| Scenario A: Diagnostic Test Ordering and Clinical Referral |
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Mrs Complex has just returned for her second visit to the practice after having first been seen a week ago with symptoms very suggestive of a simple ‘dose of the flu’. However she had rung 2 hours ago, to say she was still not better, was feeling a little breathless, and would like to be reviewed. The receptionist had taken the call, checked the days appointments for Dr Luke and informed her that on present indications (based on the number of patients with appointments and the numbers waiting for Dr Luke in the waiting room) that if she took an available appointment for two hours hence she would have a very good chance of being seen within 15 minutes of the appointment time. [A] The receptionist also checked on her computer that no-one had booked the computerised lung function evaluator (electronic spirometer) that was used in the practice for two hours hence and booked it for an hour. [B] The receptionists also told the computer system that she anticipated at least a 20 minute consultation and the computer produced a list of the patients who may be impacted with contact details so they could be asked to come a little later if they were contactable. [C]
On her arrival, the receptionist logged Mrs Complex’s arrival in the computer, and was shown that there was only one person due to be seen before Mrs Complex and concluded it was likely she would indeed get seen within 15 minutes of her appointment. [D]
As expected, after waiting about 10 minutes, Dr Luke shows the previous patient out and asks Mrs Complex to come in. As he had been pressed for time on the last encounter, Dr Luke had only recorded the basic details relating to Mrs Complex at the last visit, and saw when he opened her Electronic Health Record that the record was not flagged as having been initially completed. [E] Before addressing the immediate problem, he decided to complete the remainder of the basic clinical and demographic information his computer system used.
Completing the record, where a strong family history of breast cancer was noted, automatically bought up a recommendation that consideration should be given to regular annual mammography, even though Mrs Complex was only in her very early 40’s. [F] The system also noted that her last PAP Smear had been done and reported quite recently, was normal, and therefore scheduled a recall for two years time for a repeat smear.
After completing and recording a detailed examination Dr Luke was unsure as to quite what was the cause of the breathlessness. He consulted the appropriate diagnostic and investigatory guideline and determined that the basic investigations required included [G] :
Dr Luke then accessed the appointment availability home page for the local radiology practice and organised a time for Mrs Complex to have her X-Ray. [I] He then selected an electronic X-Ray request form for the practice, filled in the specific clinical details and comments he wanted, and produced the completed request along with an envelope having the instructions on how to find the practice and Mrs Complex’s name on it and handed them to her for her to check and take away. After this he placed orders for the Haematology, Biochemistry and Serology with his preferred pathology provider, (after having looked up the service details eg. collection details, cost etc) printed instructions for Mrs Complex as to where she should go to have the blood taken for the tests and committed all the information to Electronic Health Record. [J]
Dr Luke then asked Mrs Complex to come through to the Lung Function Evaluation Area where he conducted the test, and saw the results captured in graphical and numeric form directly into her Electronic Health Record. [K]
Dr Luke then took Mrs Complex back to his consulting room, spent some time explaining to her what the test showed and what he was hoping to discover in the investigations he had ordered. Dr Luke then recorded in the record a summary of their discussion, coded the major previous illnesses and the current episode data, and made an appointment for three days time with clear instructions to return promptly if she felt any worse. [L]
Three days later Mrs Complex returns. Dr Luke recalls he has seen the results of the basic investigations and the Chest X-Ray and brings them up on his terminal for review. [ M] He also notes that a warning is flashing saying the serology is overdue. [N] He decides to call the laboratory, finds out that a result is now available, and will be transmitted to his desktop in the next 10 minutes, but that it is normal.
Dr Luke discovers during the consultation that Mrs Complex is no better and decides that the time has come to refer Mrs Complex to a specialist Respiratory Physician. Just before beginning the referral note, Dr Luke consults a diagnostic decision support database to see what the available coded diagnostic and investigatory data suggests by way of a diagnosis. On the basis of decision support system’s suggestion he decides to suggest that the specialist carefully eliminate both recurrent pulmonary emboli and chronic infective lung disease when seeing Mrs Complex. [O] Dr Luke then brings up a profile of the four specialist Respiratory Physicians he has used and assesses how happy he has been with the service provide by each of them. [P] He notes that only one of the four provides secure e-mailed electronic copies of their reports and decides to use her again. A quick phone call secures an appointment for Mrs Complex early the following week. Dr Luke suggests Mrs Complex comes back to see him two to three days after that and makes an appointment for the follow up.
After getting her consent, Dr Luke then, again using secure e-mail, makes his record available to Dr Hightech and gives Mrs Complex a printed clinical summary for her to check and take along to her appointment. [Q]
Late the next week, Dr Luke sees a secure email back from Dr Hightech, saying that Mrs Complex appears to have an atypical lung infection and that she has been commenced on some special antibiotics to attempt to eradicate it.
When Dr Luke sees her again the next day she says she is already feeling a lot better. The success prompts Dr Luke to remember he has not done the billing for Mrs Complex so he creates an invoice for the three encounters that have made up this episode with a breakdown of the refund Mrs Complex can expect from Medicare. [R] Mrs Complex happily provides the expected total payment with her credit card which is validated via Dr Luke’s computer system. [S]