmayresultinpatientsseekingtreatmentfromadoctor,when(unsubsidised)treatmentfromanotherhealthprofessionalmaybemoreappropriate

o limitedincentivesformedicalpractitionerstodelegatelesscomplexserviceprovisiontoothersuitablyskilledbutmorecost-effectivehealthprofessionals

o entrenchedworkforcebehavioursthatareheavilyinfluencedby‘customandpractice.’

Findings Pathology Workforce Thereisarealproblemwithworkforceshortagesinpathology,andthe

availableprojectionsinferafurtherandsignificantimpactonservicequalityandtimelinessifurgentactionisnottaken.

Thecriticalshortagesarebestdocumentedforspecialistpathologists,andthereisgoodevidenceofacriticalshortageofscientists.

Thoseworkinginpathologybelievethatco-ordinationatanationallevelisrequired,asthesituationcannotwaitfora‘comprehensiveindustry-wide’solution.

Theactualvolumesplitbetweenpublicandprivatepathologyisnotknown,buthasbeenestimatedat60%privateand40%public.

Theaveragepathologyserviceepisodeinvolvesaroundonehourofworkedtimefromacomplexworkforceteamusingadiverserangeofskills.


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Thepathologyworkforceteamconsistsof:o specialistpathologistso medicalscientistso healthinformaticianso technicalofficersormedicaltechnicianso laboratoryassistantso collectorsandnurseso pathologycourierso clericalstaffandotherdirectoryinvolvedintestingo managementandsupportservices.

Thepathologyworkforceisestimatedatbetween30,000and50,000whichismorethan5%ofthetotalhealthworkforce.Atleast70%ofthepathologyworkforceisfemale.

Approximately50%ofSeniorScientistsareaged50orover,while20%ofPathologistsactivelypracticinginAustraliaareaged60orover.

Education and Training Onlypathologistshavearegistrationscheme. Educationprogramsrelevanttothepathologyworkforceareofferedby

universities,institutesoftechnology,TAFEcolleges,throughaccreditededucationcoursesconductedbypathologyorganisationsandthroughon-the-jobtraining.

Inadditiontoeducationinstitutions,16otherorganisationshavearoleinrepresentingandeducatingmembersofthepathologyworkforce.Thesecanbedividedintospecialistcolleges,scientificsocietiesandassociations,andindustryassociations.

Technicalofficersandmedicaltechnicianshavethegreatestvariationinthetrainingoffered,jobtitleandworkplaceexpectations.

Theneedsofthepathologysectorarenotcurrentlyrecognisedinthelargerhealthworkforcereviewactivities.

TheissuesrelatingtothepathologyworkforcehavealsobeenexperiencedbyothercountriessuchasNewZealand,theUSandCanada.

Australia’scomprehensivequalityandaccreditationsystemhasbufferedtheindustryfromincidentshappeningincountriessuchasCanada,andmanycountrieshaveobservedanddrawnonthesystemforlaboratoryaccreditationthatwasestablishedcooperativelyinAustralia.

Thestrongestofthedriversleadingtoworkforceshortageisdemography,andparticularlytheimpactofthe‘babyboomer’birth-ratebulgereachingretirementage.Whenthisiscombinedwithincreasedlifeexpectancythereisadoubleimpactforhealthcare;areducedsupplyofworkersandanincreasingdemandforservices.Theimplicationsofthissituationaremoreacutelyfeltinpathologybecausetheyarecompoundedbyothersector-specificissues.

Impacts and Demands on the Pathology Sector Theimpactoftechnologyonthepathologysectorisrelatedmoretodoing

‘newthings’ratherthandoing‘existingthings’faster. Therehashistoricallybeenanaverageincreaseinthevolumeoftestingof

around8%perannumwithoutamatchingriseinfundingwhichhasresultedina25-year‘efficiency’dividend.Thesituationisoftenexacerbatedbytheintroductionofnewtestsintocommonclinicalpracticebeforethesometimeslengthyprocessoffundinghasbeendetermined.


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Thedemandforpathologyisexpectedtoriseandisbeingdrivenbyfactorsincluding:

o increaseddiseaseprevalenceandcomplexitywithanageingpopulation

o increasedcancerprevalencewithincreasedlongevityo increasedemphasisonevidence-basedmedicinethatrequires

pathologyfordecisionmakingo increaseduseofpathologytestingforeligibilityforsubsidiseddrug

therapyandmonitoringo increasedgenetics(epigeneticandmolecularpathology)testingfor

pre-emptiveandpersonalisedmedicineo increasedconsumerexpectationthattestingispartofdiagnosisand

treatment. Thereisawidelyheldperceptionthatpathologyhaddeclinedinitsprestige

andcapacitytowinfundingagainstothermedicaldisciplineswhere“partisanmutualadjustment”isthenormintheresource-limitedenvironmentofhealthcare.Reasonsofferedforthisinclude:

o thelimitedactualcontactbetweenpathologistsandtheirpatientso areductioninclinicalemphasisonthescienceofmedicine,including

significantreductioninpathologycontentinmedicaltraining,withaconsequentunderestimationofthevalueofthecontributionmadebypathologytesting

o theerroneousperceptionbytheusersofpathologyandtheirpatientsthatpathologyisamachine-baseddisciplinewithlittlehumaninvolvementorexpertiserequired

o lackofpromotionofthevalueofpathologybythepathologyprofessionthemselves

o competitionwithintheindustryandthehighservicelevelsofferedbypathologypracticestorequestersandconsumers

o the“commoditisation”ofpathology,particularlyinthehospitalenvironment,whereithasbeensometimesgroupedanddealtwithinthesamewayassupportservicessuchaslaundryandcatering.

Theissuesspecifictopathologybutcommontoallpathologyworkforcegroupsinclude:

o alackofunderstandingandprofileofwhatpathologyisanditsvalueandsoalowerstandinginthecommunityandhealthcaresector

o theoptionofincreasingsupplybytheuseofoverseas-trainedpathologistsandscientistsishamperedbyaworld-wideshortageofwelltrainedpersonnel,especiallyinthesubspecialtieswithgreatestneedsuchastoxicology

o thereisanargumentthatlaboratoriesarenotbeingusedoptimallybyrequestersandthatfewermoreappropriaterequestswouldresult–however,thisisbalancedagainsttheevidencethatifprotocolsforcommondiseasessuchasdiabeteswerebeingadheredto,manymorepathologytestswouldbeorderedsuchasdoublethenumberofglycatedhaemoglobin(HbA1c)testsfordiabetics.

o theopportunitytofurtherremodeltheworkforceisimpairedbysomeoftheexistingworkpractices,awardstructuresandregulations.

Issues Specific to Medical Scientists o difficultyattractingnewrecruitsofappropriatequality


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o difficultyintrainingstaffo difficultyinre-entrytotheworkforce.

Issues Specific to Pathologists o toofewtraineepathologistsduetotoofewfundedtraineepositionso reducedexposuretopathologyinmedicaltrainingandtheassociated

lossofrolemodelsisreducingtheattractionoftheprofessionandthecalibreoftrainees

o thecurrentrateofadvanceofknowledgeisdifficulttokeeppacewith,especiallywhendemandsonserviceprovisionarehigh

o highworkloadso professionalisolationofpathologistsworkinginregionallaboratorieso decliningtraineesasgeneralpathologistso dual-trainedpathologistsspendingmostoftheirtimeinclinical

practiceo specificshortagesinsub-specialties.

Recommendations 1. ThepathologyworkforceisnottrackedbytheAustralianInstituteofHealth

andWelfare(AIHW)asforotherareasofhealthcareintheirbiennialreportsonAustralia’shealth,butitsfutureinclusionwouldimprovemonitoringoptions.

2. Acomprehensiveandregularlyupdateddatasetisrequiredtomanagethepathologyworkforceeffectivelyonanongoingbasis.Thisshouldincludenumbers,ages,sex,geographicaldistribution,educationallevels,employmentlevelsandotheressentialinformation.Strategiestodothismightinvolve:

a. fullworkforceandworkloadauditb. inclusionofpathology-relatedworkforcedataintheAustralian

InstituteofHealthandWelfare’s(AIHW)twoyearlyreportsc. increasetheprofileofpathologyinthenationalhealth-workforce

reviewactivities.3. TheCouncilofAustralianGovernments(COAG)responsetotheProductivity

CommissionReportincludedthefollowingrecommendations,manyofwhicharealreadyunderconsiderationand/orinplace:

a. reducehealthworkforceshortagesthroughsignificantinvestments,includingadditionalmedicalschoolandhighereducationnursingplacesandcapitalfundingformedicalschoolsandnurses’clinicaltraining.Theincreaseinmedicalschoolplaceswouldresultinanexpansioninthenumberofmedicalschoolplacesbondedtoareasofworkforceshortage

b. promoteworkforcemobilityandconsistencybetweenjurisdictionsbycreatingnationalregistrationandaccreditationschemesforhealthprofessions

c. providegreaterhealthserviceaccessforrural,remoteandindigenouscommunitiesbyintroducinganewMedicareitemforpracticenursesandregisteredAboriginalhealthworkerstoprovideongoingsupportforpatientswithchronicdisease

d. helpmedicalspecialisttraineesbuildappropriateskillsandexperiencebyprovidinganewsystemoftrainingrotationsthroughanexpandedrangeofsettingsbeyondtraditionalpublicteaching


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hospitals,includingregional,ruralandambulatorysettings,privatesectorhospitalsandpracticesandcommunitysettings

e. createanationalhealthworkforcetaskforcetoundertakeworkforceprojectsandadvisegovernmentsonworkforceinnovationsandreforms.

4. Thereisaclearneedforbetterinformationaboutthepathologyworkforceandbettermatchingoftrainingtotheworkplace.

5. Addresstheimageofpathologyby:a. continuingandacceleratingtheworkdonebytheRoyalCollegeof

PathologistsofAustralasia(RCPA)b. lobbyingforagreatershareofmedicalcoursetimec. engagingpathologyconsultativecommitteemembersandtheir

suppliersinanindustry-wideprogramd. coordinatingactivitiesthroughthePathologyAssociationsCommittee

toincreasetheimpactandmaximisethe‘bangforbuck’.Pathologists 6. Increasetheopportunitiesforeducationandtrainingandrecruitmentfor

medicalscientistsandtechniciansandpathologists(alistofpossibleapproachesareincludedinthereport).

7. Retaintheexistingworkforceforlonger(alistofpossibleapproachesareincludedinthereport).

8. Attractre-entryofthosewhohaveexited(alistofpossibleapproachesareincludedinthereport).

9. Providesubstitutionfromthoseoutsidethesectorbytrainingotherspecialistsinspecificsub-specialtyandsuper-specialtyareasofpathology(e.g.ophthalmicsurgeonsinhistopathologyoftheeye)andthensupportingthemthroughexistinglaboratories.

Other strategies 10. Redistributetheexistingworkforcegeographicallyandbydiscipline.11. Improvetheproductivityoftheworkforcethroughimprovedworkdesign,

newtechnologyandfurtherconsolidation.12. Reducethedemandforpathologyservicesbyimprovingthequalityof

ordering,orrationingthroughtheuseofmorerulesinthePathologyServicesTable.

13. Thenextstepsmayinclude:a. invitingcommentfromthoseconsulted,inparticularfromtheRCPA,

scientificsocieties,industrygroupsandeducationproviders,abouttherangeofstrategiesproposedinthisreportandtheirrelativepriority

b. engagingwiththeAustralianHealthMinisters’AdvisoryCouncilanditsrelevantcommittees(includingtheNationalHealthWorkforceTaskforceGroup)

c. engagingwithotherjurisdictionaldepartmentsthathavearoleinpathologyworkforceplanningsuchasAttorneysGeneralwhohavearoleinforensicpathology

d. establishinganationalsteeringgroupandagreeontheactionstobetakenbyprioritisingthesuggestionsprovidedhere,andanythatmaybepromptedbyreviewofthereport,byassessingthemagainstcriteriaofimportance,‘doability’,cost,impactandtimelinessinordertodraftastrategicplanforaction


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e. actingontheoutcomewithamulti-prongedapproach.Follow on Initiatives and Projects ReviewofPathologySpecialistDevelopmentPathwaysonpage143 ImpactofWorkloadofAnatomicalPathologistsonQualityandSafetyon

page147 SurveyofthePathologyWorkforceonpage150 CareerStructuresandPathwaysfortheScientificWorkforceinMedical

PathologyLaboratoriesonpage153 Theprofileofpathologyworkforceandassociatedissueswasraisedand

negotiatedsuccessfullyforinclusioninthePathologyFundingAgreement.Areas for Future Consideration Investigatebetterdatacapturingmethodsforthepathologyworkforce. Devisestrategiestoincreasetheprofileofpathology. Continuetoaddresspathologyworkforceissues.

Review of Pathology Specialist Development Pathways (2010) Description Thisprojectexaminedoptionstoachievemaximumefficiencyandeffectivenessofthepolicyandproceduresforpreparingnewspecialistpathologistsworkforceentrants.Thiswasinresponsetothecurrentandlong-standingworkforceshortageofpathologistsinAustraliawherestrategiestopromotetheuptakeofpathologyasacareercanbeconsideredinthreebroadareasofneed:

1. toenhancethevisibilityofpathologistsaskeymembersofhealthcareteamsandprovidersofvitalinputthatinfluencesaveryhighproportionofclinicaldecisions

2. toinvestigateandaddresspossiblebarrierstoundertakingpathologytraining,andtoactivelypromotepathologyasacareertomedicalstudentsandjuniordoctors

3. formoreflexibletrainingoptionsavailableinanextendedrangeofsettingswhicharesupportedandevaluatedtoensuretherequiredstandardsaremaintained.

Grant Recipient RoyalCollegeofPathologistsofAustralasia(RCPA)Aims toexamineoptionsforachievingmaximumefficiencyandeffectivenessofthe

policyandproceduresforpreparingnewspecialistpathologyworkforceentrants

todevelopstrategiestopromotetheuptakeofpathologyasacareer todevelopastrategicapproachtothesupplyofspecialistsforidentified

areasofsub-disciplineshortages(e.g.paediatric,neuropathologyandgeneralpathology)

togiveconsiderationtofutureplanningfortheprovisionofqualitypathologyservicesindifficult-to-servicelocations,includingregionalcentres.


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Objectives stage1involvedthepreparationofareviewofnationalandinternational

pathwaysforpathologyspecialisttrainingwhereinformationonarangeofstrategieswascollatedandpresentedforconsideration

stage2requiredtheexaminationofstrategiesindentifiedinStage1intermsofbestpractice,theirrelevanceandopportunitiesfortheirpossibleadoptionintheAustralianpathologycontext

stage3involvedareviewofthecurrentRCPAoptions,policy,proceduresandtraining/developmentsupportcapacityofitsFellows,withaviewtomaximisingandstreamliningopportunitiesforentrytothepathologistworkforceatanadequatelytrainedstandard

toreviewassessmentprocessesforoverseasqualifiedpathologistswhoneedfurthertrainingandassessmentpriortobeingabletoworkinAustraliaunsupervised

toreviewstrategiesforthedevelopmentofeducationalresources,particularlythosethataredeliverableonline,tosupportthelearningrequirementssetoutinthecurricula

toreviewcurrentstrategiesusedtoattractyoungdoctorsintoacareerinpathology,andidentifyfurthermeasurestheRCPAcouldundertaketopromotepathologyasacareer

Stage4requiredthefinalisationofrecommendationsforthepathologyprofessionandthedevelopmentofstrategiestoimprovethetrainingofpathologists

toproviderecommendationsregardinghowtoassessUKFellowstoenablethemtoobtainRCPAFellowshipwithoutexaminations.

These aims and objectives were achieved by this project although reviewing strategies to develop educational resources required further substantial resources. Outcomes Curriculum Review Thereviewforstage1waspreparedbytheCurriculumDevelopmentOfficer

andpresentedtotheBoardofCensorsoftheRCPAon10July2009.Thereporthighlightedthefollowingcharacteristicsofbestpracticecurriculaincluding:

o explicitcompetenciesrequiredforallaspectsofprofessionalpracticeo basingtheassessmentprogramonablueprintwhichmapsoutcomes

againstthemethodsbywhichtheywillbeassessedtoensureconstructivealignmentbetweenoutcomesandassessment

o arangeofvalid,reliable,feasibleworkplace-basedassessmentmethodsforformativeassessment

o suitablelearningexperiencesfordevelopingthedesiredcompetencieso emphasisingtheimportanceoftraineesreceivingregular,supportive

diagnosticfeedbackfromavarietyofsourcesbeforefinaljudgementsaremadeabouttheirperformance

o arangeofvalid,reliablemethodsformakingsummativejudgementsofcompetenceacrosstherangeofeducationoutcomes

o notassumingthatproficiencydevelopsafteraparticulardurationoftraining.


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Disciplinarypanelsrevisedtheircurriculainrelationtobestpracticeincludingdevelopingclearoutcomestatements.Theythendevelopedblueprintsforassessmentbasedupontherevisedcurriculatoconsiderreducingtheoverallloadofformalsummativeassessment,replacingsomeexistingassessmentwithmorereliableformsofassessment,andabroaderrangeofin-trainingandformativeassessmentenhancingopportunitiesforfeedbackandearlyremediationofproblems.

TheBasicPathologicalSciences(BPS)curriculumwasextensivelyrevisedwithmoreexplicitdefinitionoflearningoutcomes.Essayquestionshavebeenreplacedwithmultiple-choicequestions(MCQs)mappedtothelearningoutcomesintheexamination.

Extensivestakeholderconsultationanditerativerevisionshavecontributedtothedevelopmentofthenewmicrobiologycurriculumaccompaniedbyaportfolioincorporatingdocumentationoflearningactivitiesandoutcomesandasuiteofworkplace-basedassessmenttoolswhichweretrialedin2011.

Restructuredcurriculahavebeendraftedforanatomicalpathology,chemicalpathologyandimmunology,withotherdisciplinesunderdevelopment.

TheCurriculumDevelopmentOfficerhasbeenworkingwiththeChiefExaminerinanatomicalpathologyandotherstodevelopacurriculumforaDiplomainPaediatricPathology.

CurriculummappingforeachdisciplinewithdefinedparametersfordevelopmentofWPBAtools,withprocessesinplacetofacilitateearlyrecognitionandremediationofproblemswithtraining.

Examination Processes Examinationprocessesweremodifiedinmicrobiologytoprovidemore

authenticandreliableformsofassessment.EssayquestionswerereplacedwithMCQsandshortanswerquestions.Examinertrainingvideoswereproducedandusedforthe2010structuredoralexaminations.

Supervisor’sreportsarebeingmodifiedinalldisciplinestoclarifyoutcomesandstandards,toaccommodatedocumentationofworkplace-basedassessment(WPBA)andtoenableinputfrommorethanonesupervisor.

ApeerreviewpathwayhasbeendevelopedtofacilitatetheprogresstoFellowoftheRoyalCollegeofPathologistsofAustralasia(FRCPA)forpathologistswithqualificationsandexperiencethataresubstantiallycomparabletothestandardsforRCPA-trainedpathologists.

TherewillbecontinuedeffortstoreducetheoverallburdenasWPBAareestablishedtoimprovethereliabilityofexaminations,clearlyarticulatingstandardsandimprovingtheselectionandtrainingofexaminers.Thiswillbecompletedbytheendof2011andwillbefollowedbyongoingevaluationandreview.

Aprocessisinplaceforrigorouspeer-assessmentoverthecourseof12monthsofsupervisedpracticeforUKFellowsinanatomicalandchemicalpathology.Otherdisciplinesmayalsoofferthisassessmentfollowingmoreextensivereviewofanindividual’spasttrainingandexaminations.Considerationisbeinggiventoapplyingsimilarprocessestoothercountries.

Educational Resources TheMoodlelearningmanagementsystemasaplatformforatrainee

educationportalhasbeeninstalledtoofferconvenientaccesstolearning


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resourcesineachdiscipline.TheprogramQuestionmark PerceptionhasbeenpurchasedtointegratewithMoodlewhichwillfacilitatethebankingofassessmentitemsanddeliveryofonlineformativeassessments,aswellasconstructionofinteractivecasestudiesandmockexams.

OnlinelearningmaterialshavebeenmadeavailabletosupportpreparationfortheBPSexaminationwithanonlinemockexaminationavailableinearly2011.Existingresourcesforalldisciplinesisbeingrevisedforthenewonlineenvironment.Furtherresourcesarebeingplannedinaccordancewithneedsanalysisandpriority.

Training ThestudyreviewedhowtheRCPAmaybebetterabletoprovidetrainingfor

pathologistsindifficulttoservicelocations,includingregionalareas,andtodevelopastrategicplantoaddresstheseissuesandidentifycurrentobstaclesandpossiblesolutionsforovercomingthem.TheonlineenvironmentwillhelpwiththeseissuesandtheworkisbeingfurthersupportedthroughanAustralianGovernmentgrantundertheSpecialistTrainingProgram.Similarstrategiesmaybeusedtosupplementeducationandtraininginidentifiedareasofsub-disciplineshortages.

TheReviewofInternationalandNationalApproachestoPathologyTraining,andtheidentificationofareasthatareconsideredbestpracticeforpathologytrainingforAustralia,formsthebasisofaplanforongoingdevelopmentofanoutcomes-basedcurriculum.

Pathology as a Career Choice FundingfromthisprojecthassupportedtheengagementoftheDirectorof

Educationwithanumberofstrategiestoaddressattractingyoungdoctorsintoacareerinpathology.Theseinclude:

o formingaMedicalSchoolTaskforcetoidentifyopportunitiestoworkconstructivelywithmedicalschoolstopromoteandsupportqualityteachingofpathologyandengagestudents’interestinpathologyasacareer

o theRCPAactivelysupportinganadvancedstandingpathwayformedicalstudentsattheUniversityofNewSouthWales(UNSW)

o computer-basedsimulationsmayalsopromotepathologytodoctorsattheprevocationallevel

o thedevelopmentoftemplatesforpathologyrotationsforpost-graduationyearone(PGY1)andPGY2doctors

o theBoardofEducationcurrentlyreviewingcriteriaforofferingscholarshipsandsupporttomedicalstudentswhoundertakepathology-relatedprojectstoprovidegreaterincentives

o RCPAparticipationinCareerDaysatuniversities,high-schoolsandothernationalcareerevents

o theproductionofbrochures,vodcasts(onYouTube)andposterspromotingpathologyasacareer.

Finding Standardsettinganditemanalysisprocedureshaveimprovedthefairness

andreliabilityoftheexaminationintheBPScurriculum,andelectronicmarkingallowsmuchfasteravailabilityofresults.


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Recommendations 1. TheappointmentofanEducationDesignertodevelopanonlinelearning

environmentandfacilitatethedeliveryofonlineeducationalresources.2. FurtherstaffsupportmaybeneededasWPBAarerolledout,andtherewill

beaneedtotrainsupervisorsandexaminersandtoassistwithmonitoringandevaluationofongoingdevelopments.

3. Thedevelopmentofeducationalresourcestosupporttherevisedcurriculumisunderwaybutwillrequiresubstantialongoingfundingandhumanresourcestocontinuetheworkofconstruction,editinganduploadingofresourcesforsupervisors,examiners,workplaceassessorsandinternationalmedicalgraduates.

4. Developmentandimplementationofstrategiestoreviewandqualitycontroltheeducationalresourcesisamajorprioritythatwillrequireongoingexpertinputfrompathologists.

Areas for Future Consideration TheDirector,Educationwaspreparingastrategicplanatthetimeofthe

reporttoidentifyfutureprioritiesfortechnologiestosupportongoingeducationalneeds.

Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) Description Thisstudysoughttoidentifywaysinwhichworkloadimpactsonprofessionalpathologypracticethroughthreecomponentsdesignedtoprovideaworkforceperspective,maximisetheutilisationofMedicaredataandprovideaperspectiveoftheindividualpathologists.Thesewere:

1. identificationoftherelativetimevaluesofpathologists’workviatheMedicareSchedule

2. asurveyofthetotalworkloadofindividualpathologistsoverayearusingMedicarebillingandrelativetimevalues

3. adiarythatidentifiedthetimespentonindividualitemsbyparticipatingpathologistsoveragivenweekincludingasurvey(theDiarySurvey)oftheimpactofexistingworkloadonqualityandsafetyofpathologywork,includingtheimpactonthehealthofpathologists.

Therearealsonocurrentbenchmarksforstaffingandworkloadforpathology. Grant Recipient RoyalCollegeofPathologistsofAustralasia(RCPA)Aims and Objectives todevelopabetterunderstandingofhowthequalityandsafetyofpathology

servicewerebeinginfluencedfromtheperspectiveofAnatomicalPathologists

toaddresstheimpactofworkforceshortagesinthequalityandsafetyofpathologyservicesinAustralia,andtheimpactonpathologists.


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These aims and objectives were achieved by this project. Outcomes Pathologists(65outofthe96surveyed)identifiedthefollowingareasthat

couldbechangedtoimprovethequalityandsafetyofpathology:o morepathologistso lessworkload/safeworkloadlimits,betterbalancedworkloado betterinformationtechnology(IT)infrastructure/supporto moretimeforprofessionaldevelopmentactivities/readingo betterreimbursement/improvedremunerationper

specimen/improvedremunerationbyMedicareo morescientific/technicalstaffo moresecretarialsupport/clerical-adminstaffo moretrainees.

AworkshopofseniorexperiencedpathologistswasconvenedtoprovideexpertopinionintotheRelativeTimeUnits(RTUs)foritemsontheMedicareBenefitsSchedule(MBS).Theactualtimereportedinthediarieswaslessthantheestimateofbestpracticeidentifiedintheexpertworkshop,however,thesemaybeaduetoreasonssuchastestingtaskssuchascut,qualityassuranceandcaseconferencebeingmeasuredseparatelyinthediary.

Followingthisworkshop,asurveyofpathologists’annualworkvolumewasundertakenwhichfoundawidedistributionofclinicalworkloadrangingfromlessthan200RTUstoover3000RTUswithanaverageof1,439RTUs.

Findings Pathologistsareunabletofullyundertakequalityassuranceactivitiesdueto

excessiveworkloadswhichrepresentsapotentiallyseriouspublichealthconcern.

Thepathologists’surveyedreportedthatanincreaseinworkforcenumbersisrequiredtosustainexistingworkloadsandaddresstheissuesofqualityandsafety.

WhiletheRCPAhasbeensuccessfulinincreasingthenumberoftrainingplacesforpathologistsinAustralia,thereappearstobeadisconnectwithrecruitmentatspecialistlevelforgraduatingpathologistswhichmeanstheincreasednumbershavenottranslatedintoanimprovementofspecialistworkloads.

Full-timepathologistsworkedanaverageworkingweekof48hours,whilethosewhoworkedlessthanfull-timereportedaworkingweekof34.7hours.

43%ofpathologistswhokeptadiaryforaweekreportedworkingsdaysof10hoursormore.

TheactualhoursrecordedintheDiaryweresubstantiallyhigherthanthereportedusualhoursworkedinaweekwhichsuggeststhatpathologistsmayunderestimatethehourstheywork.

55%ofpathologistsreportedtheywereworkingmorenowthantheyhadbeentwoyearsago.

24%ofpathologistsconsideredtheywereworkingabovetheircapacity,andasubstantialproportionstatedtheywereonlyabletosustaintheirworkloadforalimitedperiodoftime(23%forayear,38%fornomorethan2years).


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71%ofthoseworkingabovetheirfullcapacityindicatedtherehadbeentimestheyweretoobusytoqualityassuretheirwork,73%reportedtheirworkloadcompromisedqualityand45%reportedtherehadbeentimeswhenpatientcarewascompromised.Afurther51%workingatcapacityreportedtheirworkloadimpactedontheirabilitytoundertakequalityassurance(QA)activities.

41%ofthepathologistsinregionalcentresreportedsituationswherepatientcarehadbeencompromisedcomparedto17%ofthepathologistsincapitalcities.

Adversequalityandsafetyimpactsincreasedsharplywhenpathologistsworkedmorethan39hoursaweek.

68%ofpathologistsindicatedtheirworkloadhadimpactedontheirhealthandwellbeing,while91%ofthoseworkingabovetheirfullcapacityreporteditwasaffectingtheirhealthandwellbeing.Thefourmainareasmentionedwereincreasedstress,feelingconstantlytired,decreasedphysicalfitnessandimpactonpersonalrelationshipsoutsidework.

33%ofpathologistsinregionalcentresreportedincreasedturnaroundtimes,while17%ofpathologistsinthemetropolitanareasreportedincreasedturnaroundtimes.

8%oftheactualworkingweekofpathologistsisallocatedtoQAactivities. Thecriticalpointatwhichqualityandsafetyissuesappeartobemostatrisk

isafterthe39hoursperweekmark. Thereisastrongrelationshipbetweencapacityandthenumberofareasin

whichadversequalityandsafetyimpactsassociatedwithworkloadwereidentified.

Therelationshipbetweenhighworkloadandcompromisesinqualityandsafetyisasystematicissueandnotrelatedtopublicorprivatelaboratories,locationorpathologists.

Recommendations 1. Thereisastrongimperativetoestablishsafeworkingguidelinestoaddress

thecurrentdeficiencyforanatomicalpathologistsinAustralia.2. Thesolutiontoaddressingthequalityandsafetyissuesliesinaddressingthe

workforceshortage.3. Increasingthenumberofqualifiedpathologistswillnotsignificantlyreduce

theworkloadsofpracticingpathologistsunlessthenumberofspecialistpositionsisincreased.Thesecouldbefilledbytheincreaseintraineesgraduating,orbypracticingpathologistsmovingfromapart-timetoafull-timearrangement.TheRCPAwillneedtocollaboratewithAustralian,StateandTerritorygovernmentsandtheheadsofprivatelaboratories.

4. Ongoingmonitoringoftheworkloadisrequired.OnemethodisforindividuallaboratoriestousethetoolsdevelopedinthecourseofthisprojecttorefineRTUestimates.

5. Ensuringgoodoccupationalhealthandsafetypracticeswithinlaboratoriesisasoundstrategyforassistinginminimisingtheimpactofworkload.

Follow on Initiatives and Projects TobetakenupbytheWorkforceAdvisoryCommitteeandthisissuewasalso

specificallyidentifiedasaninitiativeinthePathologyFundingAgreement.


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Areas for Future Consideration Continuetomonitortheworkloadforpathologists.

Survey of the Pathology Workforce (2011) Description Thisprojectprovidedasnapshotofthe2010pathologyworkforceasreportedbyparticipatingpathologyworkforceemployersandemployees.Theprojectreportidentifiedanumberofstatisticsrelatingtothepathologyworkforce,withonlythemainpointsincludedinthissummary.Grant Recipient URBISAim todescribeincompleteandaccuratetermsthesizeandmake-upofthe

AustralianPathologyworkforceintermsofkeyworkforcegroupings,demographiccharacteristicsandworkplacecharacteristics.

Objectives reviewexistingpathologyworkforcedatacollections,methodologiesand

surveyinstrumentsandincorporatethelearningsintothedevelopmentofaneffectivemethodonwhichtoconductthefirstevernationalpathologyworkforcesurvey(Survey)

finalisethelistofrequireddataitemsforinclusionintheSurveyinconsultationwiththeprojectsteeringgroupandprojectreferencegroup

developSurveyinstrumentstocollectthedatainconsultationwiththeprojectsteeringgroup

developanimplementationstrategyfortheSurveywithpathologyproviders/employerstonegotiateagreeabledatacollectionmechanismsandtomakearrangementsfordatacollection

collect/coordinatethecollectionofdataandmanagequalitycontrol clean,processandanalysedata developacurrentpathologyworkforceprofile conductanauditofeducationalinstitutionsinordertoascertainthecurrent

supplysourcesforidentifiedworkforcegroupings identifystrategiesforongoingmonitoringofthepathologyworkforce.The aim and objectives were achieved by this project. Outcomes The2010PathologyWorkforceSurveycaptureddatathatcoveredthe

followinggroupsthroughtheuseofanemployersurveyandanemployeesurvey:

o pathologistso scientistsandseniorscientistso medicallaboratorytechnicianso laboratoryassistants


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o healthinformationprofessionalso phlebotomists/pathologycollectorso mortuaryattendantso courierofpathologyproductso clerical/clericalsupporto management&supportservices.

Therewereatotalof4,743responsestotheemployeesurvey,whichwasreducedto4,631(Table8)oncethemissingdatapointswereexcluded.Thisrepresentsabout20%oftheestimatedpathologyworkforce.

TABLE 8 – SAMPLE SIZE WORKFORCE GROUP FREQUENCY %

Pathologist (includes Specialists and Trainees) 359 7.8% Senior Scientist 334 7.2% Scientist 2,308 49.8%

Laboratory Technician 572 12.4%

Laboratory Assistant 273 5.9% Health Information Professional 80 1.7% Phlebotomist/Pathology Collector 390 8.4%

Medical/Anatomical Pathology typist 146 3.2% * Other pathology 169 3.6% Total 4,631 100% * A breakdown of ‘Other pathology’ includes those mainly performing administrative functions (n=27) and assistant/aid functions (n=22). This was followed at much lower levels of mention by academic/teaching functions (n=13), clinical functions and warfarin (both n=13) and quality management functions (n=12). All other mentions were lower than n=10.

Atotalof28employersurveyswerecompletedrepresentinga22%response

rateofalltheApprovedPathologyAuthorities(APAs)(Table9)contacted(n=130)

TABLE 9 – NUMBER OF EMPLOYEES IN APAS NUMBER OF EMPLOYEES NUMBER OF APAS CUMULATIVE NO. OF APAS

Fewer than 15 6 6 15-80 5 11

81-500 10 21 501-1,500 5 26 Greater than 1,500 2 28

Oneverylargeorganisation(morethan1500employees)declinedto

participateintheemployersurveywhichmayhaveactedasadiscouragementtostaffparticipation.

AbriefauditofAustralianeducationalinstitutionswasconductedoveraneight-weekperiodtogaugetheextenttowhichtheeducationsupplymeetscurrentandanticipatedfutureworkforcedemand.

Findings Theestimatedsizeofthepathologyworkforceis24,157. Thereweresignificantdifferenceswithinage,genderandlocationbetween

workforcegroupsbetweenstates. Notableresponsesrelatingtojob/workplaceindicatedthat43%ofsenior

scientistsintendedtoleavethepathologyworkforceinthenextfiveyearsand58%ofspecialistpathologistsworkedmorethan45hoursperweek.

Ittakesabout3.1monthstofillthevacantpositionsofscientists.


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Themainreasonforpathologistsintendingtoleavetheprofessionwereduetoimpendingretirement(73.5%)comparedtothoseinotherpathologyworkforcegroupings,andtheyweremuchlesslikelytobeseekingachange/employmentinanotherprofession(1.5%)orfeeltheyhadlimitedcareeropportunities(0.0%).

Themostpressingissuefacingthepathologyworkforceistheshortageofskilledlabour(particularlyseniorscientistsandpathologists),whichwasmentionedbyallAPAscompletingthesurvey.Theyalsonotedthegenerallackofinterestamongsomescientiststoundertakefurtherpersonaldevelopment,andtheneedforseniorscientiststostep-upandrunlaboratories.

Thelackofseniorpositionstoprogressandpromotestaffwasalsoidentifiedasacurrent‘bottleneck’exacerbatingtheskilledlabourshortage.

Thereisalsoashortageofhealthinformationprofessionals,possiblyduetotheaccelerationofeHealthinitiatives.

Othersecondaryissuesincludehighstaffturnover(particularlyamongstphlebotomy,clericalandreceptionstaff),thetimeframestoreplacestaff,andtheexpenseofprovidingpracticalon-the-jobtraining.

ThereisanunevenspreadofjobsacrosstheStates,witharound50%oflaboratorytechnicianslocatedinNewSouthWales,whilethereisahighconcentrationoflaboratoryassistantsinQueenslandandsignificantlyfewerinVictoriaandSouthAustralia.

Otherissuesincludeinsufficientincentivetoattracttherightpeoplefrommetropolitanareastomoveintoandworkinsmallerregionalcommunities(e.g.pathologyregistrars),poorMedicarerebates,highcostofwagesinamarketofdecliningrevenues,difficultystaffingout-of-hoursshifts,thedesireamongstseniorstafftoworkfewerhoursandtheneedformoreefficientworkpractices.

About20%ofemployeerespondentsintendtoreducetheirworkinghours,withpathologists(34%)returningthehighestincidenceinthisgroup.

Thesizeandeffectivenessofthefuturepathologyworkforcewillbelargelydeterminedbytheprovisionofsuitablyqualifiedentrantsintotheworkforce,particularlyataseniorlevel(e.g.pathologists).

Recommendations 1. Thereisaneedtocreatemorepositionsandworkplaceopportunitieswhile

alsomakingpathologyanattractivecareerchoiceinordertofillthesepositions.Thisneedismorepressingatthehighlyskilledendofthejobspectrum,particularlyforpathologistsandscientists.

2. Tosuccessfullyattractnewpeopleintoacareerinpathologytheprofessionneedstobemademoreattractivethroughpositivestructuralchange(internalfocus)aswellasthedevelopmentofamarketingcampaigntopositivelyadvertiseandpromotetheindustry.Animportantaspectofthisshouldbetheactivepromotionofregional/ruralplacements.

3. TheMedicalBenefitspayableforpathologyshouldbeincreased.4. Aflexibleandeffectivemanagementstructurethatallowsforsuccession

planning,intelligentrotations,providesworkreplacementfortrainees,maximisesthenumberofworkplacetrainingpositionsandalignsthestrategicgoalsoftheorganisationwithworkforceissuesshouldbeprovided.


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5. Improvecommunicationandcoordinationwithtertiarycourseproviderstoensurethatgraduatesarebetterabletomeetjobrequirementsbasedontrainingthatisrelevantandpractical.ThisprocessshouldalsohelpAPAsattractbettergraduates.

6. Createpaidpositionsforscientiststhatarenotdirectlyrelatedtoresultoutputs.

7. Introduceinitiativestohelpovercomethesignificantshortageofscientistsincludingtheprovisionofscientistapprenticeshippositionswiththeassistanceofcooperativegovernmentfunding,supportingmedicalscientists’careerstructureinitiativesandprovidingsupportforrestructuringtheawardforscientists.

8. Providesustainabletrainingbyallocatingsufficientfundingfortrainingpositions,andensuretrainingremainsatopagendaitemgoingforwards.

9. Continuingtolobbyforindustrybestpracticeonanumberoffrontsincludingtertiaryinstitutions(forbettertraining/betterqualifiedgraduates),medicaladministrators(forbettermedicalandpathologytraining)andtocontributetoworkforcereformandtheseparationofindustrialversusprofessionalissues.

10. Offergoodremunerationandcareerprospectstoattractnewpeopleintopathology,andtomakeitmoreappealingforpart-timeworkerstoworklongerhours.

Key Project Learning Developinganeffectivemethodologyforthisprojectwaschallengingdueto

thefacttherewasnotadirectandstraightforwardmeansofgainingaccesstoallworkersinthepathologysector.Therewereonlyalimitednumberofprofessionalassociationsandindustrypeakbodiesbothableandwillingtoprovideaccesstosegmentsofthepathologyworkforce,butnonewhichrepresentedallpathologyworkers.

Follow on Initiatives and Projects CareerStructuresandPathwaysfortheScientificWorkforceinMedical

PathologyLaboratories PathologyWorkforceWorkshoponpage177.Areas for Future Consideration Investigatestrategiestopromotepathologyasanappealingcareerchoice. Investigatestrategiestoprovideincreasedaccesstopathologytopeoplein

ruralandregionalareas.

Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011) Description ThisprojectanalysedthescientificworkforceandproposedamodelforacareerframeworkfortheAustralianscientificworkforceinmedicalpathologylaboratories.Thescientificworkforceisdefinedasincludingseniorscientists,medicallaboratoryscientists,medicallaboratorytechniciansandlaboratory


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assistants,althoughindividualswithineachworkforcegroupmayholddifferenttitles.Grant Recipient HumanCapitalAlliance(HCA)Aims and Objectives toprovideanunderstandingofcurrentandfutureworkforcerequirements

andtheappropriatenessandadequacyofcurrentsupplystrategies toinvestigateoptionstopromoteworkforceretentionespeciallythrough

careerpathwaysdevelopmentforthescientificworkforceinmedicalpathologylaboratories.

These aims and objectives were achieved by this project. Outcomes Aone-dayworkshopwasheldon24November2010withall12membersof

theProjectReferenceGroup(PRG). Secondarydatasourcesweregatheredandanalysed. Aliteraturesearchwasconductedtoresearchcurrentpractices,specialist

viewpointsofspecialistsandsurveyreports. Writtensubmissionswereinvitedfromselectedstakeholders,andextensive

stakeholderconsultationswereundertaken. Areviewofawardstructuresfromvariousstateswerecollectedand

analysedforsimilaritiesandcompatibilitieswithspecialattentionpaidtotheprosandconsofeachinregardtopotentialcareerframeworks.

Aone-dayworkshopwasheldwiththePRGtofinalisetheproject. Majorissuesidentifiedandexploredinclude:

o workforceboundariesaroundthemedicalpathologyscientistworkforce,andwithintheworkforcebetweenassistants,techniciansandscientistsandbetweendifferentdisciplines

o apparentlabourmarketconditionsandthepossibilityofsegmentedlabourmarketsthatbehaveindifferentways,andtheimplicationsfornewgraduatesupply,preferredtrainingprovidersandpreferredcareerstructurestofosterearlycareers

o deskillingofcertainlabourmarketsasaresultofcentralisingtestingprocesses(rural/private)

o useofcompetenciesasameansofunderstandingskillandknowledgeincomparisonwithqualificationsandhowthesemightbetterunderpinarangeofhumanresourcedecisions

o someaspectsofscientistworkforcebehaviourthatareimpactingonavailablesupplyandhaveimplicationsforcareerframeworks,suchashighturnoverofscientistsatspecificlevelsandtimeperiods,andincludingthoseassociatedwithscientists’progressionbeyondthefirstfivetosevenyearsinemploymentandbarrierstoentrytoseniorscientistlevels

o limitedpoolof‘middlelevel’scientistsabletoprogresseasilytoseniorscientistrolesasitisexpectedthatlargenumbersofseniorscientistwill(shortly)reachretirementageandexittheworkforce


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o variedpossiblepathwaystoseniorscientistlevels,butinmostcasesthereisanimplicitrequirementorspecificcommitmenttomanagementdevelopment.Thisisunattractiveformanypotentialcandidates

o supportforclinicalseniorscientistroleswheresuchrolescanbedefined,particularlyindisciplinesinwhichpathologistnumbersandinfluencearelow

o arangeofcareerstructurepossibilitiesthathavealreadybeenexploredbyemployersorprovidedbypersonsthinkingabouttheissue.

Findings Themostcompleteandcompellingcareerstructuremodelforthescientific

workforceinmedicalpathologylaboratorieshasbeendevelopedandimplementedintheUK.Itisbuiltontheconceptofskillsescalationandoffersflexiblecareeropportunitiestomeetworkforceserviceandindividualneeds.

ThePathologyAssociationsCouncil’s(PAC’s)setofcompetencystandardsforthescientificworkforceinmedicalpathologylaboratoriesrepresentanunder-utilisedresourceforimprovingthedevelopment,managementandassessmentofthemedicalscienceworkforce.

AcredibleandcurrentestimateofworkforcesizeisrequiredthrougheitherMedicareAustraliaortheNationalAssociationofTestingAuthorities(NATA).

ManyofthedifferencesintheAustralianscientificworkforceinmedicalpathologylaboratoriescareerframeworkscanbeattributedtoorconsolidatedbyprevailingindustrialarrangements.

Careerprogressioninthepublicsectordependedonapositionbecomingvacant(scientistsoccupyingseniorroleswereoftenincumbentforanextendedperiodoftime),whileintheprivatesectoritwasatthediscretionofmanagement.

Themedicalpathologyscientistworkforceisclosestinstructuretothenursingworkforcewiththreediscernablelevels;professional,paraprofessionalandsemi-skilled.

Thereareinsufficientnumbersofseniorscientistpositionstoprovideareasonableincentivetoscientiststoinvestinthepursuitofoneofthesepositions.

Anycareerframeworkforthemedicalpathologyserviceworkforceshouldsatisfythefollowingprinciples:

o thecareerframeworkshouldbecomprehensiveandincludeallcomponentsoftheworkforce.

o introducecompetencybasedprocesses,calibratedagainstcompetenciesinsteadofqualifications,tosupportcareerframeworkstructures.

o thearticulationofcareerpathwaysshouldbeclearandtransparentandnotsubjecttodiscretionaryjudgements

o learningopportunitiesshouldbebuiltintothecareerframework. Itisunlikelythatasinglecareerframeworkwouldbeappropriatetofitallof

thedifferentcircumstancesinvariousmedicalpathologylaboratorysciencelabourmarkets.

Recommendations


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1. UtilisethePathologyAssociationsCouncil’ssetofcompetencystandardsusingtheeightpathwaysidentifiedinthereport:

01. reviewcurrentindustrialarrangements02. supportthewideruseofcompetencieswithintheworkforce03. exploreandassessthefeasibilityofdifferentapproachestobuild

currentdataonworkforcenumbersandskillmix04. builddataonservice/labourdemand05. undertakelabourmarketanalysis06. supportstructuredtrainingforseniorscientists07. clinicalpracticefornewgraduatescientists08. trainingoftechnicians.

2. Recommendationsarisingfromconcernsassociatedwithcareerframeworkchangeinclude:

o thereisaneedforatleasttwopathwayswithinacareerframework–managementcompetenciesandcontinueddevelopmentofexpertiseasascientist

o thetransitionfromeducationtoworkisunstructured,andgraduatetraineepositionsshouldbereinstated

o reinstateapprenticeshiportraineeshippositionstosupportthetrainingoflaboratorytechnicians

o progressfromnovicetoproficientpractitionerforscientistsshouldbe‘mapped’againstidentifiedcompetencies,andsubsequentpayrises,promotionsandworkallocationallmadeconsequenttoassessedlevelsofcompetence

o introducearegistrartypetrainingprogramtoenablethetransitionfromproficienttoexpertpractitionerforscientists

o lengthenthecareerpathwayofmedicalscientistsbyintroducingextendedpracticeroles.

3. Apowerfulreasontochangeandseeknewcareerframeworksisnecessarytoovercomebarrierstochange.Benefitsneedtobehighlightedtoemployersthroughrelevantforums(e.g.NationalCoalitionofPublicPathology[NCOPP]andAustralianAssociationofPathologyPracticesInc.[AAPP])anddirectlytoemployersthroughbusinesscasestudiesofattemptedcareerframeworkchange.

4. TheoutlineofpossiblecareerframeworkforthescientificworkforceinmedicalpathologylaboratoriescanbefoundinFigure8onpage73ofthereport.

Follow on Initiatives and Projects FurtherpossibleworkthroughtheWorkforceAdvisoryCommitteeunderthe

PathologyFundingAgreement.Areas for Future Consideration InvestigateavenuestopromoteandutilisethePathologyAssociations

Council’ssetofcompetencystandardsusingtheeightpathwaysidentifiedinthereport.


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Consumer Focus and Information Strategies TheQualityUseofPathologyProgram(QUPP)soughttoengageconsumersinameaningfuldialoguetoincreasetheirknowledgebaseaboutthequalityuseofpathologyandidentifyconsumerissuesrelatedtopathology.Thiswasachievedthroughthreeprojects(Table10)whichhighlightedtheincreasingimportanceofengagingwithconsumersaslegitimatestakeholdersinthehealthsystem.Theseprojectsrevealedconsumerissuespredominantlybasedonaneedforimprovedcommunicationandengagement,especiallyaroundthebenefitsandrisksofpathology,andtheneedforcomprehensiveinformationstrategiestoaddresstheirconcerns.Asaconsequence,areasforfutureconsiderationidentifiedthroughthisintegratedanalysisinclude: Bestpracticeweb-basedguidelinesforconsumersregardingpathologyself-

collections. Informationstrategiestoinformconsumersaboutthestatusandprogressin

theareasofeHealthandruralandremoteissues. Developmoreinformationresourcesforthewebsite

www.labtestsonline.org.au(LTOAU). Implementaconsistent,ongoingcommunicationcampaigntoinform

consumersandhealthcareworkersabouttheexistenceofLTOAU,highlightingitasanindependent,trustworthysourceofinformationaboutpathology.

[alt=“ThefollowingtableliststhethreeprojectnamesandgrantrecipientsundertheConsumerFocusandInformationStrategiestheme”] Project Name Grant Recipient/s 1 QualityUseofPathologyConsumerConsultation

Project(2010)ConsumersHealthForumofAustralia(CHF)

2 BenefitsandRisksofPathologyTesting(Current) RoyalCollegeofPathologistsofAustralasia(RCPA)

3 LabTestsOnlineAUStage1(Current) AustralasianAssociationofClinicalBiochemists(AACB)

Table10:ReportsSummarisedforConsumer Focus and Information Strategies

Quality Use of Pathology Consumer Consultation Project (2010)

Description Thisprojectsoughttoengage,informandconsultwithhealthconsumerstoidentifyissuesofimportancetoconsumersregardingthequalityanduseofpathology.

Grant Recipient ConsumersHealthForumofAustralia(CHF)

Aims

toestablishanevidencebasethroughconsumerconsultationtoidentifyconsumerissues,includinggapsandopportunitiesandfacilitatorsandbarrierstoqualityuseofpathology


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tosuggeststrategiesthatwouldmakethepathologyexperiencemoreappropriateforconsumers.

These aims were achieved by this project.

Outcomes

AseriesofeightjurisdictionalworkshopswerecarriedoutacrossAustraliainlate2009.

AnationalworkshopwasheldinMelbourneinMarch2010whichbroughttogetherconsumersandpathologystakeholderstodiscussissuesraisedinthejurisdictionalworkshops.

Continuedinputwassoughtfromconsumers.

Findings

Issuesdiscussedinconsultationsincluded:o safetyandqualityofserviceo equityofaccessincludingavailabilityandaffordabilityo adequateavailabilityofanappropriateworkforceo communicationbetweenconsumer,referrerandprovidero privacyo PointofCareTesting(PoCT)andcosto DirectAccessTesting(DAT)o rural/remoteissuesthatrelatetopathologyo eHealthandaccesstopathologyresultso genetictesting.

Twokeyissuesidentifiedbyconsumersweretheimportanceofimprovingconsumerhealthliteracy,andtheneedformoreandbetterinformationtobecommunicatedtoconsumerspriortotesting.

Consumerswerealsoconcernedabouthowtobestensureallconsumersreceivethisinformationincludingthosefromculturallyandlinguisticallydiverse(CALD)backgrounds,peoplewithdisabilitiesandthosewithlowliteracy,giventhedemandsonthetimeofGeneralPractitioners(GPs)andSpecialists.

Itwasalsoseenasessentialthattheinformationprovidediscorrect,clear,up-to-dateandcomprehensive,andthatconsumershavetheopportunitytoseekadditionalclarifyinginformation.

Recommendations 1. Thedevelopmentandimplementationoftoolstoprompthealthpractitioners

toprovidebetterqualityinformationforthoseundergoingorconsideringpathologytesting.

2. ThedevelopmentandprovisionofgenericQualityUseofPathology(QUP)informationtoconsumers.

3. Thedevelopmentofresourcestoenhanceself-managementskillsandcapabilitiesforconsumers.

4. Promptaccesstoresultsforconsumersandpromptexplanationoftheirmeaningfollowedbywritteninformationonthoseresultsandsubsequentrecommendations.

5. IntroductionofaMedicareItemNumberfora‘PathologyResults’consultationwithaGPorotherrequestingpractitioner.

6. InvestigationofmorewidespreadimplementationofPoCT.


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7. Workforceinitiativestodealwiththeshortageofexpertise.8. Increasedfundingtoaidtheexpansionofmobilecollectionservicestomore

ruralandremotecommunities.9. Improvedavailabilityoftelemedicineservices,particularlyforthe

explanationofresults.10. Agreateremphasisoninformedfinancialconsentforpathologyservices.11. Ongoingconsumerconsultationandinputintoanychangestocurrent

pathologyfundingarrangements.12. Creationofstrongerlinkswithotheraccreditationprocesses.13. Implementationofatransparentcomplaintsprocesstoencourageand

reviewconsumercomplaintsinrelationtopathologytesting.14. Credentialingofthepeoplewhocollectsamplesatcollectionscentres.15. ContinuedconsumereducationabouttheroleofeHealthinimproving

privacybyenablingsecureelectronictransmissionofinformation,andthebenefitstoconsumersinimprovingcommunication,efficiency,safetyandquality.


ConsumersacrossStatesandTerritoriesexpresseddifferingexperiencesandviewsonwhatiscurrentlyoccurringinthepathologyfield,andalsoaboutwhattheyhopedtoseehappeninthefuture.

Consumersagreedontheneedforquality,safe,accessibleandaffordablepathologyservices.

Consumersexpectprovidersandpractitionerstolistentothemandconsidertheirviewswhenmakingpathologyrequests,takingsamplesandconveyingresults.

Consumersbelievepathologyisanareawherefurtherworkneedstobeundertakenwithconsumers.


BenefitsandRisksofPathologyTesting EffectiveCommunicationofPathologyResultsinRequestingPractitioners

andConsumersonpage133 BestPracticeinPathologyRequestingandReportingWorkshoponpage175.


Bestpracticeweb-basedguidelinesforconsumersregardingpathologyself-collections.

InformationstrategiestoinformconsumersaboutthestatusandprogressintheareasofeHealthandruralandremoteissues.

Benefits and Risks of Pathology Testing (Current)

Description Thisprojectisseekingtoincreasetheknowledgeofconsumersaboutthebenefitsandrisksofpathologytosupportmoreinformedengagementofconsumersinthepathologytestingprocess.Thesteeringcommitteeincludedrepresentativesfrom:

o ConsumersHealthForumofAustralia(CHF)


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o LabTestsOnlineAU(LTO)Boardo PathologyAssociationsCouncil(PAC)o RoyalAustralasianCollegeofPhysicians(RACP)o RoyalAustralianCollegeofGeneralPractitioners(RACGP)o RoyalCollegeofPathologistsofAustrasia(RCPA)(pathologistandLay

Committeerepresentatives)o DepartmentofHealthandAgeing(DoHA).


Aims and Objectives

toproduceaconsumer-focusedAustralianpublicationbasedontheconceptoftheUKpublicationSense About Science – Making Sense of Testing(http://www.senseaboutscience.org/data/files/resources/6/Making-Sense-of-Testing.pdf)

toeducatethepublicaboutpathologytestinginaneasy-to-readformatbasedonsoundscientificprinciplesandfocusingonasetofkeyidentifiedrisksandbenefits.

This project is current and these aims and objectives are in the process of being achieved.

Outcomes

Ninefactsheetsarecurrentlyinthefinalstagesofproduction.Theseare:1. Whoworksinpathologyandwhatdotheydo?2. WhydoIneedapathologytest?3. Consent–Whatyouneedtoknow4. WherecanIhaveapathologytest?5. Howsafeisthetestingprocess?6. WhatshouldIknowaboutpathologytestresults?7. Howarepathologytestfeescalculated?8. WhatshouldIknowaboutgenetictesting?9. WhatshouldIknowaboutDirect-to-Consumergenetictesting?

Lab Tests OnlineAU Stage 1 (Current)

Description ThisprojectisseekingtodevelopanauthoritativewebsitethatprovidesinformationonpathologytestsavailableinAustralia,anddrawsoninternationalcollaborationofpathologyexperts.TheLabTestsOnlineAU(LTOAU)websiteis:http://labtestsonline.org.au/.

Grant Recipient AustralasianAssociationofClinicalBiochemists(AACB)

Aims and Objectives

todevelopanauthoritativedatabasewhichisaccessibleasawebsitetothegeneralpublicandhealthprofessionals


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toprovideinformationonpathologytestsandthehealthconditionsthetestsareusedtodiagnoseandmonitor

todeterminetheneedsofthecurrentusersandnon-siteuserstoimprovethewebsitecontentandaccessibility

toexplorewaysofpromotingthewebsitemorewidelytohealthconsumersandhealthprofessionals.

These aims and objectives were achieved by this Stage 1 of this project.

Outcomes

Atwo-partresearchprojectwasimplementedbetweenJuneandNovember2011todeterminetheneedsofcurrentusersandnon-siteusersanddetermineattitudestowardspathologyingeneral,andmorespecificallytotheLTOAUwebsite.ThefindingsfromthissurveywillbeusedtodevelopsomeofthetasksinaproposedStage2ofthisproject.

Apartfromnewsitems,verylittleadditionalmaterialhasbeenaddedrecentlyasthebulkoftheeditorialworkloadcontinuestobeaddedatthethreeyearlysitereview.Thisprocessisnearingcompletionforalltestsandconditions.

Theprojectiscurrentlyinapublishholdphasetoexhaustivelycheckthewebsitebeforere-launchingthesitewiththenewcontentmanagementsystem.

Theinitiativeofusingtraineepathologyregistrarsisworkingwellandarecentlyretiredpathologisthasbeenrecruitedtostrengthentheteam.

Theprojectnowhasasustainablesolutioninplaceforthedeliveryofeditorialcontentacrossallofthepathologydisciplines.

Therehasbeenanaveragemonthlytrafficgrowthof4%resultingina42%increaseoverthepreviousyear.

Findings Responses to Consumer Research Survey Theresearchconfirmedthatinthefouryearssinceitslaunch,LTOauhas

beenavaluableassetinempoweringpeoplebygivingthemthereliableandtrustworthypathologyinformationtheyneedtoengageinproductiverelationshipswithmedicalandhealthprofessionals.Itisalsoanimportantinformationsourcefordoctors,nurses,practicemanagers,pathologycollectorsandhealthprofessionals,bothforthemselvesandtheirpatients.

Theresearchalsohighlightedfundamentalchangestakingplacewithinpathology.Accesstotestresultsisbecomingarealisticexpectationamongthepublicandthemedicalprofession,andthisisseenbyeventhemostconservativeandchange-resistantasapositivedevelopment.

Themedicalprofessionalsandmembersofthepublicwhotookpartintheresearchwerestronglyconcernedabouttheveracityofinformationoncommercialwebsites,withthepublicparticularlywaryofanyinformationfromoverseas.

Thetrendtowardsself-educationandmoreactivepatientparticipationinhealthcareisbeingembracedbysomesectionsofthegeneralandmedicalcommunitiesandresistedbyothers.


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Theresearchflaggedaclearneedforanon-commercial,trustworthysourceofpublicinformationaboutpathology.LTOAUhasestablisheditselfasthefirstpointofcallforpathologyinformation.

Theresearchalsohighlightedthatgeneralpractitioners(GPs)weremostlyagainstpatientsbeinginformedabouthealthmattersgenerally.

Theresearchnotedthatpathologycollectionstaffwouldliketoseethepublicbetterinformedaboutpathology,thetestingprocessandinparticularthecostandvalueoftesting.Theybelievethatifpeopleunderstoodthecostofpathologytestingthentheywouldvalueitmore.

OnegroupofSydney-basedhospitaldoctorsandnursesalsothoughttherewasanissueofdoctorsnotbeingfullyinformedabouttestsandwhofelttheneedto‘over-test’theirpatients.

Pathologycollectionstaffreportedmostquestionsfromthegeneralpublicrelatedtowhethertheywouldbebulk-billedforthetest,howlongittakestogetresultsandwheretheresultsweresent.

ManyGPsinthesurveyfeltLTOAUwasmoresuitableforthemandwasratedasthemostconcisesourceofinformationonpathologytestingreadilyavailabletoGPs.

GPsalsofounditdifficulttoacceptthesitewouldhavebeenwrittenwithoutsomeformofcommercialorgovernmentagenda.

MostpeoplefoundLTOAUbyGooglewhichhighlightedtheneedforaconsistent,ongoingcommunicationcampaigntopromoteitasareliableinformationsourceforpathology.

Recommendations 1. LTOAUneedstohaveclearerreferencestoitsauthorsandsponsorsand

clearlyarticulatethatthewebsiteisAustralian,independentandnon-commercialwiththeinformationpreparedbyexpertsworkinginpathologytesting.

2. Endorsementswillbenegotiatedwithrelevantgovernmentagenciesandrecognisablemedicalandprofessionalassociations.

3. TheAACBshouldstatetheircredentialsclearlytoreassuretheaudiencetheinformationhasbeenpreparedundertheauspicesofabodywiththeappropriateauthorityandexpertise.ThismayincludealinkonthebannertoasectionabouttheAACB.

4. Appointawebprofessional(thisisinprogress)toredesignandexplorewaysofpresentingtheinformationsoitiseasilyaccessible.Newcopywillalsobeprepared.

5. Thewebsite’scontentwillbereviewedbytheSiteManagerandtestedviaanonlinesurveyof40participantsincludingmembersofthepublicandmedicalandhealthprofessionals.

6. Allinformationwillbereviewedandrevisedandmademorereadilyaccessible.


Stage2ofthisproject.


Developmoreinformationresourcesonthewebsite.


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Implementaconsistent,ongoingcommunicationcampaigntoinformconsumersandhealthcareworkersabouttheexistenceofLTOAU,highlightingitasanindependent,trustworthysourceofinformation.


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Access Initiatives – Raising Awareness ThecompromisedhealthoutcomesforAboriginalandTorresStraitIslanderpeoplesarewelldocumented.TheQualityUseofPathologyProgram(QUPP)enabledthreeprojects(Table11)toexplorewaystoimprovethehealthoutcomesforIndigenousAustraliansthroughraisingawarenessoftheneedtobecomeastakeholderintheirownhealthcare.ThiswasachievedthroughculturallyappropriateandclinicallyeffectivestrategiestoengageAboriginalAustraliansinunderstandingthebenefitsofactivelyparticipatingintheirownhealthcaretoachievepositivehealthoutcomes.Oneareaforfutureconsiderationnotedfromthisintegratedanalysisincluded: Furtherevaluationandextensionofthe‘FlipChart’conceptasnotedinthe

reportOptimisingHealthBenefitsforAboriginalPeoplewhotakeWarfarin[alt=“ThefollowingtableliststhethreeprojectnamesandgrantrecipientsundertheAccessInitiatives–RaisingAwarenesstheme”] Project Name Grant Recipient/s 1 OptimisingHealthBenefitsforAboriginal

PeoplewhotakeWarfarin(2009)RoyalAustralianCollegeofGeneralPractitioners(RACGP)

2 QualityAssuranceforAboriginalMedicalServices(QAAMS)(Current)

FlindersUniversity

3 QualityAssuranceforAboriginalMedicalServices(QAAMS)QualityAssuranceProgram(Current)

RoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)

Table11:ReportssummarisedforAccessInitiatives–RaisingAwareness

Optimising Health Benefits for Aboriginal People who take Warfarin (2009)

Description ThisprojectsoughttoexaminetheuseofanticoagulantsandInternationalNormalisedRatio(INR)testinginAboriginalandTorresStraitIslanderpeople,andtodevelopeducationalresourcesfortheiruse.LackofasharedunderstandingbetweendoctorsandpatientsofthebenefitsandrisksofWarfarintreatment(abrandofanticoagulantmedication),particularlyinvolvingpatientswithlimitedliteracyskills,hasbeendemonstratedtobeacontributingfactorinpoorINRcontrol.Thisprojecthasprogressedthroughtwostages:

1. Consultationthroughyarninggroups(focusgroups)withAboriginalandTorresStraitIslanderpatientstakinganti-coagulantmedication,andemergingfromthisconsultation;

2. Thedevelopmentofa‘FlipChart’whichisaneducationalresourcetobeusedasadiscussionaidbetweenahealthworkerandapatienttoprovideinformationabouttheneedforINRtestswhentakinganticoagulantmedication.


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Grant Recipient RoyalAustralianCollegeofGeneralPractitioners(RACGP)

Aims and Objectives

toidentifytheneedsofAboriginalpeoplewithrespecttoacommonandimportantpathologytest,namelytheINRbloodtest,performedforpatientstakingWarfarin

todesignculturallysensitiveinformationstrategiesthatimprovetheknowledgeofpathologytestinginrelationtoINRamongstagroupofAboriginalcommunities

topilotandevaluatetheinformationstrategies tomakerecommendationsaboutfutureinformationstrategiesforpathology

testsinAboriginalcommunities.These aims and objectives were achieved by this project.

Outcome

ThemostculturallyappropriateandclinicallyusefulinformationstrategytoimproveknowledgeofINRtestingwasthedevelopmentofpictorialhardcopymaterialsratherthananyelectronic/videoformat.Inthisprojecta‘FlipChart’wascreatedwhichwasa31pageA4sizedocumentstructuredtobeplacedonadeskorflatsurfaceinanA-Frameform.ThisenabledthepatienttoseetheimagesclearlydisplayedwhilethehealthprofessionaldiscussedparticularaspectsoftheimagethatrelatedtoINRtesting.

Finding

Theuseofyarninggroups/interviewswithpatientswasthemosteffectivemethodofidentifyingAboriginalpeople’sneedsinrelationtoINRtesting.

Recommendations 1. Thisproject’sdesignisarecommendedmodelforcross-organisationalwork

inAboriginalHealth.Themodel’skeyfeaturesincluded:o engagingwithAboriginalpeopleandcommunitiesinneeds

assessmentanddevelopmentofinterventions/educationalstrategieso partnershiparrangementsbetweenaleadorganisationandAboriginal

MedicalServices(AMSs),includingclarityregardingownershipanddisseminationofdatacollectedbyAMSs

o consultationwithclinicalstaffinAMSsthroughouttheimplementationoftheproject

o flexibilityintimesandoutcomesinresponsetoneedsofAMSsandpatients.

2. TheprojectdesignshouldbeextendedtootherpathologytestsofcriticalimportancetoAboriginalandTorresStraitIslanderpeopleinordertodevelopculturallyappropriatetoolstoassistpeopletoundertaketests.

3. TheprojectdesignshouldbeextendedtootherclinicalandhealthissuesinAboriginalHealth(notrestrictedtopathologytesting)inordertodevelopculturallyappropriateeducationalinterventions.

4. Astudyshouldbeundertakentotesttheeffectivenessofthe‘FlipChart’asaneducationalinterventiontoimprovemedicationandINRtestcompliancebyAboriginalandTorresStraitIslanderpatients.


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5. Thecontentofthe‘FlipChart’bedevelopedintoformatsthatcanbeeasilytakenhomebypatientsandtheirfamiliestoreinforcethemessagesfromthe‘FlipChart’discussedintheconsultation.Aleafletorcomicbookappearstobethemostappropriateformat.

6. Canvassopportunitiestofund‘reminders’forAboriginalandTorresStraitIslanderpatientstotakeWarfarinandhaveINRtests.Therangeofappropriate‘reminders’identifiedintheyarninggroupphaseoftheprojectincludefridgemagnets,textmessagestomobilephones,calendarsetc.


TherewasstrongsupportbytheAboriginalcommunitiesforthecontentofthe‘FlipChart’tobeproducedintheformofleafletsorbookletsforthepatientstotakehome.

Futureprojectsutilisingthesameprojectdesign/modelshouldconsiderincludingthefollowingamendments:

o gain‘in-principle’commitmenttotheprojectbyspecificAMSsduringthedevelopmentoftheproposalratherthanrecruitingAMSsafterfundinghasbeenreceived

o employadedicated‘projectmanager’(ideallyanIndigenousperson)intheleadagencywithminimalresponsibilitiesoutsidetheproject

o clarifythespecificHumanResearchEthicsCommitteesthatrequireapprovaloftheprojectduringtheplanningstages

o resourcingforincreasedtravel/face-to-facecontactbetweentheleadagencyandAMSs

o increasedresourcingforstaffingattheleadagencyo increasedtimeofimplementingtheprojectwhichrecognisesthat

flexibilityandtimeisneededtobuildstrongworkingrelationshipso clearerguidancetoAMSsatthebeginningoftheprojecttoensurean

appropriateclinicalstaffmemberis‘assigned’toworkontheprojecto clarifytheneed/purposeofanyReferenceorWorkingGroupduring

theproposalstageoftheproject.

Areas for Future QUPP Consideration

Furtherevaluationandextensionofthe‘FlipChart’concepttoincludeothermorbidities.

Quality Assurance for Aboriginal Medical Services (QAAMS) (Current)

Description TheQualityAssuranceforAboriginalMedicalServices(QAAMS)programsoughttoprovideculturallyappropriateandclinicallyeffectivediabetesmanagementthroughtheuseoftwo“pointofcare”pathologytests(PoCT):glycosylatedhaemoglobin(HbA1c)andurinealbumin/creatinineratio(ACR),atparticipatingAboriginalandTorresStraitIslanderhealthservicesacrossAustralia.Amanagementframeworkoftraining,technicalsupportandqualitymonitoring,andaprogramforAboriginalcommunityleadersensuredthatpathologytestingmetthequalityachievedinconventionalpathologylaboratories.Therewasan


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Australia-widenetworkofsites(150in2010-2011)forPoCTtoassistineffectivediabetesmanagementinIndigenouscommunities.

Grant Recipient FlindersUniversity

Aims and Objectives

toestablishandmaintainaQAAMSProgramManagementGroup(QPMG)toco-ordinateandcontroltheconductoftheProject

toprovidescientific,technicalandclinicalsupportandon-goingscientificreviewoftheProject

toprovidecomprehensiveeducation,trainingandon-goingsupportfortheProject

todevelopmechanismstofosterandencouragegreaterAboriginalleadershipandexpertisewithintheProject

toincreasetheparticipationrateofAboriginalMedicalServices(AMSs)andAboriginalCommunityControlledHealthServices(ACCHSs)intheProgram

tooverseethemaintenanceoftheinternalqualitycontrolandexternalqualityassuranceprocesses.


Outcomes

ThenumberofservicesenrolledintheQAAMSProgramforHbA1candACRincreasedby78%(from60to107)to146%(from37to91)duringthecontractperiodof2006to2009.Tworecruitmentdrivesresultedinthecapof100servicesparticipatingintheprogrambeingexceededwhichnecessitatedacontractvariation.

AtelephonehotlinesupportservicewassetupandmannedbyaqualifiedscientistfromtheFlindersUniversityCommunityPoint-of-CareServices(CPS)unitduringbusinesshours(9amto5pm[CST]MondaytoFriday)acrossthecontractperiod.Totalcallsinwere1650andtotalcallsoutwere2185.

AquarterlyQAAMSnewsletteronissuesrelevanttotheQAAMSprogramwasroutinelyproducedandsenttoallparticipants,andlaterpostedontheQAAMSwebsite.

AQAAMSClinicalSupportOfficerwasappointedinearly2006. InformationwasprovidedtoAMSsandACCHSstoensuretheappropriate

useandunderstandingoftheMedicareRebate. TheQAAMSProgramManagerliaisedconsistentlywithBayer(nowSiemens

HealthCareDiagnostics)toensureparticipantsreceivedhighqualityservicesinrelationtotheprovisionofreagents,qualitycontrol(QC)andconsumables,andtechnicalsupportfortheDCA2000PoCTdevice.

TheFlindersCPSunitundertookamajorprogramofworkcalledtheQAAMS Diabetes Outcome StudymidwaythroughthecontractperiodtovalidatetheclinicaleffectivenessofQAAMSbycollectingandanalysingserialPoCTHbA1cresultsfrompatientswithestablisheddiabetesfromdifferentservicesparticipatinginQAAMS.Resultsfromthisanalysisshowed:


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o astatisticallysignificantreductioninmeanHbA1cof0.5%(from8.8%to8.3%)inthisgroupofpatientsoveramediantimeofobservationof29months(p<0.0001)

o thetimeperiodoverwhichPoCTwasmonitored(amedianof2.5years)indicatedthatimprovementsinmeanglycaemiccontroloccurredoverthelongtermandwerenotjustshort-termchanges

o aseparatemeansofanalysisshowedatrendtowardsimproveddiabeticcontrol;a12%increaseinthepercentageofpatientsachievingaHbA1c<8%,a7%reductioninthepercentageofpatientshavingaHbA1cbetween8%and10%,anda6%reductioninpatientswithpoorlycontrolleddiabetes.

ThereweresignificantadvancesandnewinitiativesinthedeliveryoftraininginPoCTforQAAMSparticipantsincluding:

o redevelopmentoftheQAAMSprimarytrainingresourceso developmentoftheQAAM’Swebsiteo neweducationinitiatives.

TheannualQAAMSWorkshopsincreasedtheirattendanceratesbetween2001and2008.

TheQAAMSLeadersGroupwasformedinMay2006wherebyonepersonofAboriginalorTorresStraitIslanderdescentwasselectedtorepresenteachStateorTerritory.TheydevelopedaMissionStatementforQAAMSandaTermsofReferencedocumentandplayedanintegralrolein:

o assessingtrainingresourcesfortheirculturalappropriatenesso assistingwithregionaltrainingvisitsbytheprimaryQAAMSTraining

Teamo deliveringtheannualQAAMSWorkshopthroughprogram

development,trainingassistance,deliveringspecificcoresessionsandmakingpresentations.

TheFlindersCPSunitandRoyalCollegeofPathologistsofAustralasiaQualityAssuranceProgramsPtyLtd(RCPAQAP)held29meetingstocollectivelyreviewthequalitycontrolandqualityassuranceresultsfromeachQAAMSsiteacrossthecontractperiod.

TheQAAMSManagementTeampublishedpapersaboutQAAMSintwopeer-reviewedpapers,andtheProgramManagerdeliveredinvitedlecturesontheQAAMSProgramatanumberofconferences/meetings.

Findings

Face-to-facetrainingandcompetencyassessmentthroughon-sitevisitstoindividualservicesorregionalworkshopswerecrucialcoreactivities.

Thelatterdevelopmentofsupportingon-lineweb-streamedtrainingvideoandcompetencyprocessesmeantmoredeviceoperatorscouldbetrainedthroughthismedium.Thiswasausefuladjunctfortraining,butwasnotintendedtoreplaceface-to-facetrainingwhichwasthemosteffectivemeansofdeliveringtrainingfordeviceoperatorsintheQAAMSProgram.

Recommendations 1. TheQAAMSProgramshouldembracetheopportunitytoincludenewPoCT

devicesastheyentertheAustralianmarket,providedtheymeetanalyticalgoalsandaresafeforpatientcare.Thismayinvolvenewchallengesto


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developtrainingandqualitymanagementprocessesthatcansupportthesenewdevices.

2. TheQAAMSManagementteamshouldfurtherengagetheQAAMSLeaderstoassistthescientificteaminestablishingcontactwithandrectifyingtheissuescausingpoorparticipationinQCtestingregimes.


TheconstantchangeofhealthservicepersonnelinthelocationsmadethecontinuityofahighqualityPoCTserviceandmaintenanceoftrainingsupportdifficulttosustain.Theintroductionofweb-basedtrainingavailable24hrsaday7daysaweek,andtrainingDVDs,addressedthisissuetosomeextent,butthefundamentalissueofstaffretentioninruralandremoteAustraliawillremainapermanentissueforQAAMS.

HighstaffturnoverisalsoassociatedwiththemaintenanceofregularQCtestingregimens.

DatacollectionfortheDiabetesOutcomeStudywaslabourintensiveandnotstreamlineddespitetheeasy-to-followtemplatesandprocessesdesignedandimplementedtoassistthisprocess.Processesareinplacetoaddressthisissue.


SpecificfundingwasprovidedbytheCommonwealthGovernmentinthe2009Budgetforfouryears.ThesuccessoftheQAAMSprogramalsoledtoFlindersUniversityInternationalCentrebeingabletousetheQAAMSmodeltoassistinthedevelopmentof“pointofcare”pathologytestingprogramsinothercountrieswhichcurrentlyincludeCanada,SouthAfrica,ThailandandNewZealand.


FurtherfundingforQAAMSwillbeconsideredunderthenewChronicDiseasePreventionandServiceImprovementFund.

Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current)

Description ThisprojectsoughttoprovideandmanagetheexternalqualityassurancecomponentoftheQualityAssuranceforAboriginalMedicalServices(QAAMS)Program,andassistintheprovisionoftraining,technicalsupportandqualitymanagementtoparticipatingAboriginalandTorresStraitIslanderhealthservicesacrossAustralia.ThisreportfocusesonCycle20whichranfrom30January2009to30June2009,anditsassociatedQAAMSactivities.



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Outcomes

Therewere99enrolmentsforcycle20comprisingof96enrolmentsforglycosylatedhaemoglobin(HbA1c)and78enrolmentsforurinealbumin/creatinineratio(ACR).

InterimReportsandSupervisor’sReportswereprintedmonthlyassoonaspossibleaftertheclosingdate.

TheRCPAQAPandQAAMSmanagementmetmonthlytoreviewparticipation,qualitycontrol(QC)resultsandqualityassurance(QA)resultsanddecideifanyactionwasrequired.

Thetelephonehotlinesupportserviceiscontinuingtobeusedbyparticipants.

TheRCPAQAPcontributedtwonewslettersinthisreportingperiod.

Findings

Theparticipationrateof69%forHbA1cand64%forurineACRisanimprovementfromcycle19butstilllessthaninpreviousyears.TheAboriginalMedicalService(AMS)iscontactediftheyarenotparticipating.

ThepercentageofacceptableresultsforHbA1candurineACRremainedhighincycle20.


StaffandtrainingarethemainissuesfortheQAAMS’QualityAssuranceProgram.

Itisachallengeforallparticipantstoreturnresultsbytheduedate.AprocesshasbeenputintoplacetoalertparticipantstotheconsequencesofnotsubmittingQCandQAresults.


SpecificfundingwasprovidedbytheCommonwealthinthe2009Budgetforfouryears.


FurtherfundingforQAAMSwillbeconsideredunderthenewChronicDiseasePreventionandServiceImprovementFund.


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Communication Strategy and Stakeholder Engagement TheQualityUseofPathologyProgram(QUPP)soughttoengagestakeholdersinpathologythroughfourworkshops(Table12)toscopeoutissuesrelatingtothequalityuseofpathology.Theseworkshopsidentifiedanumberofissuesrelatingtostakeholderswithintheindustry,withtheQualityUseofPathologyCommittee(QUPC)seekingtoincreasetheirengagementwithconsumersduringthelatterworkshops.Commonissuesthatemergedduringtheseworkshopsincluded: workforcesafetyandquality,especiallyforAnatomicalPathologists recruitingandretainingaqualitypathologyworkforce lackofclearguidelinesaroundpathologyrequestingandreporting concernsabouteHealth increasedconsumerempowermentandengagement qualityassuranceissues.Theseworkshopsproducedmanyrecommendationsaboutthewayforwardinpathology,whilethisintegratedanalysiscapturedthefollowingareasforfutureconsideration: Emphasisshouldbeplacedonproducingguidelines(perhapsincorporating

patientpathways)allowinginformedchoicestobemadebyconsumersratherthanondifficulttodevelopandadministerregulation.

Reviewthepathologytestrequestformsforrelevancetothecurrentprovider/requester/consumerclimate.

Exploreoptionstodevelopguidelines/testingpathways,especiallyforhealthchecks,obesity,commonmulti-morbiditycombinationsandhypertension.

Exploreoptionstotargetrequestersatcriticaleducationandtrainingpoints. Exploretheissueofpathologytrainingandspecialtyopportunitiesfor

AboriginalandTorresStraitIslandermedicalgraduates. Explorethepossibilityofdevelopingguidelinesonsafepathologist

workloads.[alt=“ThefollowingtableliststhefourprojectnamesandgrantrecipientsundertheCommunicationStrategyandStakeholderEngagementtheme”] Project Name Grant Recipient/s 1 ReportfromtheNationalWorkshoponSafetyand

QualityinPathology(2007)MichaelLeggandAssociates

2 TheSecondNationalWorkshoponSafetyandQualityinPathology(2008)

MichaelLeggandAssociates

3 BestPracticeinPathologyRequestingandReportingWorkshop(2009)

ApisGroupPtyLtd

4 PathologyWorkforceWorkshop(2011) URBISTable12:ProjectssummarisedforCommunicationStrategyandStakeholderEngagement


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Report from the National Workshop on Safety and Quality in Pathology (2007)

Description Thisone-dayworkshopon28November2007broughttogetherkeystakeholdersfromthepathologyprofessionandindustry.TheyidentifiedanumberofkeythemesforfutureQualityUseofPathology(QUPP)investment,includingastrongconcernaboutthefuturesafetyandqualityofpathologyasaconsequenceofcurrentworkforceshortages.Stakeholdersrepresentedincluded: RoyalCollegeofPathologistsofAustralasia(RCPA) RCPAQualityAssuranceProgramsPtyLtd(RCPAQAP) AustralianAssociationofPathologyPractices(AAPP NationalCoalitionofPublicPathology(NCOPP) ConsumersHealthForumofAustralia(CHF) NationalE-HealthTransitionAuthority(NEHTA) AustralianCommissionofSafetyandQualityinHealthCare AustralasianAssociationofClinicalBiochemists(AACB) HealthInformaticsSocietyofAustralia(HISA) NationalAssociationofTestingAuthorities(NATA) ACTDivisionofGeneralPractice CancerInstituteofNSW UniversityofSydney(GPStatisticsandClassificationCentre) MedicalIndustryAssociationofAustralia

Grant Recipient MichaelLeggandAssociates

Aims and Objectives

tofocusonthefullspectrumofpathology-relatedqualityissuesfrom‘decisiontorequestaservice’through‘conductofthetesting’to‘useoftestresultsinpatientmanagement’

toreflectoncurrentplansandrecentpathologyinitiativesinpatientsafetyandquality

toidentifyanygapsthatneedaddressingandscanthehorizonforfutureissues

toproducearangeofoptionstoguidefuturedevelopmentactivityinthisareacontributingtostrategicplanningforboththeshortandmediumterm

tosuggesthowidentifiedconceptsorinitiativesshouldberankedandprioritiesforfutureattentionbytherelevantbodies.

These aims and objectives were achieved by this workshop.

Outcomes

TheWorkshopparticipantsidentifiedissuestheythoughtwouldbeimportantinrelationtosafetyandqualityintheprovisionofpathologyservicesforthenextthreeyears.Theissuesidentifiedinorderofprioritywere:1. workforce(127points)


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2. smartrequesting(87points)3. positiveidentification(63points)4. testingoutsideofthecurrentqualityframework(46points)5. smartreporting(44points)6. multidisciplinarycare(25points)7. clinicalaudit(14points).

AConsensusStatementonworkforcesafetyandqualityinpathologywasdevelopedaftertheWorkshopbasedonagreementaboutthepathologyworkforceissueidentifiedduringtheWorkshop.Itcouldbeusedtoescalatetheissueandadvocateforremedy.TheConsensusStatementdevelopedis:Thereisacritical threat to the safety and qualityoftheworld-classpathologysystemthatAustraliacurrentlyhas;itisworkforceshortages.Theproblemextendstotheentirerangeofthoseinvolvedinprovidingpathologyservicesbutinparticularitaffects

a. Pathologists and b. Laboratory Scientists/Techniciansand Health Informaticians.

Theshortageofqualifiedstaffisalready having an impactonthewaythatpathologypracticesareorganisingthemselvesandthishasbeenevidentforatleastthelastthreeyears.Theproblemisnot because of inefficienciesbecauseAustralianlaboratoriesareamongthemostefficientintheworld.Therearetoo few trainees in the system to meet current needsletalonetodealwiththeageingworkforce.Therearewillingtraineesandtrainersfrombothpublicandprivatepracticesbutthereisinsufficientstateandterritorygovernmentfunding for this education. Theworkforce shortage will only be exacerbatedbytheincreasedrelianceonpathologyinthepracticeofmodernmedicineandtheburgeoningdiseaseburdenofanageingpopulation.Actionbythevariouspartiesmustbetakennowtoavoidseriousconsequencestohealthoutcomes.

Finding

ThecurrentqualityframeworkinpathologylaboratoriesmeansmostriskandopportunityforimprovementisinthenodesofthePathologyRequestTestReportCycleinthepre-andpost-analyticalstages,ratherthanattheanalyticalstage.

Recommendations 1. Consideroptionsforactiontoaddressidentifiedprioritiesthroughthe

QualityUseofPathologyCommittee(QUPC)andNationalPathologyAccreditationAdvisoryCouncil(NPAAC).

2. Considerreconveningintwoyearstoevaluateprogressandrevisetheplan.


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TheSecondNationalWorkshoponSafetyandQualityinPathology

The Second National Workshop on Safety and Quality in Pathology (2008)

Description Thisone-dayworkshopon6November2008wasthesecondplatformtohighlightanddiscussQualityUseofPathologyProgram(QUPP)initiatives.ItshowcasedcurrentandrecentQUPP-fundedinitiativesandfurtherworktodateonprioritiesidentifiedintheReportfromtheNationalWorkshoponSafetyandQualityinPathologyonpage172.ThissecondWorkshopalsosoughttomoreexplicitlyengagewithrequestersandconsumers.Stakeholdersrepresentedincluded: RoyalCollegeofPathologistsofAustralasia(RCPA) RCPAQualityAssuranceProgramsPtyLtd(RCPAQAP) AustralianAssociationofPathologyPractices(AAPP) NationalCoalitionofPublicPathology(NCOPP) ConsumersHealthForumofAustralia(CHF) NationalE-HealthTransitionAuthority(NEHTA) RoyalAustralianCollegeofGeneralPractitioners(RACGP) AustralasianAssociationofClinicalBiochemists(AACB) HumanGeneticsSocietyofAustralasia(HGSA) HealthInformaticsSocietyofAustralia(HISA) NationalAssociationofTestingAuthorities(NATA) ACTDivisionofGeneralPractice CancerInstituteofNSW UniversityofSydney(GPStatisticsandClassificationCentre) MedicalIndustryAssociationofAustralia

Grant Recipient MichaelLeggandAssociates

Aims and Objectives

toprovideanupdatetostakeholdersontheprogressmadeinthepriorityareassincetheinitialWorkshop,anddiscussfutureproposedwork

toidentifyanygapsthatneedaddressing tofurtherscanthehorizonforfutureissuestobeaddressed.These aims and objectives were achieved by this workshop.

Outcomes

Twointeractivesessionswereheldduringtheworkshop. Thefirstwastotestthe‘QualityFramework’Mapprovidedinthepre-

readingforcompletenessofthelistbycategoryoftheorganisationsandtheirproductsthatareinvolvedinthenationalpathologyqualityframework(outsideoftheactuallaboratories),andsuggestionswerecollectedwhichwillbeusedtoexpandthisreport.


175

Thesecondsessionwasaninvitedopendiscussionontheworkbeingdonetohelpandprotectconsumersusingpathologytestingundertheircontrol(asopposedtothoserequestedbymedicalpractitioners).

Recommendations 1. Emphasisshouldbeplacedonproducingguidelines(perhapsincorporating

patientpathways)allowinginformedchoicestobemadebyconsumersratherthanondifficulttodevelopandadministerregulation.

2. ContinuetodevelopstrategiestoaddressworkforceshortagesinpathologyandreconveneagroupforthatpurposeinMarch2009.


BestPracticeinPathologyRequestingandReportingWorkshop.


AsperrecommendationNo.1above.

Best Practice in Pathology Requesting and Reporting Workshop (2009)

Description Thisone-dayworkshopon9December2009soughttopromotecollaborative,evidence-basedpathologyrequestingandreportingstrategies.Itincludedpresentationsandsomediscussioninrespecttothelateststudiesensuringpatientsafetyandqualityinpathologycommunications,emergingissuesandprioritiesandopportunitiesforfuturecollaborationofagreedpriorities.Stakeholdersrepresentedincluded: RoyalCollegeofPathologistsofAustralasia(RCPA) QualityUseofPathologyCommittee(QUPC) NationalPathologyAccreditationAdvisoryCouncil(NPAAC) NationalPrescribingService(NPS) AustralianAssociationofPathologyPractices(AAPP) AustralianGeneralPracticeNetwork RoyalAustralianCollegeofGeneralPractitioners(RACGP) CancerAustralia NationalCoalitionofPublicPathology(NCOPP) ConfederationofPostGraduateMedicalEducationCouncil NSWInstituteofMedicalEducationandTraining NationalInstituteofClinicalStudies RoyalAustralianCollegeofSurgeons(RACS) RuralDoctorsAssociation HealthInformaticsSocietyofAustralia ConsumersHealthForumofAustralia(CHF) NationaleHealthTransmissionAuthority(NEHTA) RoyalAustralasianCollegeofPhysicians(RACP) AustralianMedicalAssociation(AMA) CommitteeofDeansofAustralianMedicalSchools MedicalStudentsAssociation


176

DepartmentofHealthandAgeing(DOHA).

Grant Recipient ApisGroupPtyLtd

Objective

toexploreandpromotecollaborative,evidence-basedpathologyrequestingandreportingstrategies.

This objective was achieved by this workshop.

Outcomes

Abroadrangeoftopicswerepresentedanddiscussedcoveringthelateststudies,ensuringpatientsafetyandqualityinpathologycommunications,emergingissuesandprioritiesandopportunitiesforfuturecollaborationonagreedpriorities.

APlenarySessionfocusedonpriorityareasforfuturedevelopmentandcollaborationinpathologyrequestingandreporting.

Findings

Whereclearclinicalpathways/guidelinesexistandarewellknown,pathologyrequestingpatternslargelyappeartomirrorguidelines.Problemstendtobefoundwheretherearenotclear,agreedguidelinesand/orclinicianshavetojugglecompetingandpossiblynon-alignedguidanceforseveralconditions.

Adheringtopatientandsampleidentificationandcollectionprotocolsexternaltopathologyprovidersisoneevidence-basedmethodofpreventingharmtopatients.

Recommendations Theworkshopidentifiedpriorityareasforfurtherdevelopmentandexplorationincluding:1. EnsuringeHealthsystemcapacityprovidesaneffectiveplatformfor

transferringclinicalinformationandresultsbetweenrequestersandpathologyproviders.

2. Increasingthefocusontheformatandcontentofpathologytestrequestformsandthepossibleinclusionofmoreclinicalinformationtodrawonpathologists’expertiseregardingsmartrequesting.

3. Targetingrequestertrainingatcriticaleducationandtrainingpointse.g.postgraduationyearone(PGY1)andPGY2curriculumandgeneralpractice(GP)registrartrainingprograms.

4. Developingclinicalpracticeguidelinesontestrequestingforhealthchecksandthemanagementofobesity,commonmulti-morbiditycombinationsanduncomplicatedhypertension.

5. Focusingonconsumerempowermentandengagementthrough:a. bettereducationandtrainingofclinicianstosupportthisb. improvedaccesstoinformationincludingawarenessofrisksand

dangersofunnecessarytestingc. bettercommunication(readabilityofpathologyreports,needfor

consumer-friendlylanguage,culturalsensitivity)d. guidelinesformonitoring/maintenanceincludingself-management.


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6. Exploringtheneedforfurtherresearchontherationalesforpathologyorderingacrossvarioussettingsandprovidertypes.

7. Promotingthedevelopmentofmorecomprehensibleandusefulreportingofpathologytestresults.

8. Exploringclinicalgovernanceissuesaroundaccountabilityandtransparencyofpathologyrequestandresulttransactions.

9. Exploringthecapacityforrequesterstoordertestsaccordingtopatientcircumstances.

10. Improvingmechanismstomonitortestingalgorithmsand/ormanagedundersharedcarearrangements(e.g.anaemia).

11. Exploringtheneedtocollateandanalysepublicsectorbestpracticerequestingstrategiesforpossibleapplicationtothefee-for-servicetestingmodel.


Reviewthepathologytestrequestformsforrelevancetothecurrentprovider/requester/consumerclimate.

Exploreoptionstodevelopguidelines/testingpathways,especiallyforhealthchecks,obesity,andcommonmulti-morbiditycombinationsandhypertension.

Exploreoptionstotargetrequestersatcriticaleducationandtrainingpoints.

Pathology Workforce Workshop (2011)

Description Thisone-dayworkshopon22June2011soughttoinformstakeholdersofrecentresearchanddevelopmentsrelatingtothepathologyworkforce,andtoprovideanopportunityfordiscussionofkeyissuesforthespecialistandscientificworkforce.Bothmedicalandscientificprofessionalsattendedwithkeyissuesraisedincludinglimitedcareeropportunities,increaseddemandsontheworkforceandaforecastdecreaseinbothspecialistandscientificworkforcenumbers.TheAustralianAssociationofPathologyPractices(AAPP)wasnotrepresentedattheworkshop,andaskedthattheirdecisionnottoattendbenoted.(ThenumberofdelegatesavailabletoattendthisworkshopwassubstantiallyreducedatshortnoticeduetotheclosureofSydneyAirportrelatedtoanashcloudfromavolcaniceruptioninChile.)

Grant Recipient URBIS

Aims

toprovidearepresentativeforumfordiscussionofpathologyworkforceissues

toconsiderthefindingsofresearchrelatedtothepathologyworkforce toidentifyinformationgapsrequiringfurtherresearchorinvestigation.


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Objective

tostimulatediscussionanddebateregardingcurrentandprojectedworkforcechallengesandsolutions.

These aims and objective were achieved by this workshop.

Findings Workforce Issues Thereisadecliningproportionofworkingagepopulationandanageing

populationwithincreasingdemandsforpathologyservices. Thereareculturalchangesacrossgenerationswhicharepredictedtoimpact

onworkforcechoicesinthefuture,withmanyyoungerpeoplechoosinglifestylechoicesovercareeradvancement.

Thecareerframeworkislesswelldefinedforthescientificworkforcethanitisforthespecialistpathologistworkforce.

Influencesonthefuturepathologyworkforceidentifiedinclude:o theneedformoreflexibleworkplaceenvironmentso increasingandchangingdemandsfortechnologieso thegrowingmovewithinAustraliatowardsnationallyconsistent

accreditationandstandards. Themainchallengesidentifiedbyemployersare:

o shortageofskilledlabouro highstaffturnovero poorMedicarerebateso thehighcostofwages/remunerationo difficultiesstaffingout-of-hoursshifts.

Keyissuesforemployeeswere:o thedesirefornewchallengeso limitedcareeropportunities,particularlyforthescientificworkforceo insufficientrewards,particularlyforthescientificworkforceo stress/burnouto adesireforimprovedwork-lifebalance.

Thecurrentworkforcelevels,whichhaveincreased(particularlyinruralareas)forAnatomicalPathologists,representathreattothehealthandwellbeingofpathologists,andonthequalityandsafetyofpathologyservices.

Thereneedstoberecognitionthatparticipatingpathologistsperformotherdutiesinadditiontoreportingonpatient-relatedactivities.

Segmentingtheworkforceindiscreteroleswithdifferenttrainingpathways,accreditationrequirementsandcareerpathways,andwithdifferentindustrialarrangementsacrossStates/Territories,hasnotbeenconducivetodevelopingclearandconsistentcareerframeworks.

Issuesrelatingtothespecialistworkforceinclude:o aperceivedneedforflexibilityacrosspathologysub-disciplineso workforceshortagesandtheproposalforincreasedrecruitmentof

medicalgraduatesintopathology,includingthecreationofmoretrainingpositions

o thecreationofmorespecialistpathologistpositionstocopewiththeincreaseinthedemandforservices

o increasingservicedemandandtheimpactofworkloadpressuresonpathologists’healthandwellbeing,aswellasqualityandsafety


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o changingtechnologiesandtheproposalforenhancedtrainingincludingsupportfortrainingwhilestillworking

o flexibleworkpracticesandthedevelopmentofacareerframeworkwhichcouldprovidenewoptionsforpathologiststomoveintoandoutofpathologyspecialtiesoveralifetime’scareer.

Thereisacriticalneedtorecruitandretainseniorscientists. ThereisnodedicatedpathwayforAboriginalandTorresStraitIslander

medicalgraduates,whichmaybeaddressedinthefuture.Research Findings Thereisalargeamountofdatatosupportactiontoaddresskeyworkforce

challengesandnopressingneedfornewresearch. Theincreaseinthedemandandcomplexityofpathologyserviceswillrequire

innovative,long-termplanninginordertorespondtothechangingtechnologicalenvironmentandensurethecapacityoftheworkforcetoadapttochangingmarketneeds.

Thenumberofpathologytraineeshasincreasedfrom406in2008to474in2010.

Theincreasingdrivetowardssub-specialisationmayrequireevenmorepathologiststhanotherwisetoprovideforbothgeneralistandsub-specialtypathologydemands.

General Findings ThePathologyAssociationsCouncil(PAC)CompetencyBasedStandards

(CBS)frameworkforMedicalScientistsprovidesastructureforcreatingascopeofpracticeanddevelopingacareerpathwaywhichcouldbeformalisedinindustrialrewardstructures.

Newtechnologies,suchasdecisionsupportandpointofcaretesting,willrequireaflexibleandresponsiveworkforcetoadapttochangingworkpracticesandservicedemands.Insomecasestechnologymayincreaseworkloads,whileitmaydecreaseworkloadsandincreasecapacityforothertasks.

Itisimportantforthepathologysectorandgovernmenttoworktogethertoensuretheworkforceisabletomeetthedemandsforfutureservices.

Thereisatrendtowardsconcentratingservicesinurbanareaswhichisreducingtheopportunitiesforruralcareers.Innovativepackagingorincentivesandprofessionalopportunities,aswellasstrategiessuchascreatinggeneralistpositionsforanatomicalpathologytraineesbasedinregionalorrurallocations,couldencouragemorepractitionerstoworkinruralareas.

Recommendations 1. Abettertrainingandcareerframeworkforseniorscientistsshouldbe

exploredwhichalsoconsideredthedrivetosub-specialisation,andthepotentialforprofessionals(includingpathologists)tomoveinoroutofsub-specialtiesoverthecourseoftheircareer.

2. Exploreoptionstopromotethevalueofpathologyservicestothebroaderhealthsystemandwithinuniversitiestogainthecooperationofthoseinapositiontoassistwithaddressingrecruitment,trainingandworkloadneeds.


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3. Existingstudiesanddatacouldbefurtherminedandanannualsurveyonemploymentanddatatrendswouldbeuseful.

4. Exploretheoptionofimplementingcomprehensivenationalworkforceplanning.

5. Qualitymeasuresforanatomicalpathologyneedtobegivenmorepriority.6. Possiblefutureactionstorecruitandretainseniorscientistsinclude:

a. reviewcurrentindustrialarrangementsb. undertakealabourmarketanalysisc. supportstructuredtrainingd. provideaclearandstructuredcareerpathwaye. nationallyconsistentcompetency-basedstandards,roledefinitionand

assessmentprocessesf. remunerationrelativetoqualificationsandspecialisationg. supporttoundertakeaprofessionalfellowship.

7. Acareerframework,supportedbygreaterflexibilitywithintheworkplace,isessentialtoensurethefuturepathologyworkforcewasabletomeetthedemandsforservices.Thismayneedtobecoordinatedwithundergraduateandpostgraduatetraining,andofferoptionsforongoingprofessionaldevelopmentsupportedwhileretainingspecialistsinemployment.

8. Exploreoneaccuratemethodtocollectworkforcedataforboththespecialistandscientificworkforce.

9. Forecastthenumberofpathologyspecialistsrequiredinthefuturetoensurethereiscapacitywithinthetrainingpipelinetoaccommodateanincreasednumberofpathologytrainees,includingdefiningafull-timeworkload.

10. Identifythegapsintheavailabledataonthedemandforpathologyservices.11. Developguidelinesonsafepathologistworkloads.12. Profiletheworkforcedifferencesbetweenprivateandpubliclaboratories.13. Comparetheattritionratestothoseinotherprofessionstoassesstheextent

oftheproblem.


FurtherpossibleworkthroughtheWorkforceAdvisoryCommitteeunderthePathologyFundingAgreement.


ExploretheissueofpathologytrainingandspecialtyopportunitiesforAboriginalandTorresStraitIslandermedicalgraduates.

Explorethepossibilityofguidelinesonsafepathologistworkloads.


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Appendix A – Report Summaries Relevant to Different Themes TheQualityUseofPathology(QUPP)reportsummariesincorporateprinciplesandstrategiesrelevanttoadditionalchapterthemeswhicharehighlightedinthetablebelow. Project

Name Chapter Theme

1 EvaluationoftheImpactonPathologyPracticeoftheManualofUseandInterpretationofPathologyTests(2001)

PathologyRequestingandReporting–RequesterandConsumerFocusWorkforceCapacityandCompetence

2 AnHistoricalAnalysisofPathologyOrderingbyGeneralPractitionersbetweenApril1998andMarch2001fromtheBetteringtheEvaluationandCareofHealth(BEACH)Program(2002)


3 AProjecttoExaminetheUtilisationofPathologyTestsintheInvestigationofTirednessinGeneralPractice(2002)


4 AnalysisofCurrentPracticesinRelationtotheTeachingofPathology

WorkforceCapacityandCompetence


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(LaboratoryMedicine)(2003)

5 AnalysisofCurrentLaboratoryMedicine(Pathology)TeachingPracticeinPrevocationalandGeneralPractitionerVocationalTraining(2003)


6 AMechanismfortheDevelopment,ImplementationandEvaluationofEvidence-Based,Best-PracticeClinicalGuidelinestoFacilitateQualityUseofPathologyTests(2003)


7 RevisionofManualofUseandInterpretationofPathologyTests(2004)

eHealthCapabilityPathologyRequestingandReporting–RequesterandConsumerFocus

8 AcademicDetailingSupportingBetterOutcomesfromDiagnosticTechnologies(2004)


9 CommonSensePathology(2006)


10

ImprovedPathologyReporting,EducationandPractice(IPREP)forColorectalCancer(2009)



183

11

Evidence-Based,Best-PracticePreventionofBloodBorneVirusTransmissioninHealthCareSettingsProgram(PBBV)(2009)

RiskMinimisationPathologyRequestingandReporting–RequesterandConsumerFocusCommunicationStrategyandStakeholderEngagement

12

StructuredPathologyReportingStandardsforCancer(2009)

RiskMinimisationeHealthCapability

13

Evidence-PracticeGapinGPPathologyTestOrdering:AComparisonofBEACHPathologyDataandRecommendedTesting(2009)


14

RCPAManualTransformationProject(2010)

eHealthCapabilityPathologyRequestingandReporting–RequesterandConsumerFocus

15

CommonSensePathologyPublicationSeries(2011)

PathologyRequestingandReporting–RequesterandConsumerFocusCommunicationStrategyandStakeholderEngagement

16

PromotingandExpandingStructuredPathologyReportingofCancer(Stage2)(Current)


17

RCPA–QualityAssuranceProgramsKeyIndicatorProject(2004)


18

PilotLaboratoryAssessmentandPeerReviewMechanismforPathologyKeyPerformanceIndicators(2007)



184

19

KeyIncidentMonitoring&ManagementSystems(Current)


20

PerformanceMonitoringofExternalQualityAssurance(Current)


21

NATAFileAudit–RiskAnalysisofAssessmentNonConformancesIdentifiedinPathologyLaboratoryAssessmentAccreditation(Current)


22

VirtualMicroscope(2005)


23

DevelopmentofaQualityAssuranceModuleforHumanPapillomaVirusTesting(2008)

RiskMinimisationWorkforceCapacityandCompetence

24

PreparingforGenomicMedicine:NationalAuditandDevelopmentofaBestPracticeApproach(2009)

RiskMinimisationPathologyRequestingandReporting–RequesterandConsumerFocus

25

HighResolutionScanningMicroscopyforQualityAssuranceandEducationalApplications(2009)


26

Policies,ProceduresandGuidelinesforPoint-of-CareTesting(2011)


2 Establishment RiskMinimisation


185

7 ofaMolecularGeneticsQualityAssuranceProgram(Current)

28

MAWSON–AnOnlineRepositoryofGeneticDatatoAidReportingofMedicalGeneticTests(Current)


A Summary Report for the Australian Department of Health and

Ageing Medical Benefits Division



Table of Contents


186

Executive Summary ................................................................................................................................General Findings from the Integrated Analysis ................................................................................................Consistent Themes Identified from the Integrated Analysis ................................................................................................Conclusion ................................................................................................................................................................

Abbreviations ................................................................................................................................

Introduction................................................................................................................................Background ................................................................................................................................................................Terms of Reference ................................................................................................................................................................Structure of the Document ................................................................................................................................

Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................

Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................

Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................

eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved


187

Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................

Pathology Requesting and Reporting – Requester and Consumer Focus ................................................................................................................................Guidelines for Patient/Consumer Access to Pathology Test Reports (2001) ................................................................AUSLAB Retest Interval Trial Project (2003) ................................................................................................AUSLAB Retest Interval Project (2004)................................................................................................................................Home Monitoring of Warfarin Therapy in Children using the Coaguchek

TM Point of Care INR

Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................

Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................

Consumer Focus and Information Strategies ................................................................Quality Use of Pathology Consumer Consultation Project (2010) ................................................................Benefits and Risks of Pathology Testing (Current) ................................................................................................Lab Tests Online

AU Stage 1 (Current) ................................................................................................................................

Access Initiatives – Raising Awareness ................................................................Optimising Health Benefits for Aboriginal People who take Warfarin (2009) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) (Current) ................................................................Quality Assurance for Aboriginal Medical Services (QAAMS) Quality Assurance Program (Current) ................................

Communication Strategy and Stakeholder Engagement ................................Report from the National Workshop on Safety and Quality in Pathology (2007) ................................................................The Second National Workshop on Safety and Quality in Pathology (2008) ................................................................Best Practice in Pathology Requesting and Reporting Workshop (2009) ................................................................Pathology Workforce Workshop (2011) ................................................................................................................................

Appendix A – Report Summaries Relevant to Different Themes ................................


188

Executive Summary TheQualityUseofPathologyProgram(QUPP)isawell-establishedprogramhavingbeenestablishedin1999.Itsgoalisthecontinualimprovementinhealthandeconomicoutcomesfromtheuseofpathologyinhealthcarethroughthepursuitofbetterpracticeamongstrequesters/referrersandprovidersofpathologyservices,andthroughknowledgeableandengagedconsumers.ItismanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheAustralianGovernmentDepartmentofHealthandAgeingcommissionedCognitusPtyLtdtoundertakeananalysisoftheprojects/initiativesfundedundertheQualityUseofPathologyProgram(QUPP).Theobjectivesoftheprojectwere: toconductacomprehensivereviewofQUPPprojects/initiatives,

includingprojectresultsandrecommendations;and toproduceadocumentthatwouldrecordthepastandpresent

investmentandcouldinformthefuturestrategicdirectionoftheprogram.

ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:10. PromotingEvidence-BasedPractice11. RiskMinimisation12. QualityAssuranceandCapacity–NewTechnology13. eHealthCapability14. PathologyRequestingandReporting–RequesterandConsumerFocus15. WorkforceCapacityandCompetence16. ConsumerFocusandInformationStrategies17. AccessInitiatives–RaisingAwareness18. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.


189

Figure 1 – Report numbers by Category [alt=‘Thisfigureisagraphrepresentingthenumberofreportsundereachofthe

ninethemes’]

General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowoninitiativesandprojectsasoutlinedbelow:



and projects


17 9

PromotingEvidence-BasedPractice

16 10

eHealthCapability 12 9QualityAssuranceandCapacity–NewTechnology

8 4


6 10

RiskMinimisation 5 4CommunicationStrategyandStakeholderEngagement

4 4

ConsumerFocusandInformationStrategies

3 4

AccessInitiatives–RaisingAwareness–2outof3

3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


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Table 1: Summary of Follow On Initiatives and Projects [alt=‘Thistableliststheninethemes,thenthenumberofprojectsagainsteach

theme,thenthenumberoffollowoninitiativesandprojects’]

Areasofsignificantandrapidchange,suchaseHealthhavebeensupportedtoenableinvestigationintotheirimpactonthequalityuseofpathologyincludinghealthandeconomicoutcomes.Forexample,twelveprojectsintheareaofeHealthhaveuncoveredsignificantkeyprojectlearningssuchasissueswithsoftwareinstallationandcapacity,andidentifiedstrategiestofacilitatethefutureimplementationofeHealthcapability.TheQUPPinvestmentintoeHealthalsoenabledpathologyreportstointegrateintotheelectronicagebysupportingprojectstodevelopsoftwaresystemstoautomaticallyextractinformationfromnarrativepathologyreports,andtostandardisepathologyterminologyunitstofacilitatetheiruseinelectronicreporting.Projectstoinvestigateworkforceissuesinthepathologysectorwerealsofundedbythisprogram.Theseprojectsidentifiedstakeholderconcerns,suchastheageingpathologyworkforceandthelackofastructuredcareerpathforscientists.OfthesixprojectsfundedundertheWorkforceCapacityandCompetencetheme,tenfollowonprojectsandinitiativeshavebeenundertakentofurtherinvestigateandaddressthesekeyissues.TheQUPPalsofacilitatedincreasedengagementwithconsumersthroughworkshopswhichhighlightedissuespredominantlybasedonaneedforimprovedcommunicationandengagement,andtheneedforcomprehensiveinformationstrategiestoaddressconsumerconcerns. FromtheanalysisofQUPPinitiativestodate,therearefewidentifiedareasthatmaybenefitfromsomefurtherconsideration.Theseinclude: eHealthinformationoutliningthebenefits/risksofpathologyresults

beinguploadedontotheNationalElectronicHealthRecordSystemforconsumers.

Standardisedrequestformsandeducationofalllevelsofhealthpractitionersabouttheimportanceofcompletingtheinformationontheseforms.

DevelopmentofcomprehensiveguidelinesforGeneralPractitioners(GPs)regardingevidence-basedpathologyrequesting.

Investigateincludingpatient-specificadviceforGPsonpathologytestresults.

FocusonincreasingGPs’understandingofthepathologytestingprocess.

Consistent Themes Identified from the Analysis Fromtheanalysisthereappearstobethreeconsistentthemesthroughoutallareasofthepathologyspectrum.Theseare:4. Theneedforincreasedinformationresourcesgeneratedbyreliable

sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-collectedsamples.

5. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentof


191

theirmedicaltraining.

6. Producingreliableconsumerinformationaboutpathologytesting,andkeepingconsumersinformedaboutcurrentissues/advanceswithinpathology.

Conclusion TheQUPPhasenabledprojectstoinvestigateandimplementimprovementsinhealthandeconomicoutcomesforthequalityuseofpathology.ThisisevidencedbythehighrateoffollowoninitiativesandprojectsoutlinedinTable1,andbythechangesinpracticethathaveresultedfromthisprogram’ssupport.Forexample,theStructuredPathologyReportingofCancerprojectsdevelopedcancerprotocolsforthestructuredreportingofsixtypesofcancer.Thisprojectmayleadtothepossibledevelopmentofastandardisedreportingformatforallmajorcancersandothermajorcomplexreportingtopics.ThisintegratedanalysisalsohighlightedanumberofkeyprojectlearningsfromthepasttenyearsoftheQualityUseofPathologyProgram.Italsoidentifiedpotentialareasforfutureconsiderationacrossallofthethemeswhicharepresentedintheanalysisofeachtheme.Thisreportstandsasarecordofthevaluableinvestmenttheprogramhasmadetothequalityandcapacityofthepathologysectortodate,andwillformthebasisforreflectionwhenfutureprogramsareinvestigatedand/orsupportedbythisimportantprogram.

Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee


192

NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander

Medical Services QASEC Quality Assurance Scientific and Education Committee QUPC Quality Use of Pathology Committee QUPP Quality Use of Pathology Program WAC Workforce Advisory Committee

Introduction

Background


FundingfortheQUPPhasbeenallocatedbyacombinationofopenfundingroundsandtargetedinitiatives.Theprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedby


193

DoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.

Nationalworkshopshavebeenheldeachyearsince2007withtheaimofbringingpathology,requesterandconsumerstakeholderstogethertodiscusspathologyqualityandsafetyissues,toinformtheQUPPprioritysettingprocessanddebatethewaysinwhichpriorityissuescouldbeaddressed.In2005-2006theQUPPwasreviewedandtheoperationoftheprogramwasrefinedtoaddressstrategicissuesoutlinedinthereviewreport.Sincethereview,projectfundinghasgenerallybeentargetedtothreesub-programswiththefollowingkeyobjectives:4. Quality Consumer Services:Todevelopandimproveconsumer-

focused,accessibleandcoordinatedservicesthatpromoteinformedchoiceandmeetconsumerneeds;


6. Quality Pathology Practice:Tosupportprofessionalpractice

standardsthatmeetconsumerandreferrerneedsandprovideevidence-based,bestpractice,quality-assuredservicesthataresafe,costeffectiveandefficient.


Terms of Reference for the project DoHAcommissionedCognitusPtyLtdtoconductacomprehensiveanalysisoftheQualityUseofPathologyProgramprojectreports.Theprojectobjectiveswere:


toproduceadocumentthatwillformarecordofpastand

presentinvestmentandwillassistindeterminingthefuturestrategicdirectionoftheprogram.


Structure of the Report ThisdocumentisstructuredaccordingtoninethemesbasedontheQUPP’sareasoffocus:

10. PromotingEvidence-BasedPractice11. RiskMinimisation12. QualityAssuranceandCapacity–NewTechnology13. eHealthCapability14. PathologyRequestingandReporting–RequesterandConsumerFocus


194

15. WorkforceCapacityandCompetence16. ConsumerFocusandInformationStrategies17. AccessInitiatives–RaisingAwareness18. CommunicationStrategyandStakeholderEngagement.

Therewere74reportsanalysedforthisintegratedanalysis,witheachreportassignedtooneoftheabovethemes.Eachreportwassetoutinthefollowingtemplate: Description GrantRecipient/s Aimsand/orObjectives Outcomesand/orFindings Recommendation/s KeyProjectLearning/s FollowonInitiativesandProjects AreasforFutureConsideration. Many of the projects listed in this report fall into more than one theme – see Appendix A – Report Summaries Relevant to DifferentThemes.


195






Table of Contents


196


Abbreviations ................................................................................................................................





eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................


197

Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................






AU Stage 1 (Current) ................................................................................................................................





198






199


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


200













201






202



Introduction

Background




203
















204




205

29

PoCTTraining,Certification,SupportandSkillMaintenanceProgram(AustralianPoCTPractitionersNetwork–APPN)(Current)






Table of Contents


206


Abbreviations ................................................................................................................................







207







AU Stage 1 (Current) ................................................................................................................................





208






209


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


210













211






212



Introduction

Background




213
















214




215

30

PathologyInformaticsWorkingParty(2003)


31

DevelopmentofonOn-lineMaintenanceSystemfortheAustralianPathologyRequestandResultCodeSets(2003)


32

PathologyandGeneralPracticeSoftwareIntegrationProject(PaGSIP)(2003)


33

ChainofInformationCustodyforthePathologyRequest-Test-ReportCycleinAustralia(GuidelinesforPathologyRequestersandPathologyProviders)(2004)


34

SupportingHL7forHealthInformaticsStandards(2004)





216



Table of Contents


Abbreviations ................................................................................................................................


Promoting Evidence-Based Practice ................................................................................................Evaluation of the Impact on Pathology Practice of the Manual of Use and Interpretation of Pathology Tests (2001) ................................................................................................................................................................Revision of Manual of Use and Interpretation of Pathology Tests (2004) ................................................................RCPA Manual Transformation Project (2010)................................................................................................An Historical Analysis of Pathology Ordering by General Practitioners between April 1998 and March 2001 from the Bettering the Evaluation and Care of Health (BEACH) Program (2002) ................................Evidence-Practice Gap in GP Pathology Test Ordering: A Comparison of BEACH Pathology Data and Recommended Testing (2009) ................................................................................................................................A Project to Examine the Utilisation of Pathology Tests in the Investigation of Tiredness in General Practice (2002) ................................................................................................................................................................Analysis of Current Practices in Relation to the Teaching of Pathology (Laboratory Medicine) (2003)................................................................................................................................................................Analysis of Current Laboratory Medicine (Pathology) Teaching Practice in Prevocational and General Practitioner Vocational Training (2003) ................................................................................................A Mechanism for the Development, Implementation and Evaluation of Evidence-Based, Best-Practice Clinical Guidelines to Facilitate Quality Use of Pathology Tests (2003) ................................................................Academic Detailing Supporting Better Outcomes from Diagnostic Technologies (2004) ................................Common Sense Pathology (2006) ................................................................................................................................


217

Common Sense Pathology Publication Series (2011)................................................................................................Improved Pathology Reporting, Education and Practice (IPREP) for Colorectal Cancer (2009) ................................Structured Pathology Reporting Standards for Cancer (2009) ................................................................................................Promoting and Expanding Structured Pathology Reporting of Cancer (Stage 2) (Current) ................................Evidence-Based, Best-Practice Prevention of Blood Borne Virus Transmission in Health Care Settings Program (PBBV) (2009) ................................................................................................................................



eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................



Monitor (2003) ................................................................................................................................................................Facilitating Best Practice Pathology Utilisation by the Use of Hand-Held Decision Support Devices (2004)................................................................................................................................................................Improving GP Access to and Use of Retrospective and Current Pathology Data to Increase Detection of Early Diabetes (IGT and IFG) in General Practice (2005) ................................................................Quality Use of Pathology Services Education Program (2006) ................................................................................................Investigation into the Reasons for Incorrect or Incomplete Pathology Request Forms (2008) ................................Enhancing the Quality Use of Pathology for GP Registrars and International Medical Graduates – Assessing the Need (2009) ................................................................................................................................Effect of a Structured Microbiology Laboratory Report on Antimicrobial Prescribing for Asymptomatic Bacteriuria in Elderly Females (2010) ................................................................................................Identifying how Electronic Decision Support (EDS) in Computerised Pathology Order Entry Systems can Improve Pathology Practice, Rational Ordering and Patient Outcomes (2010) ................................The Impact of the Implementation of Electronic Ordering of Pathology Requesting and the Quality and Effectiveness of Hospital Pathology Services – Building a Robust Evidence Base and Benefits Framework for Successful e-Health Diffusions (Current) ................................................................................................Computer Assisted Patient Simulations for Education in the Rational Use of Investigations – Final Report for Phase 1 (iNvestigate Project) (2010) ................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations – Final


218

Report for Phase 2 (2011) ................................................................................................................................iNvestigate: Online Patient Simulations for Education in the Rational Use of Investigations (Current) ................................................................................................................................................................Encouraging Quality Pathology Ordering in Australia’s Public Hospitals (2011) ................................................................Effective Communication of Pathology Results in Requesting Practitioners and Consumers (Current) ................................................................................................................................................................



AU Stage 1 (Current) ................................................................................................................................





includingprojectresultsandrecommendations;and


219

toproduceadocumentthatwouldrecordthepastandpresentinvestmentandcouldinformthefuturestrategicdirectionoftheprogram.



ninethemes’]

General Findings from the Analysis TheQUPPhascontributedtotheexpansionoftheknowledgebaseofpathologypracticeandtothequalityuseofpathologyservicesinAustralia.Therewereanumberofprojectrecommendationsthatwerestrategicallyfollowedupinsubsequentprojects.Forexample,TheAustralianPathologyWorkforceCrisisreportresultedinfiveotherinitiativesandprojects.Inabroadersense,allofthethemesledtoahighrateoffollowon



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


220

initiativesandprojectsasoutlinedbelow:



and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2






221











222

Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander


Introduction

Background

TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding


223

(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.









224










225

35

AStudyoftheImpactoftheUseofGeneralPracticeComputerSystemsontheOrderingofPathology(2004)





226



Table of Contents


Abbreviations ................................................................................................................................



Risk Minimisation ................................................................................................................................RCPA – Quality Assurance Programs Key Indicator Project (2004) ................................................................


227

Pilot Laboratory Assessment and Peer Review Mechanism for Pathology Key Performance Indicators (2007) ................................................................................................................................................................Performance Monitoring of External Quality Assurance (Current)................................................................NATA File Audit – Risk Analysis of Assessment Non Conformances Identified in Pathology Laboratory Assessment Accreditation (Current) ................................................................................................Key Incident Monitoring & Management Systems (Current) ................................................................................................






Workforce Capacity and Competence ................................................................PathWay (2005) ................................................................................................................................................................


228

The Australian Pathology Workforce Crisis (2008) ................................................................................................Review of Pathology Specialist Development Pathways (2010) ................................................................Impact of Workload of Anatomical Pathologists on Quality and Safety (2011) ................................................................Survey of the Pathology Workforce (2011) ................................................................................................................................Career Structures and Pathways for the Scientific Workforce in Medical Pathology Laboratories (2011)................................................................................................................................................................


AU Stage 1 (Current) ................................................................................................................................







ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.


229

Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:46. PromotingEvidence-BasedPractice47. RiskMinimisation48. QualityAssuranceandCapacity–NewTechnology49. eHealthCapability50. PathologyRequestingandReporting–RequesterandConsumerFocus51. WorkforceCapacityandCompetence52. ConsumerFocusandInformationStrategies53. AccessInitiatives–RaisingAwareness54. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.


ninethemes’]




and projects

PathologyRequestingandReporting–Requesterand

17 9



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


230

ConsumerFocusPromotingEvidence-BasedPractice

16 10


8 4


6 10


4 4


3 4


3 2








FocusonincreasingGPs’understandingofthepathologytesting


231

process.






Abbreviations AACB Australasian Association of Clinical Biochemists


232

AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander


Introduction

Background

TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtowork


233

withtheAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthandAgeing.












234







235


36

ApplicationofPathologyInformaticstoReportingofCritical/AbnormalResultsforImprovedRequester/ProviderCommunicationandImprovedPatientCare(2004)


37

PadlokOn-linePathologyOrderingSystem(2005)

RiskMinimisation

38

InformationExtractionfromNarrativePathologyReportsonMelanoma(2008)

RiskMinimisation

39

AutomaticCompilationofSynopticReportsfromNarrativePathologyReports(Stage2)(2010Submittedwiththetitle:ThePathologyReporter)


4 Automatic PathologyRequestingandReporting–RequesterandConsumerFocus


236

0 PopulationofSynopticReportsfromNarrativePathologyReports(Stage3)(Current)

41

StandardisationofPathologyTerminologyandUnits(Current)

RiskMinimisation

42

GuidelinesforPatient/ConsumerAccesstoPathologyTestReports(2001)


43

AUSLABRetestIntervalTrialProject(2003) Integrated Analysis of Quality Use of

Pathology Program (QUPP) Final Reports





237


Table of Contents


Abbreviations ................................................................................................................................




Quality Assurance and Capacity – New Technology ................................................................Virtual Microscope (2005)................................................................................................................................High Resolution Scanning Microscopy for Quality Assurance and Educational Applications (2009) ................................Development of a Quality Assurance Module for Human Papilloma Virus Testing (2008) ................................Preparing for Genomic Medicine: National Audit and Development of a Best Practice Approach (2009)................................................................................................................................................................Policies, Procedures and Guidelines for Point-of-Care Testing (2011) ................................................................PoCT Training, Certification, Support and Skill Maintenance Program (Australian PoCT Practitioners Network – APPN) (Current) ................................................................................................................................


238

Establishment of a Molecular Genetics Quality Assurance Program (Current) ................................................................MAWSON – An Online Repository of Genetic Data to Aid Reporting of Medical Genetic Tests (Current) ................................................................................................................................................................







AU Stage 1 (Current) ................................................................................................................................



239






ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:55. PromotingEvidence-BasedPractice56. RiskMinimisation57. QualityAssuranceandCapacity–NewTechnology58. eHealthCapability59. PathologyRequestingandReporting–RequesterandConsumerFocus60. WorkforceCapacityandCompetence61. ConsumerFocusandInformationStrategies62. AccessInitiatives–RaisingAwareness63. CommunicationStrategyandStakeholderEngagement.


240

The number of reports within each theme is presented in Figure 1.


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


241


3 4


3 2










sourcesaboutpathologytestingforGeneralPractitioners(GPs)thatareshort,conciseandeasilyaccessed.ThisinformationshouldalsoincludeproceduresforGPswhencollectingpathologyspecimensfromtheirpatients,andforGPstogivetotheirpatientsforpatient-


242

collectedsamples.20. Educatingmedicalstudentsduringtheirtrainingandpost-graduate

yearsaboutpathologywasconsistentlyviewedasalongtermstrategytoimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentoftheirmedicaltraining.



Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission


243

HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander


Introduction

Background

TheQualityUseofPathologyProgram(QUPP)wasestablishedin1999undertheauspiceofthe2ndpathologyMemorandumofUnderstanding(MoU)withpathologystakeholders,andwithupto$2millionnotionallyallocatedperyearforthefundingofprojectsandotherinitiativesrelatingtoimprovementsinthequalityofpathologyservices.TheprogramhasbeenmanagedbytheAustralianGovernmentDepartmentofHealthandAgeing(DoHA)inconjunctionwiththeQualityUseofPathologyCommittee(QUPC).TheQUPCwasoriginallyasub-committeeofthePathologyConsultativeCommittee(PCC)formedtoworkwiththeAustralianGovernmenttomanagepathologyoutlaysundertheMoU.Butmorerecentlyithasbeengivenacontinuedfocuswiththecommencementofthefive-yearPathologyFundingAgreement(PFA)betweentheCommonwealthGovernmentandkeypathologystakeholdersinApril2011.TheQUPCprovidesadvicerelationtostrategicdirectionsandprojectsand/orinitiativesimplementedundertheprogram.Thiscommitteecurrentlycomprisesnomineesfromthepathologyprofession,generalpractice,theRoyalAustralasianCollegeofPhysicians,Doctors-in-Training,theConsumersHealthForumofAustralia,MedicalDeansAustraliaandNewZealandandrepresentativesfromtheDepartmentofHealthand


244

Ageing.















245




246

44

HomeMonitoringofWarfarinTherapyinChildrenusingtheCoaguchekTMPointofCareINRMonitor(2003)







247

Table of Contents


Abbreviations ................................................................................................................................





eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................


248

Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................






AU Stage 1 (Current) ................................................................................................................................





249






250


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


251













252






253



Introduction

Background




254
















255




256

45

AUSLABRetestIntervalProject(2004) Integrated Analysis of Quality Use of

Pathology Program (QUPP) Final Reports





Table of Contents


257


Abbreviations ................................................................................................................................







258







AU Stage 1 (Current) ................................................................................................................................





259






260


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


261













262






263



Introduction

Background




264
















265




266

46

FacilitatingBestPracticePathologyUtilisationbytheUseofHand-HeldDecisionSupportDevices(2004)






Table of Contents


267


Abbreviations ................................................................................................................................







268







AU Stage 1 (Current) ................................................................................................................................





269






270


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


271













272






273



Introduction

Background




274
















275




276

47

ImprovingGPAccesstoandUseofRetrospectiveandCurrentPathologyDatatoIncreaseDetectionofEarlyDiabetes(IGTandIFG)inGeneralPractice(2005)






Table of Contents


277


Abbreviations ................................................................................................................................







278







AU Stage 1 (Current) ................................................................................................................................





279






280


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


281













282






283



Introduction

Background




284
















285




286

48

QualityUseofPathologyServicesEducationProgram(2006)






Table of Contents


287


Abbreviations ................................................................................................................................







288







AU Stage 1 (Current) ................................................................................................................................





289




ThisanalysisincludesasummaryoftheQUPPprojects/initiativesoverthepasttenyearsandalsoprovidesananalysisofwhethereachoftheprojects/initiativesachievedtheiraimsandobjectivesandwhethertherewereanykeyprojectlearnings.Therewere74projectreportsanalysed,whichwerefurtherdividedintothefollowingninethemesthatwerebasedonQUPPareasoffocus:100. PromotingEvidence-BasedPractice101. RiskMinimisation102. QualityAssuranceandCapacity–NewTechnology103. eHealthCapability104. PathologyRequestingandReporting–RequesterandConsumer

Focus105. WorkforceCapacityandCompetence106. ConsumerFocusandInformationStrategies107. AccessInitiatives–RaisingAwareness108. CommunicationStrategyandStakeholderEngagement.The number of reports within each theme is presented in Figure 1.


290


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


291













292






293



Introduction

Background




294














100. PromotingEvidence-BasedPractice101. RiskMinimisation102. QualityAssuranceandCapacity–NewTechnology103. eHealthCapability104. PathologyRequestingandReporting–RequesterandConsumer


295

Focus105. WorkforceCapacityandCompetence106. ConsumerFocusandInformationStrategies107. AccessInitiatives–RaisingAwareness108. CommunicationStrategyandStakeholderEngagement.



296

49

InvestigationintotheReasonsforIncorrectorIncompletePathologyRequestForms(2008)

RiskMinimisation

50

EnhancingtheQualityUseofPathologyforGPRegistrarsandInternationalMedicalGraduates–AssessingtheNeed(2009)






297


Table of Contents


Abbreviations ................................................................................................................................





eHealth Capability ................................................................................................................................Pathology Informatics Working Party (2003) ................................................................................................Development of on On-line Maintenance System for the Australian Pathology Request and Result


298

Code Sets (2003) ................................................................................................................................................................Pathology and General Practice Software Integration Project (PaGSIP) (2003) ................................................................Chain of Information Custody for the Pathology Request-Test-Report Cycle in Australia (Guidelines for Pathology Requesters and Pathology Providers) (2004)................................................................................................Supporting HL7 for Health Informatics Standards (2004)................................................................................................A Study of the Impact of the Use of General Practice Computer Systems on the Ordering of Pathology (2004) ................................................................................................................................................................Application of Pathology Informatics to Reporting of Critical/Abnormal Results for Improved Requester/Provider Communication and Improved Patient Care (2004) ................................................................Padlok On-line Pathology Ordering System (2005) ................................................................................................Information Extraction from Narrative Pathology Reports on Melanoma (2008) ................................................................Automatic Compilation of Synoptic Reports from Narrative Pathology Reports (Stage 2) (2010 Submitted with the title: The Pathology Reporter) ................................................................................................Automatic Population of Synoptic Reports from Narrative Pathology Reports (Stage 3) (Current) ................................Standardisation of Pathology Terminology and Units (Current) ................................................................






AU Stage 1 (Current) ................................................................................................................................




299








300


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


301


3 2











38. Educatingmedicalstudentsduringtheirtrainingandpost-graduateyearsaboutpathologywasconsistentlyviewedasalongtermstrategy


302

toimprovepathologyknowledgeandpractice.Thisincludedrotatingmedicalstudentsthroughpathologylaboratoriesasacomponentoftheirmedicaltraining.



Abbreviations AACB Australasian Association of Clinical Biochemists AAPP Australian Association of Pathology Practices AIHW Australian Institute of Health and Welfare APPN Australian Point of Care Practitioners Network ACRRM Australian College of Rural and Remote Medicine AMA Australian Medical Association BEACH Bettering the Evaluation and Care of Health CHF Consumers Health Forum of Australia DATIS Drug and Therapeutics Information Service DoHA Australian Government Department of Health and Ageing GP General Practitioner HGSA Human Genetics Society of Australasia HIC Health Insurance Commission HISA Health Informatics Society of Australia KPI Key Performance Indicators LTO Lab Tests Online


303

MBS Medicare Benefits Schedule MTAAC Medical Testing Accreditation Advisory Committee NATA National Association of Testing Authorities NeHTA National E-Health Transition Authority NCOPP National Coalition of Public Pathology NHMRC National Health and Medical Research Council NPAAC National Pathology Accreditation Advisory Council NPS National Prescribing Service PAC Pathology Associations Council PFA Pathology Funding Agreement PoCT Point of Care Testing QHPSS Queensland Health Pathology & Scientific Services RACGP Royal Australian College of General Practitioners RACP Royal Australasian College of Physicians RACS Royal Australian College of Surgeons RCNA Royal College of Nursing Australia RCPA Royal College of Pathologists of Australasia RCPA QAP RCPA Quality Assurance Programs Pty Ltd QAAMS Quality Assurance for Aboriginal and Torres Strait Islander


Introduction

Background


FundingfortheQUPPhasbeenallocatedbyacombinationofopenfunding


304

roundsandtargetedinitiatives.TheprogramhasoperatedunderoverarchingprinciplessupportedbyguidingassumptionsdevelopedbyDoHAandtheQUPCinconsultationwiththebroaderpathologystakeholdersector.













109. PromotingEvidence-BasedPractice110. RiskMinimisation111. QualityAssuranceandCapacity–NewTechnology


305

112. eHealthCapability113. PathologyRequestingandReporting–RequesterandConsumer




306

51

EffectofaStructuredMicrobiologyLaboratoryReportonAntimicrobialPrescribingforAsymptomaticBacteriuriainElderlyFemales(2010)






Table of Contents


307


Abbreviations ................................................................................................................................







308







AU Stage 1 (Current) ................................................................................................................................





309







310


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


311













312






313



Introduction

Background




314
















315




316

52

IdentifyinghowElectronicDecisionSupport(EDS)inComputerisedPathologyOrderEntrySystemscanImprovePathologyPractice,RationalOrderingandPatientOutcomes(2010)

QualityAssuranceandCapacity–NewTechnology







317

Table of Contents


Abbreviations ................................................................................................................................







318







AU Stage 1 (Current) ................................................................................................................................





319







320


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


321













322






323



Introduction

Background




324
















325




326

53

ComputerAssistedPatientSimulationsforEducationintheRationalUseofInvestigations–FinalReportforPhase1(iNvestigateProject)(2010)

QualityAssuranceandCapacity–NewTechnology







327

Table of Contents


Abbreviations ................................................................................................................................







328







AU Stage 1 (Current) ................................................................................................................................





329







330


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


331













332






333



Introduction

Background




334
















335




336

54

iNvestigate:OnlinePatientSimulationsforEducationintheRationalUseofInvestigations–FinalReportforPhase2(2011)






Table of Contents


337


Abbreviations ................................................................................................................................







338







AU Stage 1 (Current) ................................................................................................................................





339







340


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


341













342






343



Introduction

Background




344
















345




346

55

EncouragingQualityPathologyOrderinginAustralia’sPublicHospitals(2011)






Table of Contents


347


Abbreviations ................................................................................................................................







348







AU Stage 1 (Current) ................................................................................................................................





349







350


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


351













352






353



Introduction

Background




354
















355




356


56

EffectiveCommunicationofPathologyResultsinRequestingPractitionersandConsumers(Current)







357

Table of Contents


Abbreviations ................................................................................................................................







358







AU Stage 1 (Current) ................................................................................................................................





359







360


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


361













362






363



Introduction

Background




364
















365




366

57

iNvestigate:OnlinePatientSimulationsforEducationintheRationalUseofInvestigations(Current)






Table of Contents


367


Abbreviations ................................................................................................................................







368







AU Stage 1 (Current) ................................................................................................................................





369







370


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


371













372






373



Introduction

Background




374
















375




376

58

TheImpactoftheImplementationofElectronicOrderingofPathologyRequestingandtheQualityandEffectivenessofHospitalPathologyServices–BuildingaRobustEvidenceBaseandBenefitsFrameworkforSuccessfule-HealthDiffusions(Current)






Table of Contents


377


Abbreviations ................................................................................................................................







378







AU Stage 1 (Current) ................................................................................................................................





379







380


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


381













382






383



Introduction

Background




384
















385




386

eHealthCapability

59

PathWay(2005)







387

Table of Contents


Abbreviations ................................................................................................................................







388







AU Stage 1 (Current) ................................................................................................................................





389







390


ninethemes’]




and projects


17 9


16 10


8 4


6 10


4 4


3 4


3 2



eHealth Capability



Risk Minimisation




0 2 4 6 8 10


391













392






393



Introduction

Background




394
















395




396

CommunicationStrategyandStakeholderEngagement

60

TheAustralianPathologyWorkforceCrisis(2008)


61

ReviewofPathologySpecialistDevelopmentPathways(2010)


62

ImpactofWorkloadofAnatomicalPathologistsonQualityandSafety(2011)

RiskMinimisation

63

SurveyofthePathologyWorkforce(2011)


64

CareerStructuresandPathwaysfortheScientificWorkforceinMedicalPathologyLaboratories(2011)


65

QualityUseofPathologyConsumerConsultationProject(2010)


66

BenefitsandRisksofPathologyTesting(Current)


67

LabTestsOnlineAUStage1(Current)


68

OptimisingHealthBenefitsforAboriginalPeoplewhotakeWarfarin(2009)


69

QualityAssuranceforAboriginalMedical



397

Services(QAAMS)(Current)

70

QualityAssuranceforAboriginalMedicalServices(QAAMS)QualityAssuranceProgram(Current)


71

ReportfromtheNationalWorkshoponSafetyandQualityinPathology(2007)


72

TheSecondNationalWorkshoponSafetyandQualityinPathology(2008)


73

BestPracticeinPathologyRequestingandReportingWorkshop(2009)


74

PathologyWorkforceWorkshop(2011)

WorkforceCapacityandCompetenceConsumerFocusandInformationStrategies

Documents

Integrated Analysis of Quality Use of Pathology Program ... · Integrated Analysis of QUPP Final Reports – 22 June 2012 – v0.3 3 Executive Summary The Quality Use of Pathology