Registers Recall and Reminder Systems

Practice self-assessment survey - Disease Registers and Recall/Reminder Systems

Do you need help with setting up and maintaining an effective register, recall/reminder systems? Below is a short questionnaire that is designed to help you identify areas of your practice register/recall and reminder systems that require improvement. Once completed you can contact the Division and we can assist you with what is needed to setting up and maintaining an effective register, recall and reminder systems.

Practice Incentive Payments

In November 2001 the Commonwealth Government expanded the Practice Incentive Program (PIP) to improve earlier diagnosis and management of specific chronic diseases including. All Accredited General Practices are eligible for the Practice Incentive Program (PIP).

The Diabetes PIP initiative is made up of 3 components;

1. Patient Register and Recall/Reminder System 
   PIP practices will receive a one-off payment if they use a patient register and recall/reminder system for their patients with diabetes.
   
2. Service Incentive Payment (SIP – diabetes) 
   To be eligible for diabetes service incentive payment (SIP – diabetes) it is necessary to complete an annual diabetes cycle of care (outlined below) for a patient of the practice. 
   
3. Outcome payments
   Diabetes outcome payments are made to practices that reach target levels of care for their patients with diabetes. For a summary sheet of the diabetes PIP payments and MBS Items numbers, please refer to the resources listed below.

Diabetes Annual Cycle of Care

The minimum requirements are;

*Based on RACGP Diabetes general practice guidelines, 2006/07.

Resources - Diabetes PIP/SIP

PIP Helpline Phone: 1800 222 032 Available for queries and PIP/SIP resources/forms

Useful website

Medicare Australia http://www.medicareaustralia.gov.au/providers/incentives_allowances/pip.shtml 

Recall and Reminder Systems

Evidence shows that many chronic illnesses (such as diabetes) can be better managed with the support of information systems, in particular computerized systems. These systems include;

1. Disease registers - Disease registers allow for the identification of patients with particular diseases, or at risk of them, the recording of treatment plans, test results, etc. and the tracking of clinical outcomes;
2. Recall and reminder systems - Recall and reminder systems provide the facility for systematic recall and review of the patients on a regular basis, according to clinical management guidelines.

Register, recall and reminder systems allow general practices to establish a system whereby they can notify patients of the need to make an appointment to see their GP.  The term REGISTER usually refers to a database.

The RECALL and REMINDER component refers to the active identification and recall of patients for visits with their GP. Recall is usually used for abnormal results and reminders are usually used for preventative care such as with Diabetes.

Following is a summary of the process for electronic register, recall/reminder systems for diabetic patients;

• Record clinical data for patients
• Search for diabetic patients (can be undertaken via MD and Diabetes Data Extraction tool)
• Set-up Diabetes Review Recalls
• Search for Recalls due
• Send reminder letters
• Maintain Recall

Medico–Legal Issues relating to Recall and Reminder Systems

a) RACGP guidelines for patient recalls

Initiating the register and recall system

• Only patients who normally attend the practice should receive recall notices
• Seek patient consent before placing them on a recall register
• Recall notification should only be for a specific aspect of continuing care and/or specific preventative care

Continuing Care

• It is appropriate to monitor patients with established diseases by recall
• There is a clear obligation on the doctor to recall patients who have failed to follow-up abnormal tests

Preventative Care

• The recall of patients at appropriate intervals for preventative care is recommended;
• The RACGP accepts a protocol of preventative care recalls. Such a schedule would be regarded as constituting a minimal standard of preventative care, subject to variation at the discretion of the doctor

b) Obtain Patient Consent

• Raise the issue of prevention in the consultation
• Outline to the patient the reason why you think CDM is important
• Link the preventative activity with the patient’s presenting complaint – this will increase the relevance and acceptability of the activity
• Explain both the nature and extent of your’s and your patient’s responsibility
• Obtain consent, which should include both the method and frequency of contact
• Back up what you are saying with patient information and literature; give the Practice Information Sheet (see pg 14) to the patient to advise them of the reminder system and of the practice’s policy to enrol patients in the system unless they advise otherwise. Example: “Our practice will send out a reminder letter to you (or we will phone you) to attend a 3 monthly blood pressure check”

c) Provision of Informed Consent

• A patient has every right to refuse your advice – but the burden is on you to ensure that refusal is informed. This also applies to patients who refuse your offer of being entered into a computerized reminder system. A patient refusal should be documented in their file.

Resources - Recall and Reminder Systems
 

Division Support

For further information on these iniatiatives please contact Shona Dutton CDM Program Officer at the Division. For GPs and practices within SDGP boundary you can also arrange a practice visit with Shona Dutton if you need further onsite support.  

Diabetes Data Aggregation Strategy

An activity under the Division’s Chronic Disease Prevention & Management Program, is the Diabetes Data Aggregation Initiative. The strategy involves implementing a software tool developed by Canning Division of General Practice that aggregates and manages diabetes data at a practice level.

The “Diabetes Data Aggregation Tool” can improve practice systems by identifying those patients that have diabetes and assisting with the following;

• Establishment and maintenance of Recall Reminder Systems for patients with diabetes
• Assist practices with forward planning for consultation reviews
• Assist practices with downloads of diabetes pathology results using HL7 messaging format for direct upload to medical software including; Medical Director; Medtech32; Best Practice; Medical Spectrum Classis and more to follow
• Support practices in implementing best practice strategies such as; Diabetes PIP/SIP, Medicare CDM Items (GPMP and TCA)

Amanda Rattray from the Division provides practice visits regarding this initiative. Please contact her at the Division to arrange a practice visit.