Australian Safety And Quality Goals For Health Care

Consultation (February 2012) Prepared for Diagnostic Imaging Pathways Steering Committee By Phillip Bairstow, Manager, Diagnostic Imaging Pathways February 2012 Telephone: 08 9224 1398 Email: phillip.bairstow@health.wa.gov.au

 

SUBMISSION FROM:

Diagnostic Pathways Steering Committee Division of Imaging Services Royal Perth Hospital PO Box X2213 GPO Perth, WA, 6847 Telephone: (08) 9224 1398 Email: phillip.bairstow@health.wa.gov.au SUBMISSION RELATES TO:

GOAL 1: Safety of care – that people receive their health care without experiencing harm. GOAL 2: Appropriateness of care – that people receive appropriate, evidence-based care. SUBMISSION PURPOSE:

Propose another priority topic area that should be considered in addressing GOAL 1 and GOAL 2 BRIEF BACKGROUND:

There is significant literature highlighting problems in diagnostic referrals. Many clinical audits have shown examples of the following:

• patient referred for a particular investigation when an alternative would have been preferable (greater benefit and/or lesser risk)

• patient referred for an investigation at the wrong time • patient referred for an investigation when none is needed (no relevant clinical

question to be answered; no change in diagnosis; no management change would result)

• conversely, patient not referred for an investigation when one is needed Inappropriate diagnostic referrals have adverse outcomes:

• may expose patients to risk without benefit including ionising radiation, delay in diagnosis, false positive diagnosis and inconsequential findings

• are a significant risk to the effective allocation of scarce resources in the delivery of health services.

 

 

PROPOSAL:

The improved implementation of Diagnostic Imaging Pathways (DIP) as a priority topic area would

• reduce the incidence of unnecessary examinations which may expose patients to risks without benefit, including the risk of false-positive results (GOAL 1)

• increase the incidence of appropriate evidence-based examinations which will result in cost-effective diagnosis (GOAL 2)

This proposed priority topic meets the eight criteria set by the ACSQHC for including a specific topic within a goal. 1. THE IMPACT ON THE HEALTH SYSTEM IN TERMS OF ISSUES SUCH AS THE BURDEN OF DISEASE, COST TO THE SYSTEM AND NUMBER OF ADVERSE EVENTS.

Expenditure on diagnostic imaging is a major contributor to rising health-care costs. Inappropriate examinations stimulate this expenditure unnecessarily. Hammett RJ, Harris RD. Halting the growth in diagnostic testing. Med J Aust 2002;177:124-5. Hollingworth W. Radiology cost and outcomes studies: standard practice and emerging methods. AJR 2005; 185:833.

2. THE EXISTENCE OF SIGNIFICANT SAFETY AND QUALITY PROBLEMS, SUCH AS HIGH LEVELS OF PREVENTABLE HARM AND SIGNIFICANT GAPS BETWEEN EVIDENCE AND PRACTICE.

There is a significant literature highlighting problems in diagnostic referrals which include the following:

• no tests indicated (no relevant clinical question to be answered; no change in diagnosis; no management change would result)

• conversely, patient not referred for a test when one is needed • incorrect choice of test • correct choice of test but wrong timing

Picano E. Sustainability of medical imaging. BMJ 2004;328:578-80. McCreath GT, O’Neill KF, Kincaid WC, Hay LA. Audit of chest x-rays in general practice – a case for local guidelines? Health Bull (Edinb) 1999;57:180-5. Brenner DJ, Hall EJ. Computed tomography – an increasing source of radiation exposure. N Engl J Med 2007;357:2277-84. A recent audit of referrals from the Emergency Department in a major teaching hospital showed that 56% of patients had evidence of inappropriate diagnostic practice according to evidence-based best practice.

 

 

Bairstow PJ, Persaud J, Mendelson R, Nguyen l. Reducing inappropriate diagnostic practice through education and decision support. Int J Qual Health Care 2010;22:194-200 3. THE EXISTENCE OF A BODY OF WORK THAT COULD BE BUILT ON TO MAKE IMPROVEMENTS, WITH BROAD AGREEMENT ABOUT CLINICAL GUIDELINES OR OTHER EVIDENCE-BASED STRATEGIES.

Diagnostic Imaging Pathways (DIP) is an evidence-based and consensus-based education and decision support tool for clinicians. It has been developed over more than 10 years with input from a large multidisciplinary panel of contributors. It guides the choice of the most appropriate sequence of diagnostic examinations in more than 150 common clinical scenarios covering all of the major organ systems. Access is provided to supporting information and references. DIP is published at the following web-site:

http://www.imagingpathways.health.wa.gov.au/ The Production Manual is published at the web-site. The primary goals are to: • reduce the incidence of unnecessary examinations which may expose patients to risks

without benefit

• increase the incidence of appropriate examinations which will result in cost-effective diagnosis

DIP also contains information about imaging procedures, general principles in requesting and providing, ionising radiation, contrast agents, imaging during pregnancy and lactation, image galleries of normal anatomy and pathology, teaching points, and information for patients and carers. The mission is to continuously review, revise and further develop the clinical and academic content of DIP according to the published production manual, disseminate DIP as widely as possible, implement the guidance in clinical practice, evaluate compliance and measure the impact on referral patterns and outcomes. DIP is a major quality improvement and demand management tool for the Division of Imaging Services at Royal Perth Hospital and elsewhere in WA, as well as the de facto national suite of guidelines for medical imaging. 4. THAT THE POTENTIAL GOAL IS AMENABLE TO NATIONAL ACTION AT MULTIPLE LEVELS OF THE HEALTH SYSTEM.

DIP is an educational and decision support application which aims to achieve evidence-based and consensus-based best practice in diagnostic referrals. It is web-based and is freely available without the need for a password. The web-site receives millions of hits per annum. Information that is provided for patients and carers is one of the areas that is accessed very frequently. The organisation which supports DIP is willing to collaborate with any suitable information technology enterprise which has an interest in developing clinical information communication technology applications for clinicians.

 

 

5. THE LIKELIHOOD THAT IMPROVEMENTS WOULD BE ACHIEVED IN A THREE TO FIVE YEAR TIMEFRAME.

Education of clinicians on DIP recommendations and providing decision support resulted in a significant reduction in inappropriate diagnostic practice over a one month period. Bairstow PJ, Persaud J, Mendelson R, Nguyen l. Reducing inappropriate diagnostic practice through education and decision support. Int J Qual Health Care 2010;22:194-200 Targeted use of imaging decision support resulted in large decreases in the inappropriate utilisation of imaging tests over a four to five year period Blackmore CC, Mecklenburgh RS, Caplan GS. Effectiveness of clinical decision support in controlling inappropriate imaging. J Am Coll Radiol 2011;8:19-25 6. THE EXISTENCE OF LINKS TO OTHER NATIONAL PRIORITIES.

The National Prescribing Service (NPS) has been commissioned by the Commonwealth Government to undertake projects to improve the quality of referrals to imaging and pathology services. DIP has aims which are obviously in common with those of the NPS. The Editor of DIP is a member of the Diagnostic Expert Advisory Panel of the NPS. A proposal has been drafted to develop a decision support tool that combines guidelines on diagnostic imaging and pathology (laboratory) tests. This has support from a multidisciplinary team of pathologists, imaging specialists and general practitioners, and in principle support from the Royal College of Pathologists of Australasia. 7. THE POTENTIAL FOR THE GOAL TO BE RELEVANT ACROSS DISEASE GROUPS, SECTORS AND SETTINGS OF CARE.

DIP guides the choice of the most appropriate sequence of diagnostic examinations in more than 150 common clinical scenarios covering all of the major organ systems. The following groups are targeted in the improved implementation of DIP through education and decision support:

• current and future referrers to diagnostic imaging services, including medical and surgical specialists, general practitioners, junior medical officers and medical students

• current and future providers of diagnostic imaging services, including imaging specialists and students, imaging technologists and students.”

http://www.imagingpathways.health.wa.gov.au/includes/aboutguidance.html#Target 8. THE EXISTENCE OF MEASURES, OR POTENTIAL TO DEVELOP MEASURES, THAT COULD BE USED TO MONITOR PROGRESS.

A proposal is attached which outlines a work-plan and includes measures to monitor progress.

 

 

Diagnostic Imaging: Electronic Referral With Decision Support

Research and Development Prepared for Diagnostic Imaging Pathways Steering Committee By Phillip Bairstow, Manager, Diagnostic Imaging Pathways August 2011

 

 

BACKGROUND.

There is significant literature highlighting problems in diagnostic referrals [1, 2, 3, 4]. Many clinical audits have shown examples of the following:

• patient referred for a particular examination when an alternative examination would have been preferable (greater benefit and/or lesser risk)

• patient not referred for an examination when one is needed • patient referred for an examination when no examination is needed

One reason for these kinds of referral problems is ‘lack of knowledge’. The task of keeping up-to-date with developments in clinical practice is increasingly difficult due to expanding research activity, clinical specialisation and subspecialisation, and new applications of technology. It is difficult to acquire and maintain the necessary breadth and depth of knowledge for confident and correct decision-making. A ‘medical knowledge crisis’ is well recognised, as is the need for improved knowledge management. The development and deployment of decision support systems has been suggested as a specific strategy to ensure that each diagnostic referral is appropriate and cost effective for the clinical circumstance [5]. An application called Diagnostic Imaging Pathways (DIP) has been developed at Royal Perth Hospital (RPH) over many years to assist clinicians to choose the most appropriate diagnostic examinations in the correct sequence. More than 150 pathways covering all the major organ systems and common clinical scenarios have been developed. Imaging specialists, referring consultants and general practitioners contribute to the pathways. A Fellow is permanently employed to coordinate the development of new pathways, review and revise the pathways, and mine the literature for the best available evidence to support recommendations in the pathways. Evidence is graded according to the Oxford system. The pathways are therefore based on broad clinical consensus, supported by evidence when available, and are under continuous review and development. DIP is delivered electronically from a single source, and has been available from the 'desk-top' of personal computers (PCs) in all public hospitals throughout Western Australia. DIP is also available from the Internet. The application receives over 5 million ‘hits’ per year.

www.imagingpathways.health.wa.gov.au Each of the pathways within DIP is laid out as a diagnostic flowchart. Commencing with a presenting condition (e.g. low back pain) the user can step through various clinical possibilities (e.g. back pain +/- sciatica) and indications for investigation (e.g. ‘red flags’), to receive advice on a sequence of examinations which is recommended according to broad consensus and the best available evidence. Each flowchart also allows access to supporting information and source references. The application is endorsed by the Royal Australian & New Zealand College of Radiologists (RANZCR), is accredited by the Health On The Net Foundation and meets standards for partnership with HealthInsite and the Joanna Briggs Institute. DIP has been adopted into the curricula of several Australian medical schools including the University of Western Australia and the University of Notre Dame Australia. The World Health Organisation (WHO) is collaborating with the International Radiology Quality Network (IRQN) on the development of imaging referral guidelines. Draft WHO/IRQN

 

 

guidelines are based on three existing sets of diagnostic imaging guidelines from around the world, one of which is DIP. The primary objectives of DIP are:

• provide an education resource to promote evidence-based best practice • provide easy access to information which supports confident diagnostic referral

decisions The work of a number of groups has shown that ‘stand-alone’ guidelines are usually not well implemented. To illustrate, clinicians at RPH have easy access to DIP and are encouraged to follow the recommendations via regular reminders at ‘Grand Rounds’ and clinico-radiological meetings, in the medical newsletter and in the orientation and induction programme of junior doctors. Yet when patients presenting to the Emergency Department with one of four conditions were audited, it was found that there were problems in diagnostic referrals in 56% of cases. Importantly, however, there were no clinical indications from this audit regarding why patients were referred for inappropriate or unnecessary examinations or why they weren’t referred for an examination when one was needed. Even after a period of intensive education of clinicians with respect to DIP recommendations, there was only a small reduction in the percentage of patients with evidence of referral problems from 56% to 40% [4]. It was evident that in a busy Emergency Department environment, it is difficult for doctors to find the time to log onto the DIP website, navigate to the appropriate pathway, step through the pathway to determine the recommended sequence of examinations and then return to a paper based system of referral. To achieve better access to guidance, decision support should be embedded into clinical work flow. Paper-based processes of referral should be replaced by an electronic system, and the steps in completing an electronic referral should be linked to guidance afforded by DIP, saving time in accessing another application to determine the best pathway. ‘Smart’ functionality is required. Referrers should be alerted on-line to provide necessary prerequisite information. Importantly, acceptance of guidance should not be mandatory; if there are clinical indications for taking a different direction then this should be allowed and the reason recorded. In order to save time, the electronic referral form should be pre-populated with relevant patient information, including clinical information generated from following a pathway and which provides the context of the referral. Ideally, referrers should also have access to the status of their referral (e.g. ‘received’, ‘scheduled’, ‘report available’) and information received should automatically feedback into an electronic health record. Referrers should also be able to audit their own referral patterns, which will increase confidence that they are applying evidence-based best practice. Based on the experience of previous audits, it is anticipated that a reduction in referral problems will be reflected in a change in referral patterns, with evidence of improved implementation of consensus and evidence-based guidance.

ELECTRONIC REFERRAL WITH DECISION SUPPORT.

The DIP Steering Committee has collaborated with the University of Western Australia, Centre for Software Practice under the Directorship of Associate Professor David Glance in developing an Electronic Referral/Decision Support (ER/DS) application. The application can be accessed by a referring clinician via the ‘desk-top’ of a personal computer or mobile electronic devices.

 

 

The application is opened by selecting an icon. The user selects a clinical scenario (e.g. low back pain) and then steps through the diagnostic algorithm to arrive at a recommendation (e.g. a particular imaging examination, or indeed, no examination). If the recommendation is accepted by the referrer, a ‘form’ button is selected and an electronic form appears on the screen, pre-populated with the patient's demographic information obtained via a link to the electronic health record. The steps by which the user got to the recommendation via the algorithm is recorded in the 'clinical information' section of the ER/DS application, which provides the context and indication for the referral. This process is at least as rapid as manually completing a paper-based imaging request form. The completed form can then be printed or sent electronically via secure messaging to a medical imaging provider. The referrer can be alerted to any need for direct consultation with an imaging specialist, or the form can be accepted for scheduling. If the recommendation in the pathway is not accepted by the referrer, it may be overridden. in this case the referrer selects the ‘form’ button and an electronic form appears on the computer monitor pre-populated with the patient's demographic information obtained by a link to the electronic health record (as above). For examinations that may have serious implications for the patient (e.g. those that are invasive or are associated with a high radiation dosage), this override function may have to be approved by an imaging specialist prior to acceptance. The completed electronic form is sent electronically to a medical imaging provider where it is accepted, subject to consultation between the referrer and provider. For other examinations, the override may merely require a free-text justification by the referrer for it to be accepted by the provider. Information generated in the ‘override’ process is recorded as additional context for the referral. All the evidence-based and referenced narrative text that is present in DIP is available in the ER/DS application. This material is in the background and is easily accessed, although such access is voluntary. It is important to note that the ER/DS application ensures the use of the guidance afforded by DIP, but acceptance of the guidance is not mandatory; a recommendation may be overridden at the discretion of the referrer. The referrer either provides justification (in free text form) or gains approval through consultation with an imaging specialist. Which of these alternatives is required is dependent on the invasiveness and/or safety implications of the procedure that is being requested. Whilst there has been considerable GP input into the recommendations contained in DIP, and GPs have advised on the functional requirements of the ER/DS application, the application has not yet been tested and trialled. Active GP input and advice is now needed to bring the design of the application to a stage where it can be subjected to a trial in limited clinical environments. This funding proposal is concerned with testing and trialing the application with GPs in Western Australia, possibly including remote environments. The following short and long-term benefits for GPs are anticipated:

• active input into the design and functionality of an electronic requesting system with embedded decision support

• keeping up to date with the latest evidence on investigations and evidence-based best diagnostic practice

• improved confidence in referral with no loss of clinical autonomy

 

 

• time saving in the process of referral and receipt of results (pre-population of request forms, automatic notification of the status of a referral and any need for consultation, and automatic notification of the receipt of reports)

• improved record keeping including the clinical context of referrals, reports on referral patterns for self audit, and the automatic uploading of referral results into the health record.

The developer of the ER/DS application will benefit from feedback and suggestions from GPs, which will be used for re-engineering and enhancement of the application. The developers of DIP, the source of evidence base guidance, will benefit from GPs’ feedback on the appropriateness of guidance in community general practice, which will be used in any re-drafting of the diagnostic flow charts.

CONSULTATION.

Consultation with Associate Professor David Glance, Director, Centre for Software Practice, University of Western Australia led to collaboration which resulted in bringing the development of the ER/DS application to a stage where it can be tested and trialled by GPs. He is willing and able to modify, maintain and upgrade the application depending on the outcome of tests, trials, and feedback and suggestions from users. Winthrop Professor Jon Emery, Head of School of Primary, Aboriginal and Rural Health Care, University of Western Australia is an academic General Practitioner. He has advised on this proposal and is keen to collaborate in testing, trialling and evaluating the ER/DS application in a non-clinical (‘computer laboratory’) and clinical environment. Dr Jacquie Garton-Smith, Hospital Liaison GP and member of the DIP Steering Committee, Royal Perth Hospital, also works in general practice. She has advised on this proposal and is keen to advise on testing, trialling, evaluating and modifying the ER/DS application to achieve suitability for implementation is a community GP environment. Dr Philip Misur is the Chairman of the WA Branch of the RANZCR and is a Radiologist who practices in the public and private sector. He supports the need to embed decision support into the referral process, and will provide advice on the design and functionality of the ER/DS application and the identification of participating medical imaging providers. Ms Lauren Leclerc is eHealth Program Coordinator, Western Australian General Practice Network. She will assist with coordinating a test and trial of the ER/DS application and, in particular, will assist with the recruitment of general practitioners. Clinical Professor Richard Mendelson is the Editor of DIP. He is responsible for the development of all clinical and academic content of DIP and the ER/DS application. He supports the need to embed decision support into the referral process and will provide advice on the implementation of the ER/DS application Adjunct Associate Professor Phillip Bairstow is the Manager of DIP and Chairman of the DIP Steering Committee, which is responsible for advising and approving all activities related to the development, dissemination, implementation and evaluation of DIP. The Committee has assigned the highest priority to a test and a trial of the ER/DS application and will provide project management support.

 

 

All of the above are co-signatories to this proposal. PROPOSAL.

A Project Steering Group will be convened to review, advise and direct the work associated with this proposal. The group will comprise:

• Editor of DIP • Manager of DIP • Director, Centre for Software Practice, University of Western Australia • Head of School of Primary, Aboriginal and Rural Health Care, University of Western

Australia • a GP representative • an imaging specialist representative • a project officer

The activities outlined in Phase 1 and Phase 2 will take place in Western Australia and will benefit from strong local technical, academic, professional and project management support. Phase 1 (6 month test) The ER/DS application currently has the following functionality. If a GP determines during a consultation with a patient that a referral for a medical imaging examination is required, the ER/DS application is accessed by selecting an icon on the ‘desk-top’ of a personal computer. The GP selects a clinical scenario and via a series of ‘clicks’ determined by a diagnostic algorithm, arrives at a recommendation (a particular examination, or no examination). The series of clicks is stored as ‘clinical information’. If the recommendation is accepted by the GP, a ‘form’ icon is selected and an electronic request form appears on the computer monitor, pre-populated with the clinical information and the patient’s demographic information obtained via a link to the patient’s electronic health record. The completed form can be sent electronically via secure messaging to a medical imaging provider where it can be accepted by the provider. Some requests (e.g. those involving an invasive procedure or a high dose of radiation) require a consultation with an imaging provider before unconditional acceptance, in which case the GP is alerted. The provider informs the GP via secure messaging about the status of the request (received, pending approval, accepted unconditionally, scheduled, report available). If the recommendation is not accepted by the GP, it may be overridden. Depending on what examination is being requested, the override may only require a short free-text justification by the GP for the request to be accepted unconditionally. However, for examinations which have relatively serious implications for the patient, an imaging specialist needs to approve the override prior to acceptance. The acceptability and practicability of this functionality must now be tested by GPs who will provide feedback and suggestions to the ER/DS developer. The ER/DS application will be subjected to testing by groups of GPs in non-clinical environments. For example, a ‘computer laboratory’ will be set up with personal computers which basically emulate those used in clinical settings. The ER/DS application will be accessible and will be linked to a data-base which contains the electronic health record of

 

 

fictitious patients. The application will also be linked to a fictitious medical imaging provider for the submission of a request, and for consultations that are required before a request is accepted unconditionally. A demonstration module will also be made available on-line for GPs who cannot attend the ‘computer laboratory’. GPs will be identified who have an interest in the development and implementation of clinical information technology applications and are willing to participate in facilitated workshops or on-line testing. In the first workshop and on-line testing, up to 10 GPs will be presented with a series of clinical scenarios that might be expected in a busy clinic. Scenarios will include conditions for which MRI examinations are appropriate and for which GPs are planned to have limited right of referral. GPs will also review the full range of clinical scenarios covered by the application and will advise on action required to bridge any gaps. Qualitative data and information will be gathered in the workshop and telephone interviews including feedback and ratings from the GPs on the following:

• whether the application can manage the full range of clinical scenarios found in general practice

• whether the recommended examinations are mostly clinically appropriate or whether the override functionality must be invoked excessively, which may indicate a need to redraft the pathways

• whether the functionality of the application is acceptable to GPs including the method and speed of navigation, the method for accepting or overriding a recommendation, and the method of communicating with an imaging provider

Quantitative data will be gathered from the application including the following:

• the number of clicks and the time required to navigate the electronic process of referral including the override functionality

• the completeness of the electronic referral form including clinical information and patient demographic information

• metadata on the referral patterns of individual referrers All data and information will be collated, summarised and recommendations will be drafted. The Project Steering Group will determine any necessary changes to the content and functionality of the ER/DS application. The Centre for Software Practice, University of Western Australia will modify and upgrade the application appropriately. In the second workshop and on-line testing, the first group of 5-10 GPs and an additional 10-15 GPs will participate. The process used to test and assess the application initially, will be repeated with the revised application. This will enable an assessment of:

• whether the changes to the application have improved its functionality and acceptability according to the initial participants

• the functionality and acceptability of the revised application according to a ‘new’ group of GPs

Again, all data and information will be collated, summarised and recommendations will be drafted. The Project Steering Group will determine any necessary changes to the ER/DS

 

 

application and the Centre for Software Practice, University of Western Australia will modify and upgrade the application appropriately. The principle outcome of Phase 1 will be an ER/DS application that is judged suitable by GPs for trialling in selected clinical settings (Phase 2). Phase 2 (6 month clinical trial) The ER/DS application that emerges from Phase 1 will be trialled and evaluated in selected general practices and with medical imaging providers. It is anticipated that some of the planning for Phase 2 will commence during Phase 1. Up to 20 GPs and two providers will be identified who have an interest in the development and implementation of clinical information technology applications and are willing to participate. It is anticipated that GPs who participated in Phase 1 will volunteer for Phase 2. GP Clinical Software providers will be engaged to achieve interoperability with other necessary systems and sources of information. Medical imaging providers that are suitable and acceptable to the GPs will also be identified who are willing to participate in the trial and evaluation of the application. The ER/DS application will be accessible from the ‘desk-top’ of computers which are used in the clinical consultation process. It will be reciprocally linked to the practice software used by individual GPs to enable the transfer of data from patients’ electronic health records to the electronic request form. It will also have the capability via secure messaging to transmit a completed request form to the medical imaging providers and to receive reports from the providers regarding the need for consultation and status of the request (received, pending approval, accepted unconditionally, scheduled, report available). Such information will be transmitted back to the health records. In the first two month period of the trial, the GPs will aim to use the ER/DS application in all consultations in their practice for which a referral for a medical imaging examination may be required. The medical imaging providers will receive completed request forms electronically, will consult with the GPs when required, and will provide information to the GPs about the status of the request. At the end of the trial period, a workshop will be held involving the GPs and the medical imaging providers or telephone interviews will be offered if workshop attendance is not possible. The following qualitative data and information will be gathered in the workshop including feedback and ratings on the following:

• whether the application managed the full range of clinical scenarios found in general practice

• whether the recommended examinations are mostly clinically appropriate or whether the override functionality must be invoked excessively, signalling the possible need to redraft the DIP pathways

• whether the functionality of the application is acceptable to GPs including the method and speed of navigation

• whether the method for accepting or overriding a recommendation by GPs, and the method of communicating and consulting with imaging providers is acceptable

In addition, quantitative data will be gathered from the application including the following:

• the number of clicks and the time required to navigate the electronic process of referral including the override functionality

 

 

• the completeness of the electronic referral form including clinical information and patient demographic information

• metadata on the requesting patterns of individual referrers and the responsiveness of the imaging providers to an electronic request

• the number, nature and resolution of support calls All data and information will be collated, summarised and recommendations will be drafted. The Project Steering Group will determine any necessary changes to the content and functionality of the ER/DS application. The Centre for Software Practice, University of Western Australia will modify and upgrade the application appropriately. In the second two month period of the trial, the process used to trial and assess the application in the first period will be repeated with the revised application. This will enable an assessment of whether the changes to the application have improved its functionality and acceptability. Again, all data and information will be collated, summarised and recommendations will be drafted. The Project Steering Group will determine any necessary changes to the ER/DS application and the Centre for Software Practice, University of Western Australia will modify and upgrade the application appropriately. The principle outcome of Phase 2 will be ‘proof of concept’ of an ER/DS application for medical imaging referrals, which GPs and medical imaging providers in Western Australia have found to be acceptable and useful.

 

 

SIGNATORIES Associate Professor David Glance Director Centre for Software Practice University of Western Australia ________________________________ Winthrop Professor Jon Emery Head of School of Primary Aboriginal and Rural Health Care University of Western Australia ________________________________ Dr Jacquie Garton-Smith Hospital Liaison GP Royal Perth Hospital General Practitioner ________________________________ Dr Philip Misur Chairman RANZCR – WA Branch ________________________________ Ms Lauren Leclerc eHealth Program Coordinator Western Australian General Practice Network ________________________________ Clinical Professor Richard Mendelson Editor Diagnostic Imaging Pathways ________________________________ Adjunct Associate Professor Phillip Bairstow Chairman Diagnostic Imaging Pathways Steering Committee ________________________________

 

 

 

REFERENCES

1. Picano E. Sustainability of medical imaging. BMJ 2004;328:578-80.

2. McCreath GT, O’Neill KF, Kincaid WC, Hay LA. Audit of chest x-rays in general practice – a

case for local guidelines? Health Bull (Edinb) 1999;57:180-5.

3. Brenner DJ, Hall EJ. Computed tomography – an increasing source of radiation exposure.

N Engl J Med 2007;357:2277-84.

4. Bairstow PJ, Persaud J, Mendelson R, Nguyen l. Int J Qual Health Care 2010

5. Hammett RJ, Harris RD. Halting the growth in diagnostic testing. Med J Aust

2002;177:124-5.