A July poll?

It appears increasingly likely the country will go to the polls on 2 July after Prime Minister Malcolm Turnbull brought forward the Budget and recalled Parliament to debate controversial industrial laws.

A week after pushing through Senate voting reforms, Mr Turnbull announced the Federal Budget would be delivered on 3 May, a week ahead of schedule, and Parliament would resume on 18 April so the Senate could debate legislation to reinstate the Australian Building Control Commission.

By bringing forward the Budget, the Prime Minister has created room to call an early July election if, as is expected, the Government fails to muster the support in the Senate it needs to pass the ABCC Bill.

The Government needs the support of six crossbench Senators to have the legislation become law, but just two have indicated they would back it. Three have said they will oppose it, and three others are uncommitted.

If the Bill is rejected, it would give Mr Turnbull a trigger to call a double dissolution election, which the Government hopes – thanks to the Senate voting reforms – would wipe out many of the minor party and independent Senators and deliver it a working majority in the upper house.

If the Government goes ahead with a 2 July poll, it means the AMA National Conference will take place in the thick of the election campaign, providing an opportunity to boost health and health funding as an election issue.

Adrian Rollins

Time to raise the minimum purchasing age for tobacco in Australia

Increasing the minimum purchasing age may be the most straightforward way towards a tobacco-free generation

Australia is often described as a global leader in tobacco control. While this is true, it has taken two generations to reduce current smoking rates to around 15% of the population, and there is still a long way to go, especially in disadvantaged communities.

Tasmania’s tobacco-free generation

One innovative idea on the road towards minimising smoking rates is currently before the Parliament of Tasmania. Put simply, passage of the Public Health Amendment (Tobacco-free Generation) Bill 20141 would ensure that people born after 1999 could not lawfully purchase tobacco at retail outlets within Tasmania in their lifetimes.2

The Tobacco-free Generation Bill was introduced into the Legislative Council by independent member Ivan Dean, whose father was a chain smoker and who suffered terribly before dying from lung cancer.2 The Bill is currently being considered by a Parliamentary Committee, and public submissions can be viewed online.3

The Tobacco-free Generation Bill defines a member of the tobacco-free generation as “a person born on or after 1 January 2000”.1 Although the Bill does not prohibit smoking by a member of the tobacco-free generation, it does create a new offence for retailing tobacco within Tasmania to such a person, with a first-time penalty of up to $7700.1 By contrast, there would be no offence for retailing tobacco to adults born before 2000. As time passes, the legislation would create two distinct classes: adults who, by virtue of being born before the year 2000, would be entitled to continue to purchase tobacco during their lives; and adults of the tobacco-free generation, born after 31 December 1999, who would be forever unable to purchase tobacco lawfully in Tasmania.

The Bill would create an offence for a member of the tobacco-free generation to use a false proof of age to purchase tobacco, with a fine of up to $540. However, it would not penalise friends or family members from purchasing tobacco that was subsequently consumed by a member of the tobacco-free generation, provided that the tobacco was given, rather than sold, to that person.1,2

In its submission to the Committee, the Tasmanian Government raised concerns that the Bill would encourage interstate and internet purchases of tobacco by smokers who were members of the tobacco-free generation, thereby undermining the goals of the Bill. It pointed to the Tasmanian Population Health Survey as evidence that current policies were reducing smoking rates effectively.4

Predictably, the Bill has been opposed by tobacco manufacturers. One submission by a retailer on Flinders Island suggests that Imperial Tobacco systematically urged retailers to lobby the Legislative Council against the Bill.5

Seizing the opportunity for leadership in tobacco control in Tasmania

Tobacco is more than just the “risky product” that tobacco companies claim it to be. If today’s smokers do not quit, a majority will die prematurely from tobacco-related diseases. A study by Banks and colleagues published in 2015 suggests that about two-thirds of deaths among current smokers are caused by smoking.6 The authors followed more than 200 000 smokers aged over 45 years, for 4 years, showing that even ten cigarettes daily doubles a person’s risk of dying prematurely. As Tasmania’s popular former Premier, Jim Bacon, said in 2004, when he quit politics following a diagnosis of lung cancer: “The message from me to everyone is please don’t be a fool like me, don’t keep smoking, try and give it up and if you are young and you haven’t started, don’t start”.7

The idea of legislating for a tobacco-free generation is one of a growing number of tobacco endgame scenarios promoted by tobacco control advocates.8 While it is plausible that the Bill could discourage smoking initiation by members of the tobacco-free generation, it is possible that the Bill might also inadvertently create a permanent “outlaw class” of adults addicted to tobacco but unable to purchase it lawfully within Tasmania. Achieving acceptance about why two adults of different ages should be treated differently in terms of their right to access tobacco is one of the challenges the Bill faces.

If the Tobacco-free Generation Bill does not succeed, the opportunity remains for Tasmania to show national leadership by raising the minimum purchase age for tobacco to at least 21 years. A higher minimum purchase age would make it more difficult for youth to access tobacco at the ages when they are most vulnerable to smoking initiation.

The case for raising the minimum purchasing age for tobacco

The case for a higher minimum purchasing age is supported by four key factors. According to the National Drug Strategy Household Survey (NDSHS), in 2013 Tasmania’s daily smoking rate for people aged 14 years and above was 16.1%. This is second only to the Northern Territory (21.3%) and well above the national average of 12.8%.9 The same survey found that 31.6% of Tasmanians aged 18–24 years were daily smokers — more than twice the Australian average of 13.4% for this age category.9 In its submission to the Parliamentary Committee, the Tasmanian Government quoted the Tasmanian Population Health Survey 2013, which estimated a 19.7% smoking rate for 18–24-year-olds, and a 15% smoking rate overall.4 The Tasmanian Department of Health and Human Services has acknowledged that due to its methodology, the Tasmanian survey significantly under-represented males and younger age groups.10 NDSHS estimates suggest that smoking rates remain alarmingly high in young adults and that innovative strategies are needed to ensure that Tasmania does not fall further behind the mainland states.

Second, a higher minimum purchasing age for tobacco could help to reduce high smoking rates among young pregnant women. In 2013, the average rate of smoking while pregnant was 12% nationally,11 but was 15% in Tasmania and in excess of 33% among pregnant Tasmanian women aged under 20 years.12

Third, a higher minimum purchasing age for tobacco could go a long way towards encouraging the creation of a tobacco-free generation, since few people begin smoking for the first time after their mid-20s. A 2013 study of smoking initiation rates in New Zealand confirmed that while initiation after age 24 is rare, the highest initiation rates occur among those aged 15–21 years. Over a 4-year period, the rate of smoking initiation for those aged 15–17, 18 and 19, and 20–24 years was 14.2%, 7.0% and 3.1%, respectively.13

Finally, in the United States, at least 30 cities and counties, including New York City, have set 21 years as the minimum purchasing age for tobacco products.14 Four states have raised the minimum purchase age to 19 years,14 and in June 2015, Hawaii raised it to 21 years for both tobacco products and e-cigarettes.15 If linked to a proof-of-age swipe card or so-called smoker’s licence, the right to purchase tobacco could be verified instantaneously.16

In its recent report, an expert committee of the US Institute of Medicine concluded that raising the minimum purchasing age for tobacco would delay initiation by adolescents, with the largest proportion of reductions being among teenagers aged 15–17 years.14 Based on modelling, the Committee concluded that while raising the minimum purchase age to 19 years would likely yield only a modest reduction in smoking initiation by 18-year-olds, raising it to 21 years would substantially reduce smoking prevalence and smoking-related mortality, given the numerous life transitions that young adults experience between 18 and 20 years. The Committee concluded that increasing the minimum purchasing age would also improve fetal, maternal and infant health outcomes by reducing the likelihood of maternal or paternal smoking.14

A survey of Australian secondary school students’ use of tobacco found that in 2014, nearly 18% of 16–17-year-old smokers purchased their last cigarette from a commercial source.17 This finding underscores the need for rigorous enforcement of existing laws to further reduce the retail availability of tobacco to underage youth. However, the fact that current underage smokers mostly obtain their tobacco from non-commercial sources does not demonstrate that current age restrictions have no impact on youth smoking rates, nor that a higher minimum age would be similarly ineffective. Rigorously enforced age restrictions reduce tobacco purchase attempts and youth smoking rates,14,18,19 although their impact is likely to be strengthened when integrated within a comprehensive set of tobacco control policies that maintain high retail prices and de-normalise tobacco use.14,20 These features would likely boost the impact of youth access laws by reducing or interrupting sources of social supply, inhibiting initiation and leading to decreased tobacco use rather than mere substitution of purchased tobacco with tobacco from social sources.20

Summary

The time has come for Australian state governments to seriously consider raising the minimum purchasing age for tobacco. If the Tasmanian Parliament fails to support the Tobacco-free Generation Bill, as seems likely, a higher minimum purchasing age could reinforce efforts to reduce smoking initiation and help to address the significant health inequalities that Tasmanians experience relative to the mainland states. Simple amendments to the provisions in the Public Health Act 1997 (Tas) that govern underage smoking could raise the minimum purchasing age and encourage the creation of a tobacco-free generation. In late December 2015, the Tasmanian Government released a 5-year strategic plan for health that includes raising the minimum legal smoking age to 21 or 25 as an option for consideration.21 This is welcome news. Rigorous monitoring and enforcement of legislative amendments to raise the minimum purchase age for tobacco would strengthen social norms against youth smoking, and generate data that could inform tobacco control policies in other states.

News briefs

CSIRO finds new way to harvest stem cells

Scientists at the CSIRO have found a new way to harvest stem cells which reduces the time required to obtain adequate numbers of cells, without the need for a growth factor, according to research published in Nature Communications. “Current harvesting methods take a long time and require injections of a growth factor to boost stem cell numbers. This often leads to side effects. The method … combines a newly discovered molecule (known as BOP), with an existing type of molecule (AMD3100) to mobilise the stem cells found in bone marrow out into the bloodstream. Combining the two molecules directly impacts stem cells so they can be seen in the blood stream within an hour of a single dosage.” The researchers also found that “when the harvested cells are transplanted they can replenish the entire bone marrow system, and there are no known side effects”. The next step is a Phase I clinical trial assessing the combination of BOP molecule with the growth factor, prior to the eventual successful combination of the two small molecules BOP and AMD3100. The research was done in collaboration with the Australian Regenerative Medicine Institute at Monash University.

Trial deaths spark idelalisib safety warning

The Therapeutic Drugs by Administration (TGA) is reviewing information provided the manufacturers of cancer drug idelalisib (marketed as Zydelig) after some patients died while taking the drug in clinical trials overseas, the ABC reports. “The TGA said the drug was first prescribed in 2015 to patients with rare blood cancers like chronic lymphocytic leukaemia and non-Hodgkin’s lymphoma, who have failed other treatments. The drug works by blocking particular proteins inside cancer cells that encourage the cancer to grow. Drugmaker Gilead Sciences Inc was carrying out six clinical trials to find out whether idelalisib could be a frontline treatment, rather than a last resort for terminal patients. The company said adverse events were discovered during the trials, but would not say how many patients died or suffered serious side effects.” A spokesman for the TGA said doctors should avoid using idelalisib as a first-line treatment. “Patients starting or continuing treatment with idelalisib should be carefully monitored for signs of infections,” the TGA spokesman said. Lymphoma Australia said it was also concerned for patients using the drug. “We strongly advise anyone taking it to talk to their doctor and perhaps consider an alternative treatment,” said Lymphoma Australia’s chief executive Sharon Millman.

Zika link to microcephaly supported

New research published in The Lancet estimates that the risk of microcephaly is about “1 for every 100 women infected with the Zika virus during the first trimester of pregnancy”, based on data from the 2013–14 outbreak in French Polynesia. The outbreak began in October 2013, peaked in December 2013 and ended in April 2014. Over that period, more than 31 000 people saw their doctor with suspected Zika virus infection. Over the course of the outbreak, eight cases of microcephaly were identified. Of these, five pregnancies were terminated through medical abortion (average gestational age 30.1 weeks), and three cases were born. The authors, from the French Institut Pasteur, said that the risk, although low, remains an important public health issue because the risk of Zika virus infection is particularly high during outbreaks, such as the current one in South America. A linked comment in the same issue said: “Further data will soon be available from Pernambuco, Colombia, Rio de Janeiro, and maybe other sites … The fast production of knowledge during this epidemic is an opportunity to observe science in the making: from formulation of new hypotheses and production of new results that will provide confirmations and contradictions to the refinement of methods and the gradual building of consensus.”

Dramatic shift on concussion findings

The National Football League, the United States’ highest-profile sports competition, has finally admitted that the game is connected to high rates of chronic traumatic encephalopathy (CTE), the degenerative brain disease found in nearly 100 of its former players, the New York Times reports. After years of denying evidence from medical experts, a senior NFL official, speaking at a round-table discussion with US policymakers, was asked if there was a link between football and degenerative brain disorders like CTE. Jeff Miller, the NFL’s senior vice president for health and safety policy, said: “The answer to that is certainly, yes.” Lawyers for some players involved in a lawsuit with the NFL over its handling of brain injuries quickly seized on the league’s admission. The NYT reports: “The NFL’s denials of any link between football brain trauma and CTE began before the first case was even identified. In a study published in the journal Neurosurgery, which examined head injuries sustained by players from 1996 through 2001, the league’s committee on concussions said that no player had developed the disease — even though CTE can be diagnosed only by examining brain tissue after death, and no deceased player had ever undergone such a procedure.”

[Comment] Offline: The rule of law—an invisible determinant of health

In January, 2016, in Beijing, Randall Rader, a former Chief Justice of the US Court of Appeals for the Federal Circuit, gave a speech to a private gathering of Chinese Government officials. He had been invited to set out his assessment of China’s progress towards the creation of an effective legal system. “The law is the foundation of all prosperity”, he argued. By prosperity he didn’t mean only wealth. He included all aspects of a society that underpin its peaceful order and good functioning, including health.

Whiff of an election

With rumblings of an early (or at least earlier) double dissolution election gathering pace in Canberra, the AMA is refining its pre-election strategy. The key policy issues are well documented in the AMA’s pre-Budget submission, which can be read on the AMA website.

The focus of AMA’s advocacy remains unchanged. This includes ensuring adequate Commonwealth funding of the public hospital system, with changes required to the proposed arrangements with the states that were announced in the 2014 Federal Budget.

The second concern is with the sustainability of primary care as the most cost-effective and efficient part of the health system. The ongoing freeze to Medicare rebates has not stopped the rise in bulk billing rates, but it does mean that general practitioners have to make difficult choices about the way they deliver optimal care to their patients.

The third concern is ensuring the value of the private health system, which will be informed by the several reviews currently underway at the instigation of the Federal Minister for Health. These include the review of the MBS, the review of private health insurance and, as a corollary to that review, a review of the benefits paid by private health insurers for prostheses listed on the Prostheses List.

The AMA also remains concerned with the gap in Indigenous health outcomes, and the impact that a series of Budget cuts have had on areas of health most relevant to Indigenous communities.

Elsewhere in this edition of Australian Medicine is a report on the recent forum convened by the AMA on the heath of asylum seekers in detention, particularly children.

The forum was well attended by doctors, nurses, and other health care workers, with speakers highlighting the health issues faced by detainees. The forum endorsed the call by the AMA for four outcomes, including independent oversight of the health of asylum seekers in detention.

A small number of members have queried the AMA’s involvement in the debate about asylum seeker health. There is clear Federal Council policy that backs the AMA speaking on the issue – not on the question of Australia’s border protection laws, but on the more focused issue of health care.

The AMA’s National Conference is coming up at the end of May, with early registration now available via the Federal AMA website – www.ama.com.au.

One of the key events is a debate about assisted dying, and this presents an opportunity to explore the views of AMA members. The debate forms part of the regular five-year review of current AMA policy. The session will be facilitated by Tony Jones of Q&A fame.

Nominations have been called for several awards which are given as part of National Conference. These include the AMA Woman in Medicine Award and the AMA Excellence in Healthcare Award, as well as several more specific public health awards. I encourage you to consider nominating suitable candidates for these prestigious awards.

Teledermatology and clinical photography: safeguarding patient privacy and mitigating medico-legal risk

Teledermatology is an innovative model of health care that has the potential to deliver significant benefits for both patients and medical practitioners. These include increased access to specialist services and reductions in travel times, waiting times and costs for patients, and reduced professional isolation and improved access to professional education for doctors.

“Store-and-forward” is a popular form of teledermatology. It involves capturing a still clinical image that is forwarded to a specialist, who later responds with an opinion on diagnosis and management. Teledermatology at the Princess Alexandra Hospital is a successful example of this model of care.1,2

As dermatology is a visually oriented specialty, using digital images for diagnosis is a natural fit. Numerous studies have already shown the diagnostic accuracy and reliability of store-and-forward teledermatology. More rapid diagnosis and initiation of treatment coupled with improved patient outcomes have also been demonstrated.1,3,4

The growth of store-and-forward services coincides with the increasing use of email, faster Internet speeds, the development of electronic health records and the advent of smartphones. Importantly, smartphones provide an accessible mode of capturing and transmitting patient images.

To date, at least two studies have surveyed the use of clinical photography in two separate Australian tertiary hospitals.5,6 Both showed that the use of personal smart phones for capturing clinical images was widespread. However, both studies also revealed inadequate privacy practices, including inconsistencies in the consent process, inappropriate disclosure of images to third parties and poor security practices when personal devices were used.

Mitigating the risks

In Australia, medical indemnity insurers have identified privacy as an emerging medico-legal risk for the profession.7 Breaches of privacy may result in legal action against and reputational damage for individuals and institutions.8,9 Individuals also risk being the subject of a complaint to the Australian Health Practitioner Regulation Agency (AHPRA), a health complaints entity, or an internal hospital investigation.7

In 2014, the Australian Medical Association (AMA) in conjunction with the Medical Indemnity Industry Association of Australia (MIIAA) released a guide for medical students and doctors for the use of clinical imaging and personal mobile devices.7 Its main recommendations include:

ensuring the patient understands the reasons for taking the image, how it will be used, and with whom it will be shared;
obtaining informed consent before taking a clinical image;
documenting the consent process in the patient record;
having controls on mobile devices to prevent unauthorised access; and
deleting clinical images from mobile devices after saving them to patients’ health records.7

These recommendations highlight key privacy practices for practitioners. However, the AMA and MIIAA advise that the guide should always be read in conjunction with any relevant legislation, and hospital policies and contracts related to clinical images and the use of personal mobile devices.7

Mitigating the risk of breaches of patients’ privacy by health practitioners begins with an awareness of their privacy obligations under the law, together with the privacy protocols of their employer organisations and professional indemnity insurers. Apart from explaining to the patients why an image is necessary, how it will be used, and who will see it when obtaining consent, the law also requires that health practitioners take reasonable steps to protect patient information (including images) from loss, disclosure, unauthorised access or misuse.8,9 Consider the following case scenario:

An elderly man presents to the emergency department of a regional base hospital with a new onset rash. The attending resident is not confident to make a diagnosis, but knows of a teledermatology service provided by a tertiary hospital in the nearest capital city. She asks the patient if she can “take some photos of the rash”. The patient agrees. She takes several photos of the patient with her personal smartphone and emails them, from her personal email address, to the on-call dermatology registrar at the tertiary hospital, requesting an opinion. The dermatology registrar reviews the images together with the patient’s history, and replies 2 hours later with a diagnosis of discoid eczema and a recommendation for management. Meanwhile, the dermatology registrar decides to use the patient images for a teaching session for the interns at the tertiary hospital.

Two weeks later the resident’s mobile phone is stolen. The phone had no security features enabled. The thief finds the patient’s images stored on the phone and uploads them to a public website. The thief also peruses the resident’s emails and finds details of the patient, and these are also shared publicly.

In the first instance, the resident should have made it clear to the patient that the purpose of taking the photo was to email the image to a specialist at another hospital to obtain an expert opinion on diagnosis and management. Further, notwithstanding the absence of a direct relationship with the patient, the teledermatology provider does not have consent to use the images for teaching, as the treating doctor did not obtain consent to use the images for this purpose.

Consent may be obtained orally or in writing, although practitioners should follow their institution’s guidelines. When consent is obtained orally, the consent process should be documented in the patient notes. Written consent must still be accompanied by a proper verbal explanation of the procedure.9

After the theft of her mobile phone in this case, the resident would be liable for a breach of privacy and confidentiality. She may also be in breach of the privacy and confidentiality obligations of her employment contract, as well as the conditions of her professional indemnity insurance. As a consequence, the resident could face disciplinary action from her employer or the Medical Board. The hospital may also be vicariously liable for the breach.9 Serious and repeated privacy breaches can attract substantial civil penalties for individuals and organisations under privacy legislation.

Technological precautions

The case above illustrates how easily a simple photograph can result in a costly legal dispute, not to mention untold harm to the patient. This situation could have been avoided if a number of simple precautions had been adopted.

An unlocked phone with patient photographs stored on it is a breach of privacy waiting to happen. Best practice dictates that patient images should be deleted from personal devices as soon as they are added to patients’ health records.7

As best practice may be overlooked during busy periods, security controls on personal smart phone devices, such as passcode locks, should be enabled to prevent unauthorised access. Installing remote locking or data wiping software to personal devices is recommended, as it will allow practitioners to delete data from their devices in the event of theft or loss.

Device settings should be adjusted so that clinical images on devices are not auto-uploaded to social media or back-up sites.7 Once a photo makes its way into the public domain via social media, it is very difficult to limit further sharing of that image.

The process of transmitting a patient image during the teledermatology consultation introduces an additional risk of a breach of privacy. Images should be transmitted via secure methods. Transmitting images through personal email or text messages is not considered secure by some sources, as such methods are typically not encrypted or password protected.10 Despite these concerns, the practice of emailing images is common in many hospitals. Practitioners should be familiar with the policies and systems of their institution or health service in relation to transmitting clinical images.

If a practitioner is required to send images by email or a text message to a colleague or specialist, they should send a test message first to ensure they have the correct email address or phone number for the intended recipient.7,10 Sending patient information or images to incorrect email addresses or phone numbers constitutes an automatic breach of privacy. Once sent, a practitioner has limited control over what the recipient does with that information. Ideally, one should encrypt or password-protect any images before transmitting them, although some may see this extra precaution as an inconvenience.

Like images, email or text messages that were part of the teledermatology consultation should be deleted from personal email accounts and devices after they have been uploaded to the patient record, as these may contain sensitive patient information that is still accessible if a device is lost or stolen. This includes emails saved in the “sent” folder. Automatic forwarding of emails to another email account should be disabled.

Practitioners should also consider the security of other devices that they use for sending emails. Computers and tablets with email management systems that allow email to be accessed on the desktop without logging in are a potential privacy risk. They should avoid sending patient images from an email address that is connected to an email management system. Practitioners should also implement automatic log off on computers and laptops at home and at work that are used to capture and store patient images, and change computer passwords regularly.

Where videoconferencing is being used, the room should be adequately sound-proofed and access should be restricted to those permitted according to the patient’s consent. Any videorecording of the consultation needs to be securely stored.

When consent for using an image for teaching or research purposes is appropriately obtained, best practice dictates that the image should be de-identified where possible, and must comply with relevant research or ethical guidelines.7 Identifying features such as birthmarks, tattoos, metadata, or even the condition itself, if it is rare, should be removed for such purposes.

Practitioner liability

Health care practitioners are personally responsible for patient information they choose to capture and transmit on their personal devices. Practitioners can limit their legal liability in the event of a breach of privacy by demonstrating that reasonable measures were taken to protect patient information. If a privacy breach does occur, clinicians should adopt an open disclosure approach, whereby the breach is notified and acted on. In these circumstances, practitioners should seek advice from hospital management and their medical defence organisations. Once appropriate legal advice has been sought, it may be necessary to inform the patient of the breach, and to explain and apologise.

Conclusions

It remains to be seen how health institutions and policy makers will tackle the issue of patient privacy in the new era of smart phones and teledermatology services. Fear of legal action should not preclude doctors from embracing novel approaches to health care that benefit patients and doctors. Rather, practitioners should take a few sensible precautions to reduce the likelihood of sensitive patient information falling into the hands of malicious third parties.

Before taking that next clinical photograph, individual practitioners should take a moment to review their own privacy practices and make any necessary adjustments. By doing so, practitioners can avoid the financial and emotional cost of a potential lawsuit in the future.

Recording consultations: a win–win situation for physicians and patients

Encouraging patients to record consultation summaries may improve health outcomes

Technology plays a significant role in medicine, and technological advances are constantly changing how medicine is practiced. Technology is also widely used by patients, who are now able to apply it in a medical setting. For example, the rapid adoption of smart phones, tablets and other personal electronic devices has made audio or visual recording of consultations relatively straightforward.

The recording of consultations is not a new concept. A 1990 study investigated the effect of video recording consultations on physician behaviour.1 The benefits of recordings for oncology patients have been well established.2–4 The technology available for recording has expanded dramatically over the past 25 years; however, it is unknown if doctors are aware of the potential clinical usefulness of recording consultations.

Physicians can enhance patient care by using personal electronic devices in their practice. A recent study showed that 69% of respondents wanted to record consultations, motivated by the desire to improve their care experience and share the information with others.5

Benefits of recording consultations

There are several benefits of encouraging patients to record consultations, and particularly to record a management summary at the end of a consultation.

Patient recollection

Compliance with management plans and subsequent health outcomes depend on a patient’s ability to recall the management plan in the first place. To promote patient recollection of a consultation, physicians can encourage patients to record the discussion of the management plan at the end of the consultation. This would allow patients to review the crucial information provided later in a familiar environment and without time constraints. The benefit of recording a consultation has been demonstrated in an oncology setting, where the use of audiotapes has been reported to improve patient recall and satisfaction.2 One patient from a non-English-speaking background commented that an audiotape allowed for slower review of the information, which may not have been fully understood when first discussed. A review examining the effect of providing recordings to people with cancer and their families recommended that physicians consider offering recordings as most patients find them useful,3 or even prefer4 recordings. Using recording devices with the aim of improving patients’ understanding and compliance with management may result in better health outcomes.

Patient empowerment

Patient autonomy should always be considered and prioritised in medicine. Patients have the right to share decision making with their physicians. One study identified patient empowerment as the prime benefit of recording consultations.5 Additionally, patients have used recordings to share information with family and friends.4 By offering patients the opportunity to record the management plan at the end of a consultation, physicians may provide patients with a sense of control.

Ease of use

Both audio and video devices can be used to record consultations. Audio devices are readily available as independent voice recorders and on mobile phones, and allow patients to easily review medical information. Video recordings might be particularly useful when practical techniques, such as the use of an inhaled medication, are being demonstrated.

Creative integrity of the physician

Providing patients with an opportunity to record the management plan at the end of a consultation maintains a physician’s ability to carry out the majority of the consultation without feeling pressured or scrutinised. Although one study showed no evidence that video recording altered a physician’s consultation behaviour, there were several factors that were not considered, and the authors noted that decision making could be degraded or enhanced.1

Avoiding surreptitious recording

Concerns about secret recording of consultations have recently been raised.6,7 In Australia, it is illegal to make voice or video recordings of private conversations without the other party’s permission except in Queensland, Northern Territory and Victoria. Furthermore, it is illegal to communicate or publish the recording to any third party without the other party’s permission in every state and territory.7 Despite this legislation, medical practitioners are still at risk of being involved in legal action as a result of surreptitious recording.8 Physicians may derail secret recording that is already occurring, or reduce the likelihood of secret recording, by offering patients the chance to record a consultation summary. The additional benefit is that the responsibility to initiate this opportunity is removed from patients, who may feel uncomfortable about asking to record consultations, or be concerned that their motives will be questioned.5

Risks of recording consultations

Although encouraging the recording of consultations may be beneficial, there are also risks to be considered.

How the recording is used

Perhaps the most important consideration is how the recording will be used, and by whom. Despite most states requiring permission from both parties to record interactions and all states requiring permission from both parties to share recorded information with a third party, there are situations in which the agreement of privacy may need to be broken. In the Surveillance Devices Act 2007 (NSW), for example, the prohibition to communicate information obtained by a listening device does not apply in the case of an offence against the Act, or if there is imminent risk of serious harm to persons or of substantial property damage (the Act, Section 11).

Documentation

In the case of a recorded consultation summary, a physician may consider keeping a copy of the recording for the medical record, which raises a number of potential difficulties. Physicians may ask patients to forward the recordings to be added to their medical records or may have to also record consultations. There is then the matter of how the recording might be stored. If an electronic records system is available, it may be possible to upload recordings to patients’ medical records. If not, other methods of secure storage of recordings would have to be found.

Time management

One critic argues that recording may lead to consultations taking longer.9 While one study investigating the effect of video recording on a physician’s consultation behaviour did find a 1 minute increase in consultation time, the increase was not significant.1 However, in that study, the recording equipment was already set up, whereas in a standard consultation, it may take additional time for the patient, physician or both to prepare recording devices. Furthermore, to ensure the recording has been successful, the physician may request that it is replayed, which would take time.

Conclusions

The decision by physicians to encourage the recording of consultation management plans is an individual one. If a physician does decide to allow recordings, there are several factors to consider. For example, which patients should be offered recordings? It may be appropriate to start with long term patients, with whom the physician has established a trusting doctor–patient relationship, those with chronic disease and subsequent complex management plans, or patients who have received bad news. It may also be necessary to highlight the intended use for recordings. Importantly, it may benefit the patient to discuss confidentiality and when the recording may be required to be produced.

The use of recording devices for oncology patients improves recollection and satisfaction. However, it is not known if physicians outside the field of oncology have used recordings in their practice, and to what extent both physicians and patients are aware of the potential value of recordings. There are benefits and risks to be considered, and the decision to encourage the recording of consultations will be made on a physician-by-physician basis. Overall, given the benefits for patients, we recommend that physicians should encourage patients to record a management summary at the end of a consultation.

Claims of sub-standard chronic care ‘blatantly wrong’

The AMA has hit back at “blatantly wrong” claims that GPs are failing to adequately care for patients with chronic illnesses.

AMA Council of General Practice Chair Dr Brian Morton said that although there was “no doubt” management of chronic disease could be improved, a Grattan Institute study accusing GPs of serial shortcomings in their care of patients with chronic illnesses including diabetes, asthma, heart disease and mental illness, was flawed.

Using data drawn from 162 medical practices using the Medical Director patient management system, the report, Chronic failure in primary care, claims that just 15 per cent of diabetic patients had their blood glucose, weight and blood pressure checked every year, less than 30 per cent with high blood pressure had it adequately managed and two-thirds of patients with a mental illness missed out on care.

But Dr Morton strongly disputed the findings, which he said did not stand up to scrutiny.

For instance, he said, the proportion of Australians admitted to hospital with uncontrolled diabetes was 7.5 per 100,000 – one of the lowest rates among rich countries and well below the United Kingdom (23.9 per 100,000).

The Grattan Institute report itself admitted the paucity of data available to assess the effectiveness of the primary health system in managing complex and chronic disease, which Dr Morton said meant its analysis and conclusions must be treated with caution.

The report’s author, Professor Hal Swerrison, used the findings of the report to argue that the Government was getting a poor return on the $1 billion a year it provided to GPs to prepare chronic disease plans and conduct health assessments.

To rectify this, Professor Swerrison recommended that Medicare rebates be frozen at current levels and funds currently provided through the Practice Incentives Program, Service Incentive Payments and other sources to support chronic disease management be instead combined into an annual $40,000 payment to practices based on achieving performance targets and health outcomes.

A similar model was considered in the Primary Health Care Advisory Group report presented to Health Minister Sussan Ley late last year, as well as a blended model of fee-for-service and so-called capitation payments. The Minister is yet to formally respond to the report.

In its submission to the Primary Health Care Advisory Group, the AMA expressed support for a blended payment model and reform of Medicare chronic disease items to strengthen the role of a patient’s GP, cut red tape, streamline access to allied health care and reward longitudinal care.

Dr Morton said any changes to the model of care needed to be carefully considered and tested before being introduced, and a much more urgent priority was to lift the freeze on Medicare rebates.

“The burden of complex and chronic disease in this country continues to grow, and the Government needs to take a long-term view if it is to tackle this problem effectively,” he said. “The Government needs to invest significantly in general practice, [including] immediately lifting the current freeze on the indexation of Medicare rebates.”

He said the Grattan Institute report also highlighted the need for much better primary health care data: “There is very little data as to what actually works in Australia in the primary care space. Yes, we need data, and we need to collect it.”

The AMA has proposed a PIP incentive payment to support quality improvement, “informed by better data collection”.

Last month, pharmacists outlined the scope of their ambitions for involvement in the provision of health services, particularly chronic care.

Pharmacy Guild of Australia Executive Director David Quilty told a parliamentary inquiry into chronic disease prevention and management that pharmacies could play an “enhanced role” in a number of areas including: transitional care, continued dispensing and prescription renewal, treatment of minor ailments, vaccination, medicine adherence, point of care testing, risk assessments, early intervention, broader diabetes management, treatment of patients through biologics, asthma support, improved after-hours access to primary health care, illicit drug use and the use of pharmacies as rural health hubs, with a strong focus on triage services.

While the AMA has highlighted the risk to patients of allowing pharmacists to administer vaccines, conduct health tests and provide other services outside their scope of expertise, it has proposed the introduction of non-dispensing pharmacists in general practices as a way to help improve medication management, particularly for the chronically ill.

Adrian Rollins

AMA in the News

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

Focus on health wins, Northern Territory News, 20 February 2015

AMA President Professor Brian Owler visited health facilities in Alice Springs, as well as the Indigenous communities of Utopia, Ampilatwatja, and Kintore. Professor Owler said Indigenous health gains might be slow, but it is important successes are not lost in a sea of depressing statistics.

Angry medicos urge action over plight of detainees, Sydney Morning Herald, 22 February 2016

AMA President Professor Brian Owler has savaged the Department of Immigration and Border Protection for what he says has been its intimidation of doctors who speak out about the plight of asylum seekers.

Row stymies e-health rollout, AFR Weekend, 27 February 2016

Pharmacists and doctors are feuding over the Federal Government’s struggling electronic My Health Record system. AMA President Professor Brian Owler said the organisation backed e-health records as a way of controlling health costs, but the Government had failed to ask medical specialists what they needed to make My Health Record work.

Hangover cure no miracle as clinic closes, Sun Herald, 28 February 2016

NSW health authorities have launched an investigation into a national chain of hydration clinics after a Sydney woman was hospitalised following an intravenous vitamin infusion sold as a miracle hangover cure. AMA Vice President Dr Stephen Parnis has accused those behind the IV infusion trend of bringing the medical profession into disrepute.

Patients to feel pain as cuts bite, Adelaide Advertiser, 11 March 2016

Across Australia, public hospitals will lose more than a $1 billion in federal funding next year. AMA President Professor Brian Owler said as hospital capacity shrinks, doctors won’t be able to get their patients into hospital or keep them there to receive the critical care they require.

AMA warns of hospital funding crisis as cuts bite, Sydney Morning Herald, 11 March 2016

Hospitals are limiting surgery hours and forcing patients to wait longer for elective procedures as an economic disaster looms. AMA president Brian Owler said patients with life-threatening conditions such as cancer would wait longer for surgery, while emergency departments would struggle to treat half their sickest patients within 30 minutes.

Porn turning kids into predators, The Australian, 29 February 2016

Online pornography is turning children into copycat sexual predators, doctors and child abuse experts warned. AMA Vice President Dr Stephen Parnis said the internet was exposing children to sexually explicit content that taught sex was about use and abuse.

Radio

Professor Brian Owler, Radio National, 22 February 2016

AMA President Professor Brian Owler discussed calling for the immediate removal of infants and children from immigration detention centres, and for all asylum seekers to have access to quality health care.

Dr Stephen Parnis, 2HD Newcastle, 22 February 2016

AMA Vice President Dr Stephen Parnis discussed Turnbull Government plans for asylum seeker Baby Asha and her family to be returned to Nauru once medical and legal process are complete. Dr Parnis said doctors were in an untenable situation in treating patients with serious physical and mental health issues, particularly the children, who were under threat of return to conditions that will only exacerbate their health problems.

Dr Stephen Parnis, 5AA Adelaide, 28 February 2016

AMA Vice President Dr Stephen Parnis talked about hangover clinics. He said clinics which claim to cure hangovers through intravenous infusions have no benefit and could put lives at risk.

Professor Brian Owler, 2UE Sydney, 11 March 2015

AMA President Professor Brian Owler talked about public hospital funding. Professor Owler said Australia has one of the best health care systems in the world, but it relies on having adequate funding.

Television

Professor Brian Owler, ABC Melbourne, 21 February 2016

Federal Immigration Minister, Peter Dutton, says that asylum seeker baby Asha and her family will moved to community detention, and not immediately sent to Nauru. The AMA reiterated its call for all children to be immediately released from detention

Dr Stephen Parnis, ABC Melbourne, 2 February 2016

A new report warns that Australia isn’t properly prepared for health problems triggered by an increase in heat waves over the next 40 years. AMA Vice President Dr Stephen Parnis said hundreds of people could die every year if nothing is done to tackle climate change.

Dr Stephen Parnis, Channel 10, 8 March 2015

An official submission to the Government proposes increasing the tax on alcohol. AMA Vice President Dr Stephen Parnis is supportive of increasing the price.

Professor Brian Owler, Prime 7, 10 March 2016

AMA President Professor Brian Owler warns regional communities they will be worst hit when the Federal Government’s hospital cuts take effect from next year. AMA urges the Government to prioritise health when it lays down the budget in May.

Professor Brian Owler, Sky News, 10 March 2016

AMA President Professor Brian Owler talks about the No Jab, No Pay laws coming into force on March 18, when parents who don’t ensure their child’s immunisation is up-to-date stand to lose childcare benefits.

Health on the Hill – briefs

Dying with dignity

Laws legalising euthanasia in the ACT and the Northern Territory would be reinstated under a Bill introduced to the Senate with the support of a group of MPs drawn from across the major parties.

In a rare display of cross-party action, Labor MPs including Alannah Mactiernan, Katy Gallagher and Nova Peris have joined with Liberal MP Sharman Stone and Australian Greens leader Richard Di Natale in backing legislation which would restore to the ACT and the NT the right to legislate around euthanasia.

The new laws would roll back a Private Member’s Bill, introduced by Liberal MP Kevin Andrews in 1996, that nullified NT euthanasia legislation and stripped the ACT of the power to legislate for euthanasia.

The issue is politically divisive, and the Labor caucus last month decided to allow ALP MPs a conscience vote on the matter.

The push to allow for euthanasia has gathered momentum in recent months and has the backing of several high-profile advocates including broadcaster Andrew Denton.

But even if the legislation is passed by the Senate, there are doubts it will attract sufficient support in the Lower House to become law.

Indecent disclosure

Health care providers are set to come under scrutiny over the adequacy of their information disclosure as the consumer watchdog vows to crack down on confusing and misleading conduct.

Australian Competition and Consumer Commission Chair Rod Sims said the agency had “important investigations underway” into the disclosure practices of health care providers amid concerns some were in breach of Australian Consumer Law.

Flushed with success after forcing Canberra’s Calvary Private Hospital to provide patients with more information about potential out-of-pocket costs, Mr Sims said the ACCC would focus on shortcomings in disclosure to consumers.

He said the Commission’s scathing report on the behaviour of the private health insurance industry, released last year, would provide a springboard for greater scrutiny regarding the provision of incomplete information that was not only confusing but potentially misleading.

Research boost

Research to develop an AIDS vaccine and reduce the incidence of over-diagnosis are among 96 projects sharing $130 million of funding in the latest round of grants from the nation’s peak medical research organisation.

Health Minister Sussan Ley said the money was part of $850 million that will be disbursed by the National Health and Medical Research Council to fund a wide range of projects.

There has been criticism that scientists starting their research career have often been unfairly overlooked in the race for funding, but NHMRC Chief Executive Officer Professor Anne Kelso said grants were awarded to a mix of both “outstanding new talent and experienced and internationally recognised researchers”.

TPP

Drug companies may effectively hold at least an eight-year monopoly on the supply of expensive biologic medicines under the terms of the controversial Trans Pacific Partnership trade deal, activists have warned.

Trade watchers have seized on remarks made by Australia’s Special Trade Envoy, Andrew Robb, during a visit to Washington DC late last month to claim the Government was looking at using administrative delays and other bureaucratic processes to effectively extend monopoly protection for biologic medicine manufacturers to eight years – three years longer than stipulated under the treaty.

The Washing-based Politico news service reported assurances from Mr Robb, who was visiting the US capital to help rally US Congress support for the TPP, that the trade agreement would effectively provide at least eight years market protection for biologic makers, as possibly as long as 17 years.

During negotiations for the TPP, Australia and other countries resisted US demands for at least 12 years of data protection for biologic manufacturers, and there was eventual agreement on a “five-plus” approach guaranteeing makers a minimum of five years’ monopoly on supply.

Though Mr Robb told Politico Australia would not be “a party to anything that would imply that we’ve changed our position”, he emphasised the importance of providing drug companies similar protection to that they received in the US: “We’ve got a very burgeoning biologics sector in Australia, [and] if they weren’t getting the protection that they could get in the United States, they wouldn’t be setting up in Australia”.

Health advocates warn this would effectively mean at least eight years before cheaper generic versions of expensive biologic medicines – gene and cellular-based therapies that are being developed to treat diseases long-considered intractable, such as cancer, HIV/AIDS, rheumatoid arthritis, diabetes, hepatitis B and multiple sclerosis – would become available.

Get moving

Teenage girls are being urged to ‘make your move’ following findings that they are, on average, only half as physically active as their male counterparts.

Health Minister Sussan Ley has launched the #girlsmakeyourmove campaign to encourage young women to play sport and engage in other activities amid concerns many are heading for a life of poor health.

Ms Ley said research showed almost 60 per cent of girls aged between 15 and 17 years undertook little or no exercise, compared with a third of boys in the same age group.

The Minister said such sedentary habits, particularly during the formative teenage years, could lead to a lifetime of chronic disease.

“[This campaign] aims to tackle this sliding door moment in a young woman’s life when they actually are laying down the foundation for the rest of their lives,” Ms Ley said. “Physical activity in the teenage years lays down the muscle and bone you need for the rest of your life.”

Many girls get put off playing sport or engaging in physical activity because of a lack of confidence, fear of being judged or a bad experience, and the campaign uses television ads and social media to feature girls enjoying playing sport and being active.