Medical Notekeeping Standards Across English Football: The Good, the Bad and the Athlete Passport App

MEDICAL NOTEKEEPING STANDARDS ACROSS ENGLISH FOOTBALL:

THE GOOD, THE BAD AND THE ATHLETE PASSPORT APP

FEATURE / DR. RONNIE BANERJEE

THE PROBLEM

After being involved in a ground-breaking legal case where there was a failure to disclose crucial medical information at a medical, I wanted to know current notekeeping standards across English football and rugby league.

Abstract

Objective To evaluate notekeeping in athletes across football and rugby league in England to see if current guidelines are met and appropriate care is being provided.

Design Researched across teams to see if there is effective handover of data internally and externally. A comparative study was undertaken to see what electronic medical record (EMR) systems are currently being used. Then using the Delphi method, a questionnaire was completed.

Data sources Doctors across Premier League, English Football League (EFL) and Rugby Football League (RFL)

Eligibility criteria for selecting studies This had to be completed by a doctor currently working in the sport. This ranged from head first team, academy to matchday only doctors. They were selected by being the named team doctor online and through EPL, EFL and RFL chat groups. Results See infographic. In 2021, an anonymous Google questionnaire (Figure 1) was completed by 77 respondents out of 92 football clubs (26% Premier League, 23.4% Championship, 32.5% League 1 and 18.2% League 2 - Figure 2). In rugby league there were 28 respondents (46.4% Super League, 28.6% Championship, 10.7% League 1 and 14.3% covering multiple teams).

Conclusion Data is fragmented across different siloed systems. There is poor transferability between teams and healthcare sectors.

There are currently no standardised guidelines for medical notekeeping or handovers apart from follow General Medical Council (GMC) recommendations, which is not occurring.

Solutions are needed to make health data more accessible and interoperable for daily care and medicals. An integrated athlete passport app will help manage injuries and illness better and have huge financial and time implications for all stakeholders.

Current Issues

Multiple silos of information negate the excellent care provided by clinicians across sport. If several clubs do not pass on all the pertinent clinical data, the player is left with a poorly summarised record over their career. The outcome is duplication, increased cost, delays in diagnosis and treatment and potentially fatal consequences. Figure 1. Notekeeping questions 1. For your doctor consultations do you use paper notes or an online system? This refers to history/exam findings of primary care complaints, medication prescribing, medical screening, scans (MSK and non MSK), bloods, specialist letters. 2. What division is your team? 3. What is your role in the club? 4. As the team doctor are you classed as the players and staff’s ‘GP?’ 5. In the vast majority how are they registered with a GP? 6. Which online system if applicable do you enter all of your doctor notes? 7. Who files/uploads the medical notes (specialist letters, scans, bloods) whether online or paper? 8. Do you generally get previous team doctor records on signing? Please tick all relevant boxes. 9. Generally do medicals happen after the signing has already taken place? 10. Generally does a doctor perform the ‘doctor’ part of the medical (medical screen, non-MSK exam, maybe bloods) 11. What do you do with the notes when a player leaves the club? Please tick all relevant boxes. 12. How much doctor coverage is there at the training ground through the week excluding fixtures? 13. How are issued medications generally documented at the training ground and on matchday? 14. Hepatitis B blood screening. are players tested and offered vaccination if no immunity? 15. Any additional comments?

Hull City Training Ground, Millhouse Woods Lane, Hull Leeds Rhinos Training Ground, Bridge Road, Leeds

POOR RECORDING + COMMUNICATION KNOWLEDGE COST TIME POORLY INFORMED DECISIONS LITIGATION POOR DECISION MAKING

DANGER TO HEALTH & PERFORMANCE

Litigation

Lawsuits for medical negligence in sport are becoming increasingly common and recent times has seen brain injury, cardiac problems and COVID-19 take the headlines. Even if you have a notekeeping system it doesn’t necessarily translate to good medicine. The 2021 anonymous Google questionnaire (Figure 1) completed by 77 football doctors shows more than 10 different systems are in use. To view the questions in further detail please visit this link.

The number of systems is problematic when 49% of doctors are not handing over information when a player exits their club. In addition, 50% do not know if their players are registered with a GP. Consequently, doctors are oblivious to important data if there is a mix of private and NHS care; for example vaccination history, emergency care and chronic disease management.

a) Thought provoking comments from doctors across the leagues:

Premier league: ‘If other clubs are as poor as we have been then it’s time that there was a consensus within sports to have workable and cost-effective solutions. Ideally these would mirror the common GP systems.’

Championship: ‘System used not particularly useful for non-orthopaedic medical issues.’ ‘Players should be registered with a GP in my humble opinion.’

League 1: ‘Way way below GP standards. Signing we request notes, exiting nothing. No cross linking with academy notes.’

League 2: ‘No idea when players leave club. No notes exchanged. Nobody requests them. No online system at club. No governance system in place.

b) Current governing bodies and medical insurer recommendations:

Sempris: All medical teams need to ensure appropriate patient handover and continuity of care as per the overriding duties under Good Medical Practice which states that you must ‘work with colleagues in the ways that best serve patients’ interests.’

MPS: A lack of clear documentation can make defence of a claim, for example, very difficult.

FSEM(UK) Position Statement: ‘Doctors giving medical advice and treatment at any level of sport are required, under the GMC’s Good Medical Practice 2013, to keep medical records. These records must be made at the time of the event or as soon as possible after the event.’

ATMMiF: “if it isn’t written down, it didn’t happen”. Your duty of care ends when you have passed the player onto another healthcare professional (HCP) and not on leaving your club. If their career has come to an end, the GP should be informed with permission.

Chronic disease management

Players who suffer with chronic conditions like epilepsy, asthma and diabetes are not followed up well in the private sector due to moving clubs and not being registered with a local GP. They will see expert specialists but it is difficult to coordinate annual reviews and know if these are adequate or appropriate.

Emergency care and practice abroad

In A&E or care abroad, medical information is difficult to manage. These doctors will not have access to important information as it is currently not all in one place, which wastes unnecessary resources. On discharge the player may be given a letter. More commonly team doctors are trying to claw back information which is time consuming and often futile. Weiler et al (2021) recognise challenges in medical handover between national and club teams and suggest a standardised medical handover checklist.

Outside the normal clinic setting

Another challenge is when primary and emergency care advice is given in places like a corridor or pitchside. This is notoriously not documented well. The questionnaire showed that prescribed medications are not documented in 22% of cases.

Retirement

There is a huge volume of medical information accumulated over a career like data on injuries, cardiac and blood screens. This needs to be handed over and be easily accessible when transitioning away from sport to continue good healthcare and save resources. Carmody et al (2022) found osteoarthritis of the lower limb, musculoskeletal pain and mental health problems to be common amongst retired players. Risk can be lowered by being proactive during a player’s career.

Third party clinicians

A team doctor in the higher leagues is more likely to have a good EMR system, however there are multiple clinicians involved including the GP, orthopaedics, medical specialists, tournament and matchday doctor. In most circumstances these clinicians are not on the same system and will be unaware of the entire medical presentation; as they are reliant on the athlete’s recollection or a phone or email handover.

Medicals and handover

The Google questionnaire states 49% of doctors do not pass on information, whereas 39% get information through a phone call with the previous doctor.

An inadequate medical handover can lead to a waste of time, manpower and financial resources whilst potentially delaying diagnoses and management of health conditions.

Clinicians must protect themselves by keeping good records and giving a satisfactory handover of pertinent medical information with the athlete’s consent. A comment a colleague once made still resonates with me... ’what you don’t know you can’t help.’

Figure 2. Doctors involved in the questionnaire by division and role.

Key messages

• 77 doctors across the elite football pyramid and 28 RFL doctors completed questionnaires.

• There are currently no specific standardised guidelines for notekeeping or handovers.

• Multiple silos undo the excellent care provided by clinicians across sport. If several clubs do not pass all the pertinent clinical data, the player is left with a poorly summarised record over their career. The outcome is duplication, increased cost, and delays in diagnosis and treatment.

RECOMMENDATIONS

A more accessible, standardised and interoperable record is needed across a career into retirement to benefit all stakeholders, but most importantly the athlete’s health and welfare.

A) A standardised approach

• Football and rugby league need to adopt a standardised approach regardless of the system used. • English elite club and national rugby union and cricket teams are on the same EMR system. This allows all private healthcare such as screenings, injuries, scans and specialist letters to be in one place when a player moves between clubs in this country.

B) An interoperable record

• Unfortunately, a standardised approach alone does not solve the lack of information and handover from third party clinicians like: - matchday and tournament doctors - international care – national teams and emergency treatment abroad - NHS care from the GP, A&E or specialists. • A system is needed which allows clinicians to immediately see other professionals medical input as this might influence the care they deliver. There are currently delays in correspondence or nothing is received at all. • This allows better documentation of consultations and prescribed medication by all clinicians.

C) Better accessibility and portability for the athlete

• Points A and B still do not give the athlete readily available access to their own record. Better accessibility and portability are the athlete’s right under the Data Protection Act 2018. • They might be struggling to recount multiple injuries or potentially complex medical presentations in scenarios such as in an emergency, care abroad, retirement, or insurance purposes.

D) A template for medicals

• Medicals will be transformed if a system exists incorporating points A to C. • It will remove non-medical disclosure disputes • With the athlete’s consent it will allow quicker risk stratification when time might be of the essence. • It will help teams with financial constraints or limited medical provisions to see historic radiology, blood tests or mandatory cardiac screens and stop unnecessary duplication. • It will allow transparency and remove the stigma associated with certain conditions.

E) Easier transition into retirement

The athlete should have a seamless handover to NHS or abroad. Carmody et al (2017) discuss the role of an ‘exit health examination’ to minimise the risk of poor long term health outcomes.

THE SOLUTION FOR A > E = AN ATHLETE MEDICAL PASSPORT APP

• Any of the multiple EMR systems currently used can solve point A by being standardised across the sport, however this would only be in this country. • Current EMR systems do not account for points B and C, increasing the risk of missing important information and making medicals and retirement more complicated. • The read only passport allows better accessibility and portability of medical notes, following GDPR. • A standardised clinician dashboard for the team doctor syncs with a patient’s app and populates it throughout a career. • A simple user interface with 24/7 access will empower athletes to better understand their injuries, illness and screening; improve data quality and consequently health needs. • With consent, any clinician can be shown all the right medical information immediately, whatever the club, country or healthcare sector. Major life-threatening problems, consultations, letters, scans and medications are some of the instantaneous history visible. • By having features like in built forms or audio dictation, third party clinicians can now directly add to a truly interoperable system so that the regular team clinician gets immediate handover. This protects these clinicians by giving them as much relevant information as possible and the ability to record notes. • Lessons can be learnt from the strengths and weaknesses of the NHS patient app used in the public sector. Eventually unique identifiers can allow full merging of the records.

Figure 4. AB3 Medical app homepage

Next steps

The research questionnaire helped create the AB3 Medical athlete passport app as a possible solution. No current EMR system or passport tackles points A to E. Figure 3 shows how AB3 aims to benefit the athlete with additional features to make their medical passport as interactive and educational as possible. Figure 4 demonstrates the app homepage and its simple user interface.

By standardising care across a sport and empowering the athlete there are massive implications for all stakeholders in player handover and medicals.

*Visit ab3medical.com or @ab3medical for further information

Acknowledgements:

I would like to acknowledge all the Premier League, EFL and RFL doctors for taking part in the anonymised questionnaire, in order to improve medical notekeeping standards across the sports.

References:

• ATTMiF manual • Carmody S, Jones C, Malhotra A,

Gouttebarge V, Ahmad I (2017). Br J

Sports Med 53(13). Put out to pasture: what is our duty of care to the retiring professional footballer? Promoting the concept of the ‘exit health examination’ (EHE). • Carmody S, Anemaat K, Massey A et al (2022). Br J Sports Med 8(2). Health conditions among retired professional footballers: a scoping review. • Data Protection Act (2018). Available at https://www.gov.uk/data-protection#: (Accessed 25 January 2022) • General Medical Council (2013) GMC

Good Medical Practice, ‘Record your work clearly, accurately and legibly’ Domain 1, (19 – 21) • Medical Protection (2017) An essential guide to medical records. Available at https://www.medicalprotection.org/ uk/articles/an-mps-essential-guide-tomedical-records (Accessed 25 January 2022) • Sempris (2018) Contract risk and the football transfer window. Available at https://www.sempris.co.uk/2018/12/21/ contract-risk-and-the-football-transferwindow/ (Accessed 25 January 2022) • Weiler R, Collinge R, Ewens J et al (2021).

Br J Sports Med December 2021 55(24).

Club, country and clinicians united: ensuring collaborative care in elite sport medical handovers.

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