KEY POINTS:
This - in the internet age - is how Dr John Cameron books a patient into a hospital outpatients' clinic: first he types the patient's details and condition into his computer.
Then he prints the information on to a piece of paper, puts it in a fax machine and dials the number. Hopefully, someone at the other end picks up the fax and scans it into the hospital's computer to make the booking.
The trouble is that the two computers can't talk to each other.
Communication breakdowns infect our health system, running from patient-doctor misunderstandings over medication, through operations delayed when bookings go astray, to avoidable deaths.
Patients don't expect to go into hospital and have the wrong knee operated on. If we see different doctors at a medical centre, we assume they have accurate files on our medical history. If we're sent home from hospital, we assume our GP has been told.
Assume nothing, says Health and Disability Commissioner Ron Paterson. "The fact is we don't have a failsafe system."
The commission's inquiries into the deaths of two patients referred to Wellington and Wanganui hospitals have underlined the potential cost of poor communication.
In the Wellington case a man died of pneumonia 40 hours after admission to hospital. Paterson slammed clinical staff for inadequate communication, documentation and monitoring of the 50-year-old's condition.
In Wanganui, a woman with heart problems died at home after being sent by her GP to the hospital emergency department three times in 11 days. Each time, the emergency department sent her home without notifying her GP. The day after the third discharge, she died.
In their defence, the inexperienced medical staff claimed they had not fully understood the GP's level of concern.
Commenting on the Wellington case, Paterson warned that the same tragedy could unfold at other hospitals. Wellington was unlikely to be the only hospital "running out-dated systems of care ... where clinicians were frustrated by time delays and business-case inertia that impede improvements in patient care."
In the Wanganui case, a discharge letter "should have been fundamental".
Paterson is saying nothing new. The commission's files are peppered with medical misadventures in which communication was critical. The potential for misunderstandings is greatest at transition points: from GP to hospital, from emergency department to ward, between anaesthesia and surgery, in the wards between nurse and doctor and at shift changes.
Paterson calls it "left hand, right hand syndrome".
Given the stakes, you would think every effort would go into minimising the risks. In New Zealand's chronically acutely stressed public health system, that hasn't been the case.
Middlemore intensive care specialist David Galler says communication issues can arise between doctors and nurses and between younger and more experienced clinicians. Mistakes often occur in patient monitoring, particularly with the increase in more complex, acutely ill cases.
"Some [nurses] monitor properly but don't know what the results of their monitoring actually mean and don't know who to call," he told National Radio. "Often it's inexperience. Do they actually recognise that the patient is unwell and getting worse?
"Young doctors can come out of medical school without the practical knowledge to do what's asked in particular circumstances. They need system support to do their job well."
Explicit guidelines and trigger points were needed so staff knew what to look for and who to call and to ensure that senior doctors responded in good time.
"It does happen but it doesn't happen reliably. That's why these cases come up from time to time."
Of course, there are far more cases where communication glitches have less final outcomes - outpatients missing clinics because their appointment goes to the wrong address, test results missed because of confusion over who should chase up the lab.
In hospitals, wrong medication is a frequent problem, says Paterson. "You can have computerised labels but if you put the wrong label on the file and give someone else's medication ...
Then there are "simple miscommunications - the old lady who goes into hospital and they operate on the wrong knee is a classic".
In the age of the internet, email and mobile wizardry, it seems staggering that the health system continues to be dogged by such errors and practices. (Yet internationally, New Zealand is said to be ahead of most in health IT uptake.)
GPs were quick to grasp the potential of computer technology to streamline patient care in the 1990s; hospitals could see the benefits too but were slow to act and did not move as one. Different arms of the system have introduced different systems at different times, meaning they can't communicate.
Epsom GP Nick Cooper blames politicians for fragmenting the health system and for delays in investing in new technology.
When hospital boards were split into funders and providers in the 1990s, and a competitive model introduced, opportunities for a united approach were lost. Even now, the Counties Manukau and Waitemata District Health Boards have a shared services agency; Auckland goes it alone.
"We've seen a complete disintegration of communication and lines of responsibility," says Cooper.
"When I first started, if a female patient became pregnant my job was to look after her throughout her pregnancy. Now the first I may know about it is some months after the baby is born - and she's supposed to have care which I haven't been told about."
Cooper has had similar (though not as tragic) experiences to the Wanganui case of patients being bounced back by the hospital and him not being told about it.
"Can you imagine any other industry where if a technician sent a faulty machine in for a repair he couldn't cope with, he would have to send it back three times?"
He cites cases of hospitals failing to follow their own protocols and performing wrong procedures. In the Wanganui case, inexperience was undoubtedly a factor.
"They shouldn't be practising unsupervised - they don't know what they're doing," says Cooper. "The evidence is that patients are having worse health outcomes than a few years ago.
"The politicians who dismantled the system and then didn't back up their promises are to blame. There was every opportunity 15 years ago to put together a comprehensive IT system. Instead we now have multiple systems which don't intermesh with each other and which in some cases you have to pay to access."
Paterson says IT can help to minimise harm but will never eradicate it. "I don't think there's any substitute for picking up the phone in a serious case."
In a Palmerston North case, a woman complaining of swelling in a breast needed chemotherapy and a mastectomy after her mammogram was delayed. In the referral letter, her GP did not emphasise urgency.
When the patient returned with worsening symptoms, the GP requested urgency but sent the letter to the wrong hospital. Crucially, when the GP heard nothing back, she did not make further inquiries.
Old cultural attitudes play a part. Traces of clinician-knows-best syndrome continue to create barriers in and beyond the wards. Cooper says hospital clinicians "tend not to take GPs' advice seriously".
Communication breakdowns in hospitals need to be understood in context: clinicians and nurses are routinely rushed off their feet and dealing with more acute and complex cases; staff may be inexperienced and staffing levels minimal; with increased immigration, language barriers can be a problem for both patient and clinician.
Similar issues apply in the primary (GP) sector, following the exodus of experienced talent lured by better pay in Australia and elsewhere.
All of which is why, says Paterson, robust systems must be in place to reduce the chance of error.
"No doctor or nurse intends to miscommunicate. Mistakes are made by good people trying to do a job sometimes in very difficult circumstances.
"It's about getting systems that work - not just technology, but doing the basics right.
"I don't think things are getting worse - my sense is that most people get very good healthcare nearly all the time but some people fall through the cracks.
"Relying on verbal handover will work in a small team that's not changing all the time. But in most hospitals staff are changing all the time, they don't have a home team looking after a ward. That makes it more likely there will be a communication breakdown."
At shift changes it's important that clinical records are well-documented with key signs and symptoms, "but critically you talk to incoming nurses. It's the same with doctors. Good communication is at the heart of good healthcare."
It's hard to tell if hospitals are heeding Paterson's advice.
At Middlemore Hospital, the Counties Manukau board is piloting what chief medical officer Don Mackie calls a visa system - in which medical patients need documentation explaining what's wrong and what their medical plan is before they are shifted between departments. Other initiatives include standardised record-keeping for nurses and "home teams" in wards.
John Cameron, who also acts as medical executive with GP group Procare, says the system is slowly improving.
Auckland GPs now have few problems accessing the right hospital team for advice or notifying the hospital of incoming patients. It's after admission that things go awry.
"We sometimes have no idea our patients have been involved in inpatient care. The only communication is if the hospital team calls us with a question."
But he says great strides have been made with electronic referral and discharge, though implementation is far from universal.
For instance, Auckland City Hospital can send discharge summaries for medical and surgical patients electronically, but GPs are told of outpatient visits by letter. The GP is not told if a patient is sent home from the Emergency Department.
It's a two-way street, of course. Cameron says the quality of information which GPs send to specialists has some way to go. "We need to get our act together. 'Sore ears - please see,' doesn't work."
On the other hand, GPs could improve patient care if they knew what specific information specialists need, or the likely waiting times for elective procedures.
Auckland's incompatible outpatient referral system, introduced several years ago, resulted from the health board not talking to GPs in the planning phase, he says. "They saw their problems and gave us their solution."
Last month something unusual happened. The Auckland board's IT team came and talked to Procare, which represents about 500 GPs in greater Auckland.
"Simply by getting around the table we were able to advance some initiatives by years," says Cameron.
While change has come too slowly, he says some "really innovative" improvements are under way.
Fault lines
Cases where communication errors have compromised patient safety
WELLINGTON,
September 2004
Inadequate communication, documentation and monitoring are found to have contributed to the death of a 50-year-old man who died 40 hours after admission to Wellington Hospital with pneumonia.
WANGANUI,
January 2004
A heart patient with chest pain, breathlessness and lethargy was sent home from the Emergency Department three times in 11 days after she was referred by her GP. Each time, the GP was not told the patient had been discharged. She died at home the day after the final discharge. Hospital doctors maintained they did not fully understand the GP's level of concern.
NORTH ISLAND TOWN,
October 2004
Inadequate medical record-keeping was blamed when an asthma sufferer with a migraine was prescribed medication to which she was allergic by a doctor at a medical centre. The patient normally saw a different doctor at the centre but her file had no record of her allergy. The woman stopped breathing, suffered severe brain damage and later died.
TAURANGA,
2001-2003
Poor communication between staff was a factor in three preventable deaths in the Emergency Department over this time. Health Commissioner Ron Paterson found a failure to communicate the seriousness of the patients' conditions to the appropriate doctors, as well as unacceptable time delays between admission and treatment.
PORIRUA,
2003
A 42-year-old man died after he was sent home from the Emergency Department while the x-ray report that would have secured his admission lay unread on his GP's desk, Wellington coroner Garry Evans found. He blamed poor communication, the hospital's failure to properly supervise young doctors working alone and faulty practices on the GP's part.
NORTH SHORE HOSPITAL,
December 2003
A cancer sufferer transferred to hospital from a hospice died after she was given 10 times the prescribed dose of morphine by an inexperienced doctor who misread the hospice notes.
NORTH SHORE HOSPITAL,
2002-2003
A "systems error" was blamed for delays in follow-up appointments for 28 women with abnormal cervical smear results. One woman later developed a malignant tumour.
PALMERSTON NORTH,
January 2000
A woman with breast swelling was referred to Palmerston North Hospital but, readywith no indication of urgency from the GP's letter, was given low priority. After a further doctor's visit, her GP wrote again seeking urgency, but to the wrong hospital, and did not follow up when she heard nothing back. Due to delays and original misdiagnosis, the patient needed chemotherapy and a mastectomy for advanced breast cancer.
