The challenges of real-world implementation of web-based shared care software: the HopSCOTCH Shared-Care Obesity Trial in Children.

BACKGROUND: E-health initiatives hold promise to improve shared-care models of health care. In 2008-2011 we developed and trialled web-based software to facilitate a randomised trial of a shared-care approach for childhood obesity involving General Practitioners (GPs) working with tertiary specialists. We describe the software's development, implementation and evaluation, and make recommendations for future e-health initiatives. The web-based software was designed with the goals of allowing both GPs and specialists to communicate and review patient progress; integrating with existing GP software; and supporting GPs to deliver the structured intervention. Specifically, we aimed to highlight the challenges inherent in this process, and report on the extent to which the software ultimately met its implementation and user aims. METHODS: The study was conducted at the Royal Children's Hospital and 22 general practices across Melbourne, Australia. Participants comprised 30 GPs delivering the shared-care intervention. Outcomes included the following. (1) GPs' pre-specified software requirements: transcribed from two focus groups and analysed for themes using content analysis. (2) Software implementation and performance based on the experience of the research team and GPs. (3) GP users' evaluation collected via questionnaire. (4) Software usage collected via GP questionnaire and qualified through visual inspection of the software meta-data. RESULTS: Software implementation posed difficult and at times disabling technological barriers (e.g. out-dated hardware, poor internet connections). The software's speed and inability to seamlessly link with day-to-day software was a source of considerable frustration. Overall, GPs rated software usability as poor, although most (68%) felt that the structure and functionality of the software was useful. Recommendations for future e-health initiatives include thorough scoping of IT systems and server speed, testing across diverse environments, automated pre-requisite checks and upgrades of processors/memory where necessary, and user-created usernames and passwords. CONCLUSIONS: GPs are willing to embrace novel technologies to support their practice. However, implementation remains challenging mainly for technical reasons, and this precludes further evaluation of potential user-specific barriers. These findings could inform future e-health ventures into shared-care, and highlight the need for an appropriate infrastructure. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN126080000553.

'Your lack of organisation doesn't constitute our emergency' - repeat prescription management in general practice.

BACKGROUND: The importance of quality and safety in repeat prescribing is well documented, but few studies have examined how practices manage urgent requests for repeat prescriptions and why patients require them urgently. METHODS: Twenty practice staff (receptionists, practice managers, general practitioners, practice nurse) from 10 general practices participated in semi-structured interviews, which were audio-recorded, transcribed and analysed thematically. RESULTS: Requests for same-day appointments for patients needing repeat prescriptions emerged as problematic for most clinics in our study. Reasons included convenience, lost prescriptions and running out of medication. Clinics gave patients appointments, left prescriptions for collection at reception or ran prescription clinics. A need emerged for GPs to support individual clinic policy on repeat prescriptions. DISCUSSION: Many urgent requests for repeat prescriptions are avoidable. Improvements are needed in the way repeat prescriptions are managed, pointing to a closer examination of general practice systems, the role of practice staff, pharmacists and patients.

Shared care obesity management in 3-10 year old children: 12 month outcomes of HopSCOTCH randomised trial.

OBJECTIVE: To determine whether general practice surveillance for childhood obesity, followed by obesity management across primary and tertiary care settings using a shared care model, improves body mass index and related outcomes in obese children aged 3-10 years. DESIGN: Randomised controlled trial. SETTING: 22 family practices (35 participating general practitioners) and a tertiary weight management service (three paediatricians, two dietitians) in Melbourne, Australia. PARTICIPANTS: Children aged 3-10 years with body mass index above the 95th centile recruited through their general practice between July 2009 and April 2010. INTERVENTION: Children were randomly allocated to one tertiary appointment followed by up to 11 general practice consultations over one year, supported by shared care, web based software (intervention) or "usual care" (control). Researchers collecting outcome measurements, but not participants, were blinded to group assignment. MAIN OUTCOME MEASURES: Children's body mass index z score (primary outcome), body fat percentage, waist circumference, physical activity, quality of diet, health related quality of life, self esteem, and body dissatisfaction and parents' body mass index (all 15 months post-enrolment). RESULTS: 118 (60 intervention, 56 control) children were recruited and 107 (91%) were retained and analysed (56 intervention, 51 control). All retained intervention children attended the tertiary appointment and their general practitioner for at least one (mean 3.5 (SD 2.5, range 1-11)) weight management consultation. At outcome, children in the two trial arms had similar body mass index (adjusted mean difference -0.1 (95% confidence interval -0.7 to 0.5; P=0.7)) and body mass index z score (-0.05 (-0.14 to 0.03); P=0.2). Similarly, no evidence was found of benefit or harm on any secondary outcome. Outcomes varied widely in the combined cohort (mean change in body mass index z score -0.20 (SD 0.25, range -0.97-0.47); 26% of children resolved from obese to overweight and 2% to normal weight. CONCLUSIONS: Although feasible, not harmful, and highly rated by both families and general practitioners, the shared care model of primary and tertiary care management did not lead to better body mass index or other outcomes for the intervention group compared with the control group. Improvements in body mass index in both groups highlight the value of untreated controls when determining efficacy. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12608000055303.

Managing same day appointments--a qualitative study in Australian general practice.

BACKGROUND: General practices are required to have flexible systems to accommodate urgent appointments. Not all patients requesting a same day appointment receive one. There is scant research detailing how requests for same day appointments are managed. Our study examined this issue from the perspective of practice staff. METHODS: Twenty practice staff (receptionists, practice managers, general practitioners, practice nurse) from 10 general practices participated in semistructured interviews, which were audiorecorded, transcribed and analysed thematically. RESULTS: All but three practices set aside appointments for patients requesting a same day appointment. Themes included contradictions between policy and practice and the role of experience in determining urgency. Five types of urgent needs for same day appointments were identified: medical, administrative, therapeutic, logistic and emotional. DISCUSSION: Practice policies must make clear roles and responsibilities for all staff managing patient appointments. Aspects of clinic policies and practices could be reviewed to reduce medicolegal risk and additional workload caused by non-medically urgent needs.

A shared-care model of obesity treatment for 3-10 year old children: protocol for the HopSCOTCH randomised controlled trial.

BACKGROUND: Despite record rates of childhood obesity, effective evidence-based treatments remain elusive. While prolonged tertiary specialist clinical input has some individual impact, these services are only available to very few children. Effective treatments that are easily accessible for all overweight and obese children in the community are urgently required. General practitioners are logical care providers for obese children but high-quality trials indicate that, even with substantial training and support, general practitioner care alone will not suffice to improve body mass index (BMI) trajectories. HopSCOTCH (the Shared Care Obesity Trial in Children) will determine whether a shared-care model, in which paediatric obesity specialists co-manage obesity with general practitioners, can improve adiposity in obese children. DESIGN: Randomised controlled trial nested within a cross-sectional BMI survey conducted across 22 general practices in Melbourne, Australia. PARTICIPANTS: Children aged 3-10 years identified as obese by Centers for Disease Control criteria at their family practice, and randomised to either a shared-care intervention or usual care. INTERVENTION: A single multidisciplinary obesity clinic appointment at Melbourne's Royal Children's Hospital, followed by regular appointments with the child's general practitioner over a 12 month period. To support both specialist and general practice consultations, web-based shared-care software was developed to record assessment, set goals and actions, provide information to caregivers, facilitate communication between the two professional groups, and jointly track progress. OUTCOMES: Primary - change in BMI z-score. Secondary - change in percentage fat and waist circumference; health status, body satisfaction and global self-worth. DISCUSSION: This will be the first efficacy trial of a general-practitioner based, shared-care model of childhood obesity management. If effective, it could greatly improve access to care for obese children. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12608000055303.

Divisions of general practice, capacity building and health reform.

The development of the divisions of general practice network has been one of the major health innovations of the past decade. Its establishment was an innovative plan to build capacity in general practice to respond to health needs in the community and develop good quality health services. The network has a secure place in the health system and assists general practitioners to become involved at all levels of health policy and decision making. This capacity has facilitated multiple health reforms including immunisation and information technology, leading to improved health outcomes for the Australian community.