Be better prepared to respond to disclosures of intimate partner violence

BY VICTORIA COOK, VICE PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

This year, like the ones before it, Australia has been shocked by stories of horrific violence against women reported in the media. Yet for every story that is reported, many go unmentioned. Women die by violence in Australia at a rate of more than one per week. The organisation Destroy the Joint which ‘counts dead women’ holds this year’s total at 47 women killed in Australia by September 14. There are another 13 weeks left in 2018, meaning we can expect that at least 13 more Australian women will be killed by the end of this year alone.

We know that healthcare professionals are often first responders in disclosures of domestic violence. Health professionals are the second most commonly sought source of support for women experiencing domestic violence, after family and friends. Of women experiencing domestic violence, 30 per cent will seek advice from a general practitioner and 20 per cent from another health professional. On average, eight women are hospitalised each day due to intimate partner violence, and the rate is rising. The person that a woman reaches out to, to disclose violence at home, will likely be one of us. Yet, medical students don’t feel as if medical school adequately prepares them to respond to disclosures of intimate partner violence.

Medical student representatives across Australia recently unanimously endorsed a position calling for improved access to education and training around intimate partner violence. In 2015, a study showed that the median time spent on intimate partner violence in Australian medical schools, across all years of the curriculum, was only two hours¹. One can only assume that access to education in this area after medical school is less again. Intimate partner violence is the greatest contributor to mortality and morbidity among women aged 18 to 44 in Australia. It outranks smoking, illicit drugs, and obesity. Yet the burden of illness is not reflected in the time dedicated in medical curricula or training.

Intimate partner violence is a complex and distressing topic, making it hard to teach but even more difficult for professionals to respond to without adequate training. Students must be taught to recognise intimate partner violence, assess risk, document disclosures, record evidence and understand legal implications. Medical practitioners are under-prepared to respond appropriately, which risks reinforcing women’s feelings of powerlessness and violation. This is a whole society issue, and action is needed not only from medical schools, but from medical training colleges, health services, Governments (Federal, State and Territory), and individual practitioners and students. When a woman reaches out she must find someone who is equipped to help. As future doctors we know we will be faced with disclosures, and when we are, we want to be prepared.

In the wake of the tragic death of Eurydice Dixon, students and young women reckoned with an awful paradox; despite entreaties to be safe and stay home, they often aren’t safer at home at all. One medical student told me she began university in Melbourne when Jill Meagher was murdered, and is graduating as Eurydice Dixon was killed. These seemingly random acts of violence remind us to fear what we do not know, whilst distracting us from the facts we do; most women who die by violence will be killed by a man that they know. Our medical education must prepare us to help prevent that.

References

Valpied J, Aprico K, Clewett J, Hegarty K. Are future doctors taught to respond to intimate partner violence? A study of Australian medical schools. Journal of interpersonal violence. 2017;32(16):2419-32.

My Health Record important, but let’s fix the problems

BY ASSOCIATE PROFESSOR ANDREW C MILLER, CHAIR, MEDICAL PRACTICE COMMITTEE

The policy problems the My Health Record seeks to address are genuine. The Australian health system operates as a collection of disconnected siloes. Patient records exist as isolated fractions scattered among their treating doctors. Without the MHR there is no other institutional mechanism that facilitates the flow of patient information between healthcare settings, and between healthcare practitioners.

Many of the greatest failures in patient care and safety result when patients are required to move across the health system but their clinical information does not follow them.

At the recent Senate Community Affairs Inquiry into the My Health Record System, the Chair of the AMA’s Ethics and Medico-Legal Committee, Dr Chris Moy, used the following case study to illustrate the practical benefits generated by a My Health Record. The story was provided to Dr Moy by a colleague and an AMA member, Dr Danny Byrne. He wrote:

“Earlier this year I had a new patient move to Adelaide from Nepean Blue Mountains in NSW, one of the opt out trial areas.

He had a serious neurological condition and could no longer look after himself, so he had to move to Adelaide to be looked after by his brother.

Normally a new patient like this would arrive with little or no information. I would have to write to his GP and specialists in NSW for copies of his clinical records.

Invariably I would expect to receive little or no information. After weeks of waiting I would usually then start from scratch by repeating the patient’s tests and starting another merry-go-round of specialist referrals. This would be at huge cost of time and money in duplication of tests and specialist referrals already done in NSW.

However, in this case the patient had a MyHR. It was immediately able to see his NSW hospital letters and results of his investigations. Within minutes I was able to pick up the required treatment plan for him recommended by his NSW specialists and begin implementing it from day one in Adelaide. This was something I had never experienced before.

The savings in time, stress and money were enormous – for the patient, his family and the wider health system.

It is ironic that I received better information from a NSW hospital that uses MyHR than I get from my local hospital a few kilometres away from me that does not.

I can see clearly now how much better care can be for patients in an opt out world for MyHR.”

Despite general agreement on the need for an electronic health record, the debate about My Health Record data security and patient privacy reached fever pitch following the Minister’s announcement of the start of the three-month opt out period.

The hyperbolic nature of the media debate means that it is not easy to decipher between discussion of genuine flaws in the security and privacy of the My Health Record System, and ill-informed alarmism.

What we know

The My Health Record System has multiple layers of security. Software cannot connect to the My Health Record unless it is secure, encrypted and certified as conformant. All connected software is subject to automated checks to ensure it maintains conformity standards. To access the My Health Record System through a clinical information system a health practitioner must:

Install conformant clinical software;
Apply for a NASH PKI certificate for healthcare provider organisations;
Install the NASH PKI; and then
Access the system using local log on details.

Conformant clinical software assigns unique staff member identification codes. A log is automatically generated to record each time a patient’s My Health Record is accessed by a health provider organisation. It is unlawful to access a My Health Record unless it is for the purpose of providing treatment to a patient who is a registered patient in the healthcare practice. Unlawful access to a patient’s record is subject to criminal and civil penalties.

The privacy controls available to patients add further security to patient data. Patients can instruct their health provider at the point of care not to upload information they consider sensitive. They can put a Record Access Code across their whole record or an individual document so only the providers who have been given the pin code can see them. Patients can also set up alerts to receive a text or email notification if their Record is accessed by a new health provider. Patients can also remove documents from their Record.

This represents a logged communication chain that far surpasses the existing standard in the vast majority of institutions and practices.

Proposed amendments

At the President’s press club address in on July 25, he told journalists he would “do what-ever it takes” to prevent the rich data base of sensitive patient information in the My Health Record System being used by Governments for purposes unrelated to healthcare. The Minister responded quickly to these concerns and introduced a new bill – the My Health Records Amendment (Strengthening Privacy) Bill 2018 (the Bill).

The amendments in the Bill provide protection to data stored in the My Health Record data base that is substantially tighter than the controls that apply under the Privacy Act 1988 (Commonwealth) to patient data stored in the clinicians own patient records. If the Bill passes the Parliament, the system operator will be prohibited from releasing My Health Record information without a court/tribunal order and only for very limited purposes.

Australians who opt out will have their MHR extinguished; as will also happen when they die. There will be no centrally collated echo to prompt privacy concerns.

Fit for purpose?

If the Bill passes Parliament and authorised disclosure concerns are addressed, will the My Health Record then be fit for purpose and acceptable to doctors? Depends who you ask. If you ask a Specialist, the answer is likely ‘no’.

Many Specialists remain deterred from connecting to the My Health Record because their clinical software providers have not invested in the upgrades necessary to provide seamless interoperability with the My Health Record System. Most specialist software does not provide the option to upload Specialist letters, despite this being the most important function for Specialists’ communication. It is time for Government intervention to remove this barrier to Specialist participation.

Specialists have not received anywhere near the same level of support to adopt the My Health Record as that provided to general practitioners over a number of years to date. It is vital this Government does not repeat the mistakes of the United Kingdom where they realised too late they had failed to provide sufficient technical support to clinicians who had trouble using the e-health records. Apart from the problematic interoperability between Specialist software and the My Health Record System, the compliance obligations on and doctors are substantial. Much more needs to be done to help specialists engage with the My Health Record if it is to succeed.

[Viewpoint] Repositioning Africa in global knowledge production

Sub-Saharan Africa accounts for 13·5% of the global population but less than 1% of global research output. In 2008, Africa produced 27 000 published papers—the same number as The Netherlands. Informed by a nuanced understanding of the causes of the current scenario, we propose action that should be taken by African universities, governments, and development partners to foster the development of research-active universities on the continent.

[Correspondence] Canine rabies vaccination reduces child rabies cases in Malawi

In 2012, the largest ever case series of rabies from a single site in Africa was published by The Lancet.1 On World Rabies Day 2018 (Sept 28, 2018), we can report a pronounced fall in the number of cases presenting to that site, following a successful mass canine vaccination programme implemented by the non-governmental organisation, Mission Rabies.

More subsidised MRI scans made available

New Medicare-subsidised MRI licences have been granted in an additional 30 locations around Australia.

More than 400,000 Australians will now be able to access lifesaving scans for cancer, stroke, heart and other medical conditions.

The Government has allocated $175 million for the rollout, with the first 10 hospitals to receive the new Medicare support being:

Mount Druitt Hospital, New South Wales
Sale Hospital, Victoria
Royal Darwin Hospital, Northern Territory
Mount Barker, South Australia
Pindara Private Hospital, Gold Coast, Queensland
Northern Beaches Hospital, New South Wales
Toowoomba Hospital, Queensland
Monash Children’s Hospital, Clayton Victoria
St John of God Midland Public and Private Hospital, Western Australia
Kalgoorlie Health Campus, Western Australia

Health Minister Greg Hunt said each of the sites had been identified as a location of critical patient need. In many cases hospitals already have this technology, ready to provide services from November 1 this year.

“Not only will our new Medicare support ensure patients get the most appropriate treatment and save money, it will also cut down the amount of time patients have to spend travelling to get a scan,” the Minister said.

“Medicare subsidised MRIs will be accessible in these locations from 1 November 2018, subject to the sites meeting the required approvals and administrative requirements.”

A competitive public application process for the location of a further 20 Medicare eligible MRIs has also been opened.

Shadow Health Minister Catherine King welcomed the new licences, but said the Government was only following Labor’s move on the issue.

“After five years of abject failure when it comes to the cost of medical scans, the Liberals have finally decided to follow Labor’s lead and award more Medicare-subsidised MRI licences,” Ms King said.

“When Labor was last in Government, we awarded 238 MRI licences – delivering more affordable scans to hundreds of communities across the country.

“In May this year, we promised a Bill Shorten Labor government would invest an extra $80 million to deliver a further 20 licences in locations of pressing need.”

Mr Hunt pointed out that earlier this year, the Government boosted Medicare support for a new MRI scan for prostate cancer checks helping 26,000 men each year. It also provided a new Medicare listing for 3D breast cancer checks, helping around 240,000 women each year.

“The Liberal National Government has also announced an additional $2 billion investment in diagnostic imaging over the next decade,” he said.

“We are retaining the bulk-billing incentive and indexing targeted diagnostic imaging services including mammography, fluoroscopy, CT scans and interventional procedures.

“By contrast, Labor has only committed $80 million and not made any commitment to the re-indexation of diagnostic imaging rebates.”

An MRI is a commonly used medical scan which gives a detailed view of the soft tissues of the body such as muscles, ligaments, brain tissue, discs and blood vessels, and helps with the diagnosis of (among other things) cancer, cardiac conditions, trauma and sporting injuries.

Addictive vaping growing more popular with Aussie youth

New research shows e-cigarette use to be increasingly popular among young Australians.

The research, first published in the Australian and New Zealand Journal of Public Health (ANZJPH) and funded by Healthway, found that young e-cigarette users in Australia have a strong preference for flavoured varieties of vaping products.

Fruit flavours are particularly popular. E-cigarettes containing nicotine are also widely popular with young Australians.

The study included an online survey of more than 1100 young adults aged 18 to 25 in Australia.

Lead author Dr Michelle Jongenelis, Research Fellow at Curtin University’s School of Psychology, said: “These results show what many health professionals have suspected for some time now, that young people are indeed vulnerable to the marketing and advertising of electronic cigarettes and even those who have never smoked traditional cigarettes are increasingly interested in trying these devices.

“E-cigarettes are often marketed as a harmless yet glamorous product. They are available in a mind-boggling number of flavours designed specifically to appeal to young people. The fact that young Australians are responding to this marketing is highly concerning given the lack of evidence of the safety of the devices.”

There are widespread concerns among health professionals that the chemicals, heavy metals and additives in e-cigarettes pose risks to health including impaired breathing, cellular-level damage, changes to blood pressure and heart rate, and adverse effects on the nervous system.

In response to this new evidence, the Public Health Association of Australia said Australian Governments need to take the findings seriously and act accordingly.

“This should ring warning bells and highlights the need for greater vigilance around regulation and monitoring of such devices,” chief executive Terry Slevin said.

“The prime concern, at a time when a tiny number of teenagers are taking up smoking tobacco, is that these devices are harmful, addictive and may be used as a gateway to traditional cigarettes.”

As of 2016, fewer than one per cent of Australian children aged 12 to 15 year had ever tried smoking cigarettes, following decades of increasing tobacco control measures and awareness campaigns by Governments and health groups.

Yet this latest study suggests vaping is fast becoming the smoking product of choice for Australian youth.

A total of 89 per cent of the young people in the latest survey who used e-cigarettes prefer the flavoured varieties. Two thirds of young users preferred e-cigarettes with nicotine.

“(This) shows the potential for addiction to these devices. Their use as a gateway to smoking traditional cigarettes is a likely risk,” Dr Jongenelis said.

“It is critical we do everything in our power to resist any slide backwards on tobacco control in Australia. Until we have more data on the risks of e-cigarettes as a gateway to regular smoking there is a need for increased vigilance in regulation of the devices.”

New laws to help protect against critical medicine shortages

Medicine companies will have to report shortages of important medicines as soon as they occur, following the successful passage of new laws through Parliament.

The Government is hailing it as ‘landmark legislation’ aimed at protecting supply of critical and life-saving medicine to Australian patients.

The new law also insists that if a critical drug is being removed from the market, the Health Department must be notified by the manufacturer at least 12 months in advance, or as soon as possible.

Health Minister Greg Hunt said the new law protects patients who rely on vital medicines, and also gives the community, medicine companies and patients the opportunity to take action to mitigate against a medicine shortage.

Mandatory reporting will apply to all prescription medicines as well as other medicines that are vital for public health, such as EpiPens and inhalers.

Tough penalties will apply to companies that do not comply with these new laws, including fines of up to $210,000 for each infringement and the possibility of further court action.

“I make no apologies for taking a hard-line approach to ensuring patients aren’t kept in the dark about a potential medicine shortage,” Mr Hunt said.

“A shortage that will severely impact on patients must be notified to the Therapeutic Goods Administration (TGA) as soon as possible, and no later than two working days after the medicine company knows or should know of the shortage.

“Medicine shortages have become an increasing problem in recent years, as medicine companies (manufacturers or importers) have failed to comply with the current voluntary reporting scheme.

“Earlier this year, Australia was one of several countries hit by a shortage of EpiPens, which provide lifesaving adrenalin for people who have had an acute allergic response.

“In this and a number of other cases, the shortages were not reported in advance to the TGA within the Department of Health. As a result, patients and doctors were not alerted in time for them to make alternative arrangements.”

Under the new law, a critical medicine is deemed to be in shortage if there is not enough, or likely will not be enough, for all patients in Australia who take it or may need to take it, at any time in the next six months.

Responses to a shortage could include re-directing the available supplies to patients who need them most, nominating alternative treatments and providing Pharmaceutical Benefits Scheme coverage for the alternatives.

Medicine companies must also notify the department of shortages that will not have a severe impact on patients. They will have up to 10 working days to do so.

“Shortages cannot always be avoided but, when they do occur, this mandatory reporting scheme will help Australian patients and health professionals to be more prepared,” the Minister said.

“I want to thank the medical sector who have worked closely with my Department and the TGA on improving the process for reporting medicines shortages and their willingness to improve the system through legislative change.

“In particular I want to thank Medicines Australia, the Australian Medical Association, the Society of Hospital Pharmacists of Australia, the Pharmacy Guild of Australia, the Australian Self Medication Industry, the National Pharmaceutical Services Association, the Pharmaceutical Society of Australia and the Generic and Biosimilar Medicines Association.

“These groups have worked collaboratively together and with Government to design a new approach that will support and protect Australian patients.”

The new mandatory reporting scheme for medicines shortages is included in the Therapeutic Goods Amendment (2018 Measures No. 1) Bill 2018, passed by the Senate in September.

The new law will come into effect on 1 January 2019.

Australia helps more PNG mums and babies

Thousands more newborn babies and their mothers will be helped in Papua New Guinea, with the expansion of a successfully piloted project across the country.

Australia’s aid program has injected more funds into the project.

The innovative program, known as the maternal and newborn care project, focuses on preventing neonatal hypothermia in newborns and managing bleeding after delivery, which is a common cause of death in mothers.

The United Nations Children’s Fund (UNICEF), in partnership with the Papua New Guinea National Department of Health, will expand the program now the funds have been committed.

“Once implemented, this initiative will save the lives of thousands of newborns and their mothers, as well as provide training to parents, carers and health workers about caring for babies over the first month of life,” said UNICEF Australia’s Felicity Wever.

“A key element of this initiative is an anti-hyperthermia bracelet, known locally as Bebi Kol Kilok, which will help prevent annual deaths from hyperthermia among approximately five thousand premature and newborn children.”

Papua New Guinea has the highest rate of newborn deaths in the region, with about 6000 babies dying every year before they reach four weeks of age.

Aside from addressing critical child survival issues, the project involves care of mothers through active management of the third stage of labour, prevention and management of post-partum haemorrhage and maternal anaemia, as well as early detection and referral of sick mothers by community health workers.

PNG Health Minister Sir Puka Temu said: “Our Government is focused on reducing the high maternal and neonatal mortality rates. This is a highly cost-effective intervention. I’m also very excited that fathers are recognizing the important role they can play in baby care by holding the baby close to their body for warmth.”

The Australian Government’s funding support will enable UNICEF to work with the PNG Government to strengthen capacity in the hospitals and health facilities that will deliver the care of newborns and mothers, to assess and remove bottlenecks in the delivery of these care services and to empower communities with skills to continue care at home.

In collaboration with the PNG Health Department, UNICEF will work directly with provincial health offices, district authorities, church health services and local non-government organisations.

Together, they will roll out the first round of the program in all provincial hospitals and district facilities. Seven additional districts will roll out community based maternal and newborn care in facilities that deliver more than 50 babies per year.

World doctors condemn torture in Uganda

The World Medical Association has rebuked the Government of Uganda, followed reports detainees in the East African nation are being tortured and denied access to specialised medical care.

Dr Yoshitake Yokokura, WMA President, has written to Uganda’s Prime Minister Ruhakana Rugunda to express the WMA’s revulsion at what he described as “the pervasive practice of torture” in Ugandan detention places.

The letter sets out details of the violence and rape that the Uganda Human Rights Commission discovered when it visited detention centres.

It also reinforces the call from the Uganda Medical Association to respect the rights of patients and to protect doctors documenting and denouncing torture in Uganda.

The letter states: “Torture and other cruel or degrading treatments are one of the gravest violations of international human rights law. It destroys the dignity, the essence of the human being. As physicians, we are revolted by the devastating consequences of this practice for victims, their families and society as a whole, with severe physical and mental injuries.”

The letter calls on Uganda’s Prime Minister to take immediate and effectives measures to prevent and stop such intolerable shaming practices and to be an inspiring model for other countries.

“We have received appalling reports about a number of detainees in Uganda being tortured while under arrest and then denied access to medical attention, even when the Uganda Medical Association has offered to help them,” Dr Yokokura said.

“Such activities are especially disappointing, since Uganda is one of only 10 African countries with anti-torture legislation and is a signatory to the United Nations Torture Convention.

“Torture is unconditionally prohibited by the United Nation Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment that Uganda ratified in 1987, hereby establishing its consent to be bound by the provisions of the Convention.

“No exceptional circumstances whatsoever, whether a state of war or a threat of war, internal political
instability or any other public emergency, may be invoked as a justification of torture.”

The letter concludes: “We call on you to act as a matter of priority to ensure effective access to comprehensive health care to those in need and to allow and ensure that physicians can follow their ethical duties to provide medical care in an undisturbed and professional manner without intimidation and repression.”

More money to fight STDs, please Mr President

The United States of America has the highest sexually transmitted disease rate in the industrialised world, and health experts say it is only a lack of resources that prevents them getting on top of the problem.

Public health experts in America recently called on US President Donald Trump to declare a public health emergency over the rapid spike in STDs across the nation.

The rate of STDs has increased in the US four years in a row, with cases of gonorrhoea, syphilis, and chlamydia rising by 200,000 between 2016 and 2017, to a total of 2.3 million.

The National Coalition of STD Directors has said the results mean the US has the highest STD rates in the industrialised world.

It also said a fall in public health funding and resources is to blame.

The organisation has called on President Trump and Health and Human Services Secretary Alex Azar to intervene and to declare STDs in America a public health crisis.

“What goes along with that is emergency access to public health funding to make a dent in STD rates and to bring these rates down and make sure all American get access to the health care they need,” said the Coalition’s executive director David Harvey.

He added that $70 million in government funding was needed immediately, and $270 million needed for the 2019 financial year.

Michael Fraser, executive director of the Association of State and Territorial Health Officials, put it even more bluntly when calling for more government funding.

“We know what works for STD prevention,” he said. “We just don’t necessarily want to pay for it.”