Where are we?
How is Medicine different from days
of Charles Dickens?
Patient’s have a complaint or illness
1. Ring up their GP
Might queue up to be seen
Doctor gathers the information
2. Information is entered into a
computer
Doctor determines a diagnosis or
approach
The doctor prescribes treatment
Medicine Today
Patient has a complaint or illness
Ring up their GP
Wait in Queue
Doctor gathers information and
puts it in computer
Patient enters information into the computer
Doctor reviews and interview
Doctor determines a diagnosis or approach
Doctor communicates with patient
The doctor prescribes treatment
Advantages Disadvantages
Phone systems?
Sarah Bruml’s Office
ACTUAL MEASUREMENTS
Time
Activity
# Pats
Time per
pat
Opportunity
8:30-9:55
Phone Triage
5-15
7 pats/80
mins = 10
min/pat
3 min/pat =10 pats/30
mins = 50% savings
9:55-1PM
Surgery
10
10 pts/180
mins = 18
min/pt
3 min/pat=10 pats/30
mins = 17% savings
Time During Day
Phone
Phone
90 minutes saved in an !!8 hour day (plus lunch)!
Link to Nursing
Link to Nurse by self
National Health Service Call ReportCall1d: 166697Patient Name: ADRIAN
Davies
Call Priority,HP01225810300, 16106/19593Call Reason: COUGH
TypeDescription
Date
TimePMHARTHRITIS14/12/200100:03 MEDICATIONDISTALGESIC14/12/200
100:03ALLERGYFISH14/12/200 100:03
User: Thomas, Sarah DatelTime: 13/12/2001 23:59 caller rang back breathing worse - reprioritised to a 3.
User: Phillips-winter, Beverley DatelTime: 13/12/2001 23:22
Had a cold earlier in the week. Breathing very heavy Burning feeling in
chest and when bad has pain in left shoulder. Family history of heart
disease but doesn’t think this is what he has. Is a heavy smoker. Taking
Wilkinson Bronchial Balsam which eased his breathing over the time on
the
Title: Cough User: Wilkes, Ann Date
Time: 14/12/2001 00:07 Cough Has the individual developed significant
breathing difficulty with high pitched or crowing sound when breathing
out?-NO Notes:COUGH AND COLD FOR A WEEK
Call Handler Okay. Right and how can we help you today?
Caller Right un well had a cold a little while ago ... well probably sort
of got rid of it um what's today... Thursday... so I probably got rid of it
Wednesday... sorry Monday or Tuesday
Call Handler Uh huh
Caller Um I've got to admit I'm a smoker but since I've had the cold
I've had this horrible burning feeling in my chest
Call Handler Uh huh
Caller Going down my windpipe and when it's really bad a chronic
pain in my left shoulder
Call HandlerRight
Caller Um, it feels as though my chest is becoming restricted and
everything else. I think I've got some form of bronchial infection
Call HandlerRight yes you are struggling to breathe at the moment
aren't you?
Caller
Call Handler Yes right
Caller Yes um which has certainly cut down my smoking which is a good
thing
Call Handler Uh huh
CallerBut it is getting to the point now where it is really getting sore and it
doesn't appear to be getting better
Call Handler Right
Caller And if I take the bronchial medicine... uh cough medicine that we
bought it just only gives about 2 minutes relief
Call Handler Right okay. So have you actually consulted your doctor at all?
CallerNot yet, it's just got very bad today
Call Handler It has
CallerYes
Call Handler Okay right. So I'm sorry .. you've got a burning feeling in your
chest and when it gets really bad you said it hurts in your shoulder?
Caller Yes. It feels as though um you know when you get a really bad chesty
cough you get that burning sensation in the windpipe
Call Handler
Right
CallerI've got that sort of feeling and I've got... when it gets
really bad like it isat the moment I get a pain in my left
shoulder
Call Handler Okay
Caller Un I don't think it's my heart cos we have... I have got a
family history of heart disease but I don't think it's that
because normally that's pins and needles in the left arm and
I've been warned on everything to lookout for so I mean its
just some form of infection but I just can't seem to knock it
away
Call Handler Okay. Right so and this has all been brought on
by the cold that you had earlier?
Caller I believe so yes
Call Handler Right. Okay, can I take your GP's details please?
Caller Yes. If I could... it's eased off completed now, I took
some medicine um sort of 10 minutes ago
Call Handler Yes
Caller I get about 2 minutes instant relief and then it really sort
of cripples me for a little while and then it starts easing off
and then it will ease off for a while and then I ... I'm doubled
up again you know sort of in absolute agony finding it difficult
to breathe again
Call Handler Right okay
Caller Um which makes me think it is something to do with
you know I .. is.. something to do with the thing because if it
was.. like I was a bit worried the first time it happened and felt
ooh hang on this could be my first heart attack coming up
here
Call Handler Uh huh
CallerUrn but I took some of this bronchial cough medicine
stuff and that cleared it away
Call Handler Right do you know what the actual name is of it?
Caller Yes ... I'll just get it
Call Handler Thank you
Caller Yes it's urn I must admit it was a bit frightening .... They
must like him
Call Handler Yes
Caller Well believe it or not its Wilkinson's you know the Wilco
brand
Call Handler Oh yes
Caller Yes mentholated bronchial balsam for the relief of ... for
the symptomatic relief of sore throats, coughs, colds and
catarrh. It's going down my neck as if it's going out of fashion at
the moment
Call Handler Right
Caller And obviously that ain't going do me any good either
Call Handler Right
CallerI don't normally like bothering the doctor but
Call Handler No
Caller You know... this has got so bad probably since 3 o'clock
this afternoon
Call Handler Right
Caller It's really started playing up
Call Handler Yes okay. Right that's no problem. If you hadn't
actually called us today what would you have done? Would you
have called your GP or?
Caller Um I would've probably suffered it to be honest
Call Handler Oh goodness, rightokay
Caller Laughing
Call Handler Oh dear okay, that's fine. What I shall do is actually
ask one of the nurses to call you back then if that's alright?
Output
Downside of having people
between doctor and patient
• Link to patient
Questionnaires
General
• Mayo Clinic-PPI 13 page form 216
questions, 25 spaces
• ACOG on line 90 questions
• How many are enough?
Domestic Violence
• J of Family Practice
using the
WAST(Woman abuse
Screening Tool)
• 8 questions
• UCC requirement. It
should be done on all
women
• 8% pick up rate
• Other things
Review of AFP in just one year
•
•
•
•
44 questionnaires (2 an issue)
4-37 questions
CAGE-alcoholism
Check list to Assessment areas for Maintaining
Healthy Geriatric Patients
• Depression scales
• Smoking Scales
• Lead
Using the questionnaires leads to
better outcomes than normal
patient interviewing!
Patients
Dr. Patrick Cadigan, a cardiologist and spokesman for Britain's Royal
College of Physicians, described Internet-based medicine as "secondbest," and said it was particularly difficult to make a diagnosis without
seeing a patient in person. "To lose personal contact with your
patients means you lose clues about what may be wrong with them,"
he said.
Cadigan worried some patients may not understand the difficulties of
being treated online.
A machine can come between
me and my patient!
• All of this is
true
• It need not
happen
He said some people might need some more inperson prodding, as opposed to the standard
questionnaires employed by most websites, to
correctly answer questions about other health
conditions or medical treatment they were
already on.
•
"If you don't get a thorough medical history from the
patient, you could prescribe something that might have
adverse effects," he said. "I am concerned these
websites could be steering patients to treatments for a
financial incentive rather than for their own good."
Dr. Lori Heim, president of the American Academy
of Family Physicians, said examining pictures to
make some diagnoses may be OK, but warned
of potential problems such as doctors missing
symptoms elsewhere on the body the patient
hasn't photographed.
She said if patients had multiple symptoms or a condition
that naturally required a physical exam, like listening to
the heart, lungs or conducting joint exams, seeing a
doctor virtually wouldn't work. She said doctors should
be particularly careful about prescribing drugs like Viagra
and worried about the web sites becoming prescription
mills.
US talking about UK
Bershow believes e-visits can help primary care physicians
practice more efficiently. “They did a study in England
which demonstrated that a provider could complete an evisit in three minutes, so if you were really working
efficiently, you could do 20 e-visits per hour, which
obviously you cannot do in the clinical setting,” he says.
“Plus there’s no office overhead in terms of table paper,
gowns, tongue blades, etc.” Bershow adds that e-visits
can cut down on some unnecessary tests such as in the
case of a patient who has a history of yeast infections
and describes classic symptoms in the electronic inquiry.
• Procrastination
A winter storm was coming and
the wood supply was not
adequate
and you have a dull saw
The Problem of Delay and
Denial
They had to stop what they
were doing!