Issue 31 / 17 August 2015

IS sending a time-sensitive letter about a patient by ordinary post an archaic means of transmission in 2015?
 
The recent findings of an inquest by the South Australian Deputy State Coroner Anthony Schapel into the death of Marjorie Irene Aston suggest that the answer is “yes”.
 
Mrs Aston, aged 86 years, had consulted a cardiologist just before Christmas, a month before she died. He recommended she begin warfarin therapy of 5 mg once daily for her atrial fibrillation, replacing the aspirin she had been taking for the condition.
 
The cardiologist (in the patient’s presence) dictated a letter to her GP about her starting warfarin therapy and advised of the need to test and adjust the dose in the usual way.
 
The letter needed to be typed and posted through a hospital mail system. The delivery process was known by the cardiologist to take some time, up to 10–14 days.
 
The coroner noted: “The letter would neither be faxed nor emailed to its intended recipient; such modern means of transmission not being routine in his practice.”
 
Because of the intervening Christmas period, the letter did not reach the GP until some 3 weeks later — 4 days after the patient had died of a right subdural haematoma, contributed to by excessive warfarin anticoagulation.
 
The GP had visited Mrs Aston at her home before her death when he discovered she was taking warfarin. He advised her to stop taking the drug on that visit.
 
The coroner outlined a series of factors that contributed to her death including failure of the patient to follow the specialist’s instructions to contact her GP and failure to have the GP copied to receive pathology test results that the specialist had ordered.
 
It was noted that the specialist had repeatedly insisted that it was common practice for a specialist to communicate with a GP as he had in Mrs Aston’s case — by sending a letter by ordinary post and providing oral advice to the patient.
 
However, the coroner made it clear he was unhappy with the cardiologist’s administrative practice, describing it as an archaic means of transmission, fraught with imprecision and bound to fail in due course. He went so far as to say: “I would have grave difficulty in describing it as a professional clinical practice”.
 
The coroner also noted that the GP’s practice and the hospital where the specialist was based were separated only by a car park.
 
Mr Schapel recommended that in circumstances where a specialist initiates warfarin therapy but does not intend to manage that therapy, the specialist should immediately advise the patient’s GP by the most efficient method of communication available.
 
It was also recommended that the practice of specialists prescribing warfarin in the first instance in the expectation that a GP would then manage the therapy be revised, saying consideration should be given to whether the GP, on the advice of the specialist, should both initiate and manage the patient’s warfarin therapy.
 
He also advised that specialists should not place undue reliance on the patient advising the GP that warfarin therapy had been initiated by the specialist.
 
Mr Schapel said that “the practice of communicating with general practitioners by way of ordinary post should be curtailed and be replaced by a means of communication that would include email and/or facsimile transmission … it may be necessary in some cases for the specialist to communicate with the general practitioner by phone …”.
 
The RACGP Standards for general practices (4th edition) says that a practice needs sufficient telephone and electronic equipment to support reliable and efficient communications.
 
Perhaps specialists should follow the same advice on standards and ensure they have the quickest and most efficient means to communicate with GPs.
 
 
Mr Bill Madden is the National Practice Group Leader, Medical Law, with Slater and Gordon.
 

Poll

Is it acceptable for doctor-to-doctor communication about patients to occur only by regular mail?
  • No – no longer acceptable (50%, 67 Votes)
  • Yes – but only non-urgent reports (43%, 58 Votes)
  • Yes (7%, 9 Votes)

Total Voters: 134

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13 thoughts on “Bill Madden: Archaic communication

  1. Oliver Frank says:

    GPs, most of whose practices are heavily if not fully computerised, do not want anybody sending letters by post, fax or standard email.  They want to communicate in both directions using messaging systems such as Argus that conform to the national Secure Messge Delvery Standard.   End of story.

  2. Oseka Onuma says:

    The facts of the case suggest that the letter was administered through a hospital mailing system and not the cardiologists’ private practice. No public hospital in SA that I am aware of employs a secure Email messaging system or faxes letters to GPs routinely. Many doctors have complained that the current system does introduce significant delays in communications with GPs but these complaints appear to have fallen on deaf ears. In fact, the anticipated, very expensive data recording system bought by SA Health cannot be said to be working in any practicable sense. Perhaps the Deputy State Coroner should have directed his criticism towards SA Health?

  3. David Love says:

    I have seen that delay in my own processing of correspondance. However, Australia post usually delivers letters with in a day or 2. As such a 10 to 14 day delay will usually mean a delay of processing the letters with the doctors office, ie dictation, typing , proof reading etc. Add a weekend into the mix and that sort of delay is not uncommon.

    As such the physical delivery of letters is not the problem but the intraoffice processing.

     

  4. Peter Gochee says:

    As a specialist in the public system, delay of transcription of letters is common.  Whenever I make critical recommendations such as this, I call the GP with the patient present during their visit.  I discuss the plan with the GP and get an appointment for follow-up before the patient leaves.  Appropriate lab request forms are also given. As short summary is entered in the chart as to who I spoke to and what the plan was.  Again – this is with the patient and family (if present) in the room.

    Does this take time?  Yes.  I do it, though, to prevent outcomes like the one in this article.  GPs are often thankful of being involved and I have yet to have a GP upset that I phoned them.  It also lets GPs know that I am available at anytime, too, if they have any particular concerns.  

  5. Stan Stevens says:

    All very well for the non medically trained coroner to make a judgement to affect clinical practice (in this case and others) with the benefit of hindsight and significant time (days or weeks to make and publish a decision).

    Decisions based on one adverse outcome (and an emotional component, often driven by a grieving relative) are often contrary to well considered diagnostic or procedural pathways with little consideration to the cost-benefit component, or to the vagaries of the public- private systems.

    The comment about the geographical location of the doctor’s separate practices is inflammatory and should be applied to the courts themselves, and to all arms of Government, they could just take a stroll next door to pass on their various pontifications!

  6. Ulf Steinvorth says:

    I think the Specialist should be applauded for having personally communicated with the GP in the first place, even though insufficiently on this occasion. Not something we can take for granted with hospitals being as busy as they are and ‘outside’ communication being seemingly the lowest priority usually delegated to the lowest ranking medical staff available and sometimes left for days after discharge.

    Where I work the ED discharge letters are mostly only given to the patients, never faxed or sent to the surgery, not even if referred. If the patient hasn’t been told or decided that s/he doesn’t need urgent follow up there is hardly any way for us to find out as we do not know what’s going on, sometimes of course with disastrous effects.

  7. Richard Emmett says:

    Am I missing something here? Regular mail as the sole form of communication requesting warfarin monitoring after initiation of therapy would have been unacceptable even before the advent of email or facsimile. I was an intern in 1989 and would not have contemplated it back then. I had an embarrassing backlog of discharge summaries but anything time-sensitive meant a phonecall to the GP. Especially just before Christmas! The coroner’s lack of medical training is irrelevant if he/she is well advised, and, arguably, correct. Written hardcopy is still used, and is appropriate in many circumstances – it is, by definition, not “archaic”. But perhaps the initial anticoagulation monitoring could have been undertaken by the clinic, in the absence of direct communicaton with the GP? Is this not the author’s (and indeed the coroner’s) point? It’s not really all that complicated.

  8. Richard Emmett says:

    Anodyne – I would suggest that it is precisely the role of “the non medically trained coroner to make a judgement to affect clinical practice…..based on one adverse outcome”. That’s what coroners do, they use hindsight to make recommendations after a single tragic event. The “pontifications” are not always relevant or practicable but, equally, sometimes they are.

    The “well considered diagnostic or procedural pathway”, in this case, was the choice of communication (Phone call? Letter? Email? Fax?). The “cost-benefit component” is hopefully obvious (cost: the time to make appropriate contact, benefit: the possibility that death may have been avoided in this instance). The “vagaries of the public- private systems” might have been overcome by a simple, brief phonecall.

    The “comment about the geographical location of the doctor’s separate practices” is not inflammatory; it is ironic and emphasises the whole point of the article.

  9. Joe Kosterich says:

    Interesting how corespondance from lawyers and coroners are always via “snail mail”. Just saying!  Whilst I agree that we need to be using 21st century communication the hypocrisy and pontificating of coroners and lawyers is breathtaking.

  10. taylorr@amamember says:

    It was 7 years ago, but a year before I retired from full time private specialist practice I contacted some 30 GP practices in Melbourne’s outer eastern suburbs who referred to me about my sending them my letters by email from my Best Practice software. One practice said “Yes”, one said “Yes but we are not set up for it yet” and the 14 others who replied at all advised they were not set up to receive correspondence by email. 

    And that was all from GPs who could get subsidies to set up, unlike specialists who had to fund it themselves.

  11. Sue Ieraci says:

    Snail mail certainly can’t be relied upon for communication of critical issues – but it;s not correct to assume that this was the problem in this case. How appropriate was it to start Warfarin therapy on an 86 yr old without discussing this with her GP FIRST? The few days without warfarin over Chistmans, in an old lady who was likely in chronic AF, presented a much lower risk than starting a potentially risky anticoagulant at a time of year when monitoring would be difficult. By all means discuss communication technology, but the example used represents poor clinical judgement, in my view. 

  12. Richard Emmett says:

    No, Dr Joe, it would only be hypocritical and breathtaking if urgent information were conveyed by regular mail. Coroners have the “luxury “of taking their time to consider evidence and come up with recommendations. That’s their job – why would you want them to rush (within reason) and miss something important? Warfarin monitoring is more acute, which is the whole point of the article. It’s not about laywer-bashing and it’s not about “21st century” versus “archaic”, it’s about using the appropriate tool for the job. In the military and aviation worlds, closed-loop communication requires a direct approach for critical information sharing. If you want to know that someone has received your urgent message, don’t use mail, email or fax, just pick up the phone. It worked in 1989 when I was an intern on a landline, and it worked today for me at work as a specialist on my mobile. 

  13. Peter Childstone says:

    Email itself is not necessarily a satisfactory method either, as unless encryption is used (products exist but require both sender and receiver to use) the legal obligations to patient confidentiality cannot be met. Email without encryption is no safer than a postcard in the mail.

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