Christopher Pearce

Doctor, patient and computer—A framework for the new consultation

PURPOSE The use of a computer during general/family practice consultations is on the rise across the world, yet little is known about the effect the use of a computer may have on the all important physician-patient relationship. This paper provides a framework for further analysis of computers influence on physician-patient interactions during general practice consultations. METHODS This is an observational qualitative study informed by hermeneutics and the phenomenological tradition of Irving Goffman, based in Australian general practice. A single digital video recording of 141 patient encounters over 6 months was made and imported into a tagging software program to facilitate analysis. Through an iterative process several keys and behaviours were described for doctors, patients and the computers in the interaction. RESULTS Physicians tended to fall into two categories; unipolar-those who tend to maintain the lower pole of their body facing the computer except were examination of the patient or some other action demands otherwise, and bipolar-those physicians who repeatedly alternate the orientation of their lower pole between the computer and the patient. Patients tended to demonstrate behaviours that focused on the physician to the exclusion of the computer (dyadic) and included the computer in the consultation (triadic). The computer was also seen to influence the physician-patient interaction passively or actively. CONCLUSION In describing and categorising the behaviours of the computer, in addition to the humans in the consultation, a framework is provided for further analytical work on the impact of computers in general practice.

Computers in the new consultation: within the first minute

BACKGROUND Computers are now commonplace in the general practice consultation in many countries and literature is beginning to appear that describes the effects of this presence on the doctor-patient relationship. Concepts such as patient centredness emphasize the importance of this relationship to patient outcomes, yet the presence of the computer has introduced another partner to that relationship. OBJECTIVE To describe the patient-doctor-computer relationship during the opening period of the consultation. METHODS Twenty GPs provided 141 consultations for direct observation, using digital video. Consultations were analysed according to Goffmans dramaturgical methodology. RESULTS Openings could be described as doctor, patient or computer openings, according to the source of initial influence on the consultation. Specific behaviours can be described within those three categories. CONCLUSIONS The presence of the computer has changed the beginning of the consultation. Where once only two actors needed to perform their roles, now three interact in differing ways. Information comes from many sources, and behaviour responds accordingly. Future studies of the consultation need to take into account the impact of the computer in shaping how the consultation flows and the information needs of all participants.

Following the funding trail: Financing, nurses and teamwork in Australian General Practice.

BackgroundAcross the globe the emphasis on roles and responsibilities of primary care teams is under scrutiny. This paper begins with a review of general practice financing in Australia, and how nurses are currently funded. We then examine the influence on funding structures on the role of the nurse. We set out three dilemmas for policy-makers in this area: lack of an evidence base for incentives, possible untoward impacts on interdisciplinary functioning, and the substitution/enhancement debate.MethodsThis three year, multimethod study undertook rapid appraisal of 25 general practices and year-long studies in seven practices where a change was introduced to the role of the nurse. Data collected included interviews with nurses (n = 36), doctors (n = 24), and managers (n = 22), structured observation of the practice nurse (51 hours of observation), and detailed case studies of the change process in the seven year-long studies.ResultsDespite specific fee-for-service funding being available, only 6% of nurse activities generated such a fee. Yet the influence of the funding was to focus nurse activity on areas that they perceived were peripheral to their roles within the practice.ConclusionsInterprofessional relationships and organisational climate in general practices are highly influential in terms of nursing role and the ability of practices to respond to and utilise funding mechanisms. These factors need to be considered, and the development of optimal teamwork supported in the design and implementation of further initiatives that financially support nursing in general practice.

General Practice and Pandemic Influenza: A Framework for Planning and Comparison of Plans in Five Countries

Background Although primary health care, and in particular, general practice will be at the frontline in the response to pandemic influenza, there are no frameworks to guide systematic planning for this task or to appraise available plans for their relevance to general practice. We aimed to develop a framework that will facilitate planning for general practice, and used it to appraise pandemic plans from Australia, England, USA, New Zealand and Canada. Methodology/Principal Findings We adapted the Haddon matrix to develop the framework, populating its cells through a multi-method study that incorporated the peer-reviewed and grey literature, interviews with general practitioners, practice nurses and senior decision-makers, and desktop simulation exercises. We used the framework to analyse 89 publicly-available jurisdictional plans at similar managerial levels in the five countries. The framework identifies four functional domains: clinical care for influenza and other needs, public health responsibilities, the internal environment and the macro-environment of general practice. No plan addressed all four domains. Most plans either ignored or were sketchy about non-influenza clinical needs, and about the contribution of general practice to public health beyond surveillance. Collaborations between general practices were addressed in few plans, and inter-relationships with the broader health system, even less frequently. Conclusions This is the first study to provide a framework to guide general practice planning for pandemic influenza. The framework helped identify critical shortcomings in available plans. Engaging general practice effectively in planning is challenging, particularly where governance structures for primary health care are weak. We identify implications for practice and for research.

Time to talk, time to see: changing microeconomies of professional practice among nurses and doctors in Australian general practice

In Australia, more nurses are entering general practice, and nurses– work is being funded in increasingly complex ways through Medicare. Little research has explored the ways doctors and nurses realign their priorities and activities when working together in general practice. We undertook rapid, intensive multimethod studies of 25 general practices to explore the ways in which the labour of nurses and doctors was structured, and the implicit decisions made by both professions about the values placed on different ways of working and on their time. Data collected included photographs, floor-plans, interviews with 37 nurses, 24 doctors and 22 practice managers, and 50 hours of structured observation. Nursing time was constructed by both nurses and doctors as being fluid and non-contingent; they were regarded as being ‘available’ to patients in a way that doctors were not. Compared to medical time, nursing time could be disposed more flexibly, underpinning a valorized attribute of nursing: deep clinical and personal contact with patients. The location of practice nurses’ desks in areas of traffic, such as administrative stations, or in the treatment room, underpinned this valuable unstructured contact with patients. Changes to the practice nurse role through direct fee-for-service items for nurses may lead to greater congruence between the microeconomies of nursing and medicine in general practice. In a time of pressure upon a primary care workforce, this is likely to lead to more independent clinical work by nurses, but may also lead to a decrease in flexible contact with patients.

Ethical questions must be considered for electronic health records

National electronic health record initiatives are in progress in many countries around the world but the debate about the ethical issues and how they are to be addressed remains overshadowed by other issues. The discourse to which all others are answerable is a technical discourse, even where matters of privacy and consent are concerned. Yet a focus on technical issues and a failure to think about ethics are cited as factors in the failure of the UK health record system. In this paper, while the prime concern is the Australian Personally Controlled Electronic Health Record (PCEHR), the discussion is relevant to and informed by the international context. The authors draw attention to ethical and conceptual issues that have implications for the success or failure of electronic health records systems. Important ethical issues to consider as Australia moves towards a PCEHR system include: issues of equity that arise in the context of personal control, who benefits and who should pay, what are the legitimate uses of PCEHRs, and how we should implement privacy. The authors identify specific questions that need addressing.

When policy meets the personal: general practice nurses in Australia.

Objective A significant focus of current health policy in Australia is to expand both the number and role of general practice nurses. Multiple new payment incentives have been instituted to encourage the use of practice nurses. This study explored the way these policies have framed their work. Methods Multimethod research using observation, workspace photographs and interviews with nurses, doctors and managers collected through rapid appraisal in 25 practices in two states, followed by case studies of the role of nurses in seven practices over one year. Results Many respondents reported unanticipated benefits in general practice functioning and teamwork as a result of employing a nurse, though this had not been a policy aim. Within funding constraints, nurses created new roles and manipulated old roles to fit their personal understanding of patient care. Policy initiatives targeting practice nurses are often based around tasks and system issues, rather than the personal creation of care and quality that patients require and nurses seek. Incentives in this study were targeted at both the uptake of nurses and specific nursing activities. Conclusion Policy development and funding structures would benefit from better understanding of nurses as agents of connectivity (rather than simply as performers of tasks) as well as the nature of teamwork in practices.

Methodological Considerations of Digital Video Observation: Beyond Conversation Analysis

Abstract This paper discusses some of the methodological issues of using digital video data in observational studies. It is based on the authors’ experiences in research involving medical consultations. Previous observational studies in this field have used either direct observation or analogue videotapes. Traditionally, analysis is then done on transcriptions of the tapes, using conversation analysis or other techniques. These techniques were formed and created using largely analogue audiotapes. We will demonstrate how digital video increases the richness of data, such that conversation analysis becomes interaction analysis. Additionally, we argue that digital video changes the relationship between reader, researcher and data. A consideration of these changes is important to framing a comprehensive methodological approach to using digital video observation. Digital video needs to be considered in terms of what it offers in and of itself, rather than relating it to other techniques.

Is technology innocent? Holding technologies to moral account

Sophisticated technologies - in different times, this could be a stone axe, or a computer system - are important to humans in cultural, economic, and existential terms. The performance of these technologies requires careful assessment. Some forms of technology assessment are fine-grained and small-scale, attending to specific technologies in specific contexts (for example, HCI evaluations, usability studies, and user-centered design methods), while other approaches are more sweeping, and critique technology in epochal terms, rather than focusing this or that example. It is proposed here that critical assessments of technology should hold sophisticated artifacts to moral account. The normative standards by which technologies are judged are thus extended from exclusively instrumental concerns, to the non- instrumental realm. Technologies must be held morally accountable for their actions, in order for those actions to be assessed appropriately.

Falls Prevention within the Australian General Practice Data Model: Methodology, Information Model, and Terminology Issues

The iterative development of the Falls Risk Assessment and Management System (FRAMS) drew upon research evidence and early consumer and clinician input through focus groups, interviews, direct observations, and an online questionnaire. Clinical vignettes were used to validate the clinical model and program logic, input, and output. The information model was developed within the Australian General Practice Data Model (GPDM) framework. The online FRAMS implementation used available Internet (TCP/IP), messaging (HL7, XML), knowledge representation (Arden Syntax), and classification (ICD10-AM, ICPC2) standards. Although it could accommodate most of the falls prevention information elements, the GPDM required extension for prevention and prescribing risk management. Existing classifications could not classify all falls prevention concepts. The lack of explicit rules for terminology and data definitions allowed multiple concept representations across the terminology-architecture interface. Patients were more enthusiastic than clinicians. A usable standards-based online-distributed decision support system for falls prevention can be implemented within the GPDM, but a comprehensive terminology is required. The conceptual interface between terminology and architecture requires standardization, preferably within a reference information model. Developments in electronic decision support must be guided by evidence-based clinical and information models and knowledge ontologies. The safety and quality of knowledge-based decision support systems must be monitored. Further examination of falls and other clinical domains within the GPDM is needed.