MIPS Review Winter 2013 by Medical Indemnity Protection Society

MIPS

Review WINTER 2013

FEATURE STORY

Medical Volunteering in Burma

Inside Managing Director’s report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Medical Volunteering in Burma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Special achievement by a MIPS member. . . . . . . . . . . . . . . . . . . . . . . . . . 5 Drugs and poisons investigation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 It’s time to renew your MIPS membership. . . . . . . . . . . . . . . . . . . . . . . . . 7 Update on eHealth (PCEHR). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Risk Education update. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

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Managing Director’s report

2013/2014 Membership Renewal 2013/2014 Membership Categories

National Injury Insurance Scheme

MIPS undertakes an annual review of membership categories prior to issuing renewal application invitations.

There continues to be considerable uncertainty in respect of the National Injury Insurance Scheme’s (NIIS) interaction with the National Disability Insurance Scheme. Clarity is required to better understand the potential impact on healthcare providers that funding of the National Injury Insurance Scheme (for qualifying healthcare accidents) will have.

Members are reminded of the importance of checking that they are in the appropriate membership category as access to the benefits of membership, including insurance covers, is linked to the membership category each member selects.

2013/2014 membership renewal application invitations have now been dispatched. Members who do not receive that invitation by the end of May but are expecting to do so should contact Member Services as a matter of urgency to ensure that there is no gap in member benefits (which will otherwise cease 30 June this year).

Student and Recent Graduates Cover under the 2013/2014 MIPS Members’ Group Personal Accident Policy now includes communicable disease protection for Students and Recent Graduates. Student and recent graduate members are referred to the Members’ Insurance Covers Handbook for full details.

It is important to remember that initial acceptance into MIPS membership and receipt of subsequent annual renewal invitations is a significant professional achievement. That is because MIPS membership is not automatic upon application and the MIPS Membership Assessment, Acceptance and Advisory Committee carefully scrutinises applications to consider whether there is a good Constitutional fit and to ensure that the interests of the membership as a whole are protected.

Conduct unbecoming

Congratulations to those new members who achieved MIPS membership during the year.

With a view to avoiding breaches of Competition and Consumer Law or escalation of inappropriate market behaviour, members are encouraged to advise MIPS of any marketing statements and/or behaviours that they become aware of that cause them concern. These can then be dealt with promptly.

Members have recently advised us of inaccurate, misleading and defamatory comments and inappropriate conduct by some competitor organisations/ representatives. MIPS has advised the management of those organisations of its concerns. Members can draw their own conclusions about what such behaviour says about any organisation that permits or condones it.

Currently it appears that even if transfer of all Cerebral Palsy matters to the National Disability Insurance Scheme occurs in accordance with the Productivity Commission recommendation and the States & Territories legislate to prevent potential double-dipping (to remove the potential to both qualify under the NIIS and obtain civil damages for the same injury) it seems likely that for the foreseeable future that current medicalindemnity insurance funding will not be adequate to fund pre- NIIS ‘run-off’ claims as they are reported as well as fully funding on an incurred basis matters qualifying under the NIIS. It is important that the likely financial impact of the NIIS is clearly understood by stakeholders so that steps can be taken to mitigate the potential adverse effects on affordability of healthcare that on currently available information appears must occur on introduction of the NIIS. One of the challenges will be to ensure that all healthcare provider craft groups that could contribute to a NIIS qualifying injury appropriately fund their fair share. MIPS is engaged in the medical injury NIIS discussions and will continue to attempt to ensure the best outcome for members and the community over both the short and longer terms.

mips.com.au . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Medical volunteering in Burma Dr Gloria Gomes

Dr Gomes was born and raised in Malaysia and graduated from the University of Singapore in 1975. Shortly thereafter, she moved to Newcastle where she did her residency at the Royal Newcastle Hospital before venturing out into General Practice. She was a GP in Newcastle for the next 30 years before retiring from active general practice five years ago. During the past 12 years, along with raising her family, she has volunteered her time overseas in East Timor, Nepal, Mozambique, Kenya, India and more recently Burma. She currently resides in Newcastle with her husband, who is a psychiatrist, and works part time as a doctor doing sestamibi stress testing with the Hunter Imaging Group. In January, I was invited by a Christian Aid organisation to take part in a medical outreach trip to some of the Karen villages on the Thai/Burma border. My previous experience with medical volunteering had served me well in preparing for this upcoming expedition. The group comprised six women including two doctors, two retired teachers, my niece and myself. Our first priority was to get our medication supplies in order. We ensured we were prepared for a vastly different environment to that of general practice in Australia. The town of Maesot resembled a typical Thai town, but it had a notorious reputation for trafficking drugs and young girls for prostitution. Noticing the lack in border customs checkpoints, we crossed the Moi River in a row boat. We were greeted graciously by the Karen Army General and the local village folk. This was going to be our home for the next week. The newly built surgery was manned by a group of young nurses with only three months training. Our visit coincided with the opening ceremony of the surgery. Our first day seeing patients was a busy day and we saw lots of mothers and babies.

The diseases presented were mainly tropical diseases including URTIâ&#x20AC;&#x2122;s, gastro, scabies, parasitic infestations, impetigo, ringworm, malnutrition and the like. There was also a tapeworm infestation acquired from pet pigs that wandered around open sewers. Although most people used the pit latrines, there was some indiscriminate defecation, which was obviously a huge health hazard. Malaria was not as rampant at that time of the year as it was the dry season, but I was told that Malaria Falciparum and Dengue Haemorrhagic Fever were very common in the monsoon months. We performed a few antenatal procedures as well but no deliveries; babies are delivered at home in the presence of the more senior women of the village. One particular case that stood out was an in-patient whom we suspected had AIDS. Due to a lack of education and treatment we were unable to establish any solid medical history from him. We were then only able to treat him for bedsores.

[Top] Dr Gloria Gomes treating [Middle] Twilight presentations [Bottom] The village clinic.

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One very significant case was that of a young man who required immediate attention. He had fallen into an open fire during an epileptic seizure, badly burned on his lower limbs. We attended to his wounds and later transported him across the border for treatment at a refugee hospital on the Thai side. We have since received a report on that young man’s progress and after a few operations he is well on his way to a full recovery.

Medical volunteering in Burma (continued) Life in Tah Lor Village and the surrounding Karen Land was very primitive. We shared a large communal house that belonged to the village headmaster. As guests, we had the luxury of sleeping on inflatable mattresses brought over from Thailand, while everyone else slept beside each other on thin mats. There were about 20 of us under mosquito nets and torch lights came in handy when the village generator was switched off for the night. The toilets were pit latrines and we bathed outdoors in a communal bathroom. Water was pumped up from the river into a large concrete tub outside. At the end of each day, following the clinics we would wrap ourselves in our sarongs and bathe around this concrete tub. Karen soldiers would keep guard nearby at all times. It was their job to protect us so they accompanied us everywhere we went.

The second week was spent at Mae Ga La Ta Village. Due to some unrest, the soldiers followed us around to ensure we were safe. Here the nurses were mainly military nurses trained by a military sargent. Patients were given two to three different antibiotics for any URTI or gastro problem. In the afternoons, I would teach the nurses some alternative methods to help them practice more effectively. We would also run mobile clinics in neighbouring villages and set up make-shift clinics in school halls or churches. On some days, we sometimes saw over 200 patients in one day!

There was another man that presented with symptoms and signs of a pleural effusion and he told me that he could not afford the treatment at a Thai hospital. Later in the day, I saw his wife, an ex-TB patient who was treated and never followed up, as well as his 16 year old daughter with a 12 month history of weight loss, tiredness and night sweats. It was obvious that the whole family had TB and needed to get proper treatment. We brought them over to an NGO hospital across the border and contributed to part of his treatment costs. All in all, it was a wonderful experience for the whole group. Although steeped in poverty everyone appeared happy. Despite the high illiteracy rate, mothers looked after their children well while fathers worked hard trying to re-build their wooden thatched huts in this war-torn zone. It seems a shame that conflict and poor governance has left the Karen tribe so far behind with what we take for granted as basic necessities in today’s modern society.

It was a wonderful experience for the whole group. Although steeped in poverty everyone appeared happy.

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Special achievement by a MIPS member

Norman James, MD, FRANZCP, Recognized for Commitment to Global Health

MIPS would like to congratulate member Dr Norman James, Psychiatrist on being the recipient of the Health Volunteers Overseas (HVO) Golden Apple Award. Dr James was selected for this award due to his dedication to international education at the HVO training sites. The following is republished from the HVO press release. Health Volunteers Overseas (HVO) is pleased to announce that Norman James, MD, is a recipient of the eighth annual HVO Golden Apple Award. As part of its World Health Day observances, HVO created this award to recognize the extraordinary educational contributions of volunteers to international program sites. Each volunteer honored with this award has demonstrated a strong commitment to HVO’s educational mission by working on curriculum development, teacher training, didactic or clinical training, or the enhancement of educational resources. Dr James, a psychiatrist, is deeply committed to supporting the development of mental health services in developing countries. Through his volunteer service with HVO, he was instrumental in initiating the first electro-convulsive therapy services in Bhutan.

He brought the first ECT machine, which had been donated by NorthWestern Mental Health (Melbourne), to the JDW National Referral Hospital in Thimphu. This service is committed to donating a second machine. He trained the local psychiatrists and mental health nurses in the proper use of the equipment, which means patients no longer have to travel to India to receive such treatment, saving them time and money. He has also worked with the local providers to improve their teaching methods and facilitated networking and communication with psychiatrists in Australia. The exchange of knowledge and information is strengthening the capacity of the health care providers and contributing to improved quality and repertoire of available services in Bhutan. A member of HVO since 2012, Dr James is a medical school graduate of Monash University in Melbourne, Australia. He recently retired from North-Western Mental Health in Melbourne and Eastern Mental Health Services in Adelaide. The World Health Organization’s Global Health Workforce Alliance has stated,”Health workers are the heart and soul of health systems. And yet, the world is faced with a chronic shortage – an estimated 4.2 million health workers are needed to bridge the gap, with 1.5 million needed in Africa alone. The critical shortage is recognised as one of the most fundamental constraints to achieving progress on health and reaching health and development goals.” They estimate that one billion in the world will never see a health worker in their lives.

“I am very pleased that the contributions made by Norman James towards improving mental health care are being recognised with this award,” said Nancy Kelly, HVO’s Executive Director.

“By highlighting the accomplishments of volunteers like Dr. James, we hope to raise awareness of global health issues and encourage others to work towards better health care around the world.” World Health Day is celebrated annually by the World Health Organization and the international community. Since 1950, it has been held each year on 7 April and focuses on a relevant global health issue. This year’s theme is ’High Blood Pressure’ and the increased health risks that can result. For more information on World Health Day 2013, visit who.int/world-health-day/en/ A private, non-profit organization, HVO was founded in 1986 to improve global health through education. HVO designs and implements clinical education programs in child health, primary care, trauma and rehabilitation, essential surgical care, oral health, blood disorders and cancers, infectious disease, nursing education, and wound care. In more than 25 resource-poor nations, volunteers train, mentor, and provide critical professional support to health care providers who care for the neediest populations in the most difficult of circumstances. For more information about volunteering, visit the HVO website.

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Drugs and poisons investigation It was only at this point the member appreciated the possible consequences of DPUs referral to the Board and contacted MIPS for further advice. Representation was provided to the member by MIPS to assist with the response to the Medical Board. On completing its investigations the Board referred the matter to a professional standards panel to conduct a hearing into the member’s professional conduct. The member was found guilty of unprofessional conduct, but as the incident was found not to be of a serious nature, the panel decided to sanction the member issuing a caution.

This case study concerns a general practitioner who was contacted by the State Drugs and Poisons Unit of the Department of Health. The issue related to the treatment of a now deceased 40-year old male who was prescribed Kapanol, a Schedule Eight drug. A permit is required to prescribe Kapanol to ensure that treatment is coordinated and monitored and concurrent prescribing by other practitioners is avoided. The permit system also serves to reduce the possibility of deliberate misuse or iatrogenic dependence. The member was contacted by the Drugs and Poisons Unit to provide written responses to a number of questions relating to the member’s prescribing and the sequence of events. Further information was required in relation to prescription knowledge, checking of existing permits held by other medical practitioners, the frequency of administration (which was in excess of the maximum quantity specified in the current permit) together with all medical record information.

The Drugs and Poisons Units investigation was concluded with a lengthy interview. The DPU findings were then brought to the attention of the Medical Board for consideration of the medical practitioner’s professional judgment and conduct. Of main concern was the frequency and quantities of morphine prescribed prior to realising that the patient was being concurrently provided scripts by another practitioner. This had continued after the member had obtained a permit and became the patient’s sole prescribing practitioner. Drugs and Poisons were concerned about the member’s difficulty is grasping the significance of the noncompliance to the safe treatment of the patient.

It is a condition of membership that you notify MIPS when you first become aware of any claim, investigation or proceeding against you in connection with the provision of health care. Handling such matters yourself may in fact escalate concerns. Failure to notify MIPS may also jeopardise your access to the benefits of membership including cover under the MIPS Members’ Medical Indemnity Insurance Policy.

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It’s time to renew your MIPS membership From Monday 20 May 2013 members would have started receiving their 2013/2014 MIPS Member Benefit Statement. This is your application for renewal of membership for 2013/14. It is important to ensure that there is no gap in your member benefits, including insurance covers as membership for all current members will cease at 30 June. If you are a student member you will not receive a Member Benefit Statement but your membership will be renewed automatically unless you have already graduated. Members who have not received their Member Benefit Statement by the end of May should contact MIPS as a matter of urgency. Over the past few months, the MIPS team has been working hard to make the renewal application process as effortless and seamless as possible for members. You can now pay your membership fee online via My Membership and payment can include setting up a direct debit arrangement.

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Membership

Benefits Handbook 2013/2014

Combined Financial Services Guide and Product Disclosure Statement

You can also get a copy of your current or previous Member Benefit Statements, get a copy of your Certificate of Currency and update your personal details using My Membership. Members should review the 2013/14 Membership Benefits Handbook to acquaint themselves with the conditions of membership and consider if the category shown on their Member Benefit Statement is still appropriate. The Member Benefits Handbook has been significantly redesigned to improve user-friendliness. The insurance covers (including the MIPS Members’ Medical Indemnity, Practice Entity and Group Personal Accident Policies) that are a benefit of MIPS membership can be found in the Insurance Covers Handbook.

Extractions on anti-coagulant medications: Dealing with patients by Dr Gerard Clausen One of the common questions that practitioners are faced with is the correct protocol for dealing with patients on anti-coagulant medications when tooth extractions or other surgical procedures are required. In the past it was often considered medication such as Warfarin should be stopped prior to surgery to minimise the risk of severe or uncontrolled bleeding. However, a more specific and tailored approach is now recommended and it is important that clinicians are aware of this. The current approach is based on the INR (International Normal Ratio); the ratio of the patient’s prothrombin time to a standardised norm. For example an INR of 2.0 indicates a patient’s blood takes twice the normal time to clot. The recommended approach is to request an INR test 24 hours prior to surgery. For patients with an INR between 2.2 and 4.0 it is recommended that a tranexamic acid mouthwash is used.

Further information about this is published in Therapeutic Guidelines; Oral and Dental Version 2. For patients with an INR less than 2.2, surgery can be undertaken without a tranexamic acid mouthwash but the patient should be given the mouthwash and appropriate instructions for home use if required. For patients with an INR above 4, surgery should not proceed and further evaluation must be undertaken. In all cases the complete medical history should also be taken into account so that INR values are not looked at in isolation. A post-surgical review protocol is also indicated, with reviews at two days and again within fourteen days being recommended. In summary a very significant part of a thorough medical history is to ascertain if the patient is on anti-coagulant therapy, particularly if oral surgical procedures are planned.

Decreasing or ceasing anti-coagulant medication is not recommended as this may precipitate other risks such as a thrombotic event. The current best practice is to request an INR test and treat based on the guidelines presented to minimise risk. It is essential, especially in cases where the patient may have a more extensive medical history, for the treating dental practitioner to liaise with the patient’s general medical practitioner to manage the patient in parallel. It is not at all unusual for a dental patient to either forget, or not completely disclose their full range of medications or medical history in the belief that these are medical matters that are not significant within the confines of dental treatment. Frank discussion with the patient’s medical practitioner is a critical part of holistic treatment planning and should be considered mandatory in these cases.

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MIPS Winners!

James Cook Dental School Professor Andrew Sandham and MIPS member Fiona Lo

Winner of dental loupes at ADC2013 - Dr Gary Mack

Update on eHealth PCEHR The Personally Controlled Electronic Health Record (PCEHR) came into effect in July 2012 following a commitment of funding from the Australian Government of $466.7 million over two years to establish some of its key components.1 The system has slowly gained momentum and it is reported that there are now more than 125,000 consumers registered.2 eHealth is defined by the World Health Organisation as ‘the combined use of electronic communication and information technology in the health sector.’ It refers to the health care components delivered, enabled or supported through the use of information and communications technology. It may involve clinical communications between healthcare providers such as online referrals, electronic prescribing and sharing of electronic health records. It can also provide access to information databases, knowledge resources and decision support tools to guide service delivery. 1 2

It is important to ensure care is always taken in dealing with patients and to remember the rules surrounding prescribing requirements; for access control mechanisms, identity verification, the handling of specified types of records and participation requirements, including security requirements for healthcare provider organisations. Please see more information on the PCEHR rules. For a more illustrative consideration of issues from a medico-legal, clinical and consumer prospective take a look at MIPS’ interactive hypothetical on our website.

RACGP webinars on eHealth Between April and June 2013, the Royal Australian College of General Practitioners (RACGP) will be running peer-to-peer education seminars across Australia on using the eHealth record system. At these a GP will explain the purpose, benefits and opportunities of the eHealth record system and the information contained within it. Attendees will also learn practical ways to include the electronic health record in their clinical workflow, be provided with a guide on when and what to upload and how to create and maintain a high quality shared health summary. Visit the RACGP website to register. Seminars are free and aimed at GPs, registrars, practice nurses, practice managers and staff.

Australian Government, Budget measures: budget paper no.2:2010–11, Commonwealth of Australia, Canberra, 2010 Dr Mukesh Haikerwal, PCEHR set to make life easier for doctors, improve care.

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Risk education update The Autumn risk education workshop program has been very successful with approximately 850 members attending the various workshops.

Some of the highlights of this program included: • The new topic ‘Beyond Negligence’

developed by MIPS and focussing on personal risks such as the complaints and investigations practitioners face, has been extremely well received. • MIPS commissioning of the world premiere of ‘Mastering Safer Practice’, a new workshop from the Cognitive Institute focussing on reliable delivery and application of knowledge and skill to provide quality care. • Dental members who were provided with the opportunity to attend three specific dental workshops in addition to a range of other relevant workshops. • The Melbourne edition of the Dental Risks in 2013 workshop was held during the Australian Dental Congress enabling interstate members to attend. The event was filmed and is now available as an online risk education module for dental members. You can watch the full video at www.mips.com.au/videos • The addition of CPR refresher training commissioned through the Red Cross has been highly successful with demand leading to a further five courses being scheduled.

Dr Gerard Clausen, MIPS clinico-legal adviser presents to MIPS members at ADC2013

All members attending workshops receive a Certificate of Attendance for the purposes of CPD and/or their CV and have their attendance noted in their MIPS membership records. Attendance enables members to share and learn from other member/peer experiences.

Planning is now underway for the Spring 2013 program which will include further CPR refresher training and a risk education event to be held in Darwin during GP13.

RACGP members should be aware that 2013 is the final triennium year for CPD accumulation and all members would be aware of the mandatory CPD registration standard.

Members participating in the PSS and who have not yet completed a MIPS approved risk education activity must complete a MIPS Online Module before 30 June 2013. Visit mipseducation.com.au to register for an online module.

In addition to providing risk education as a membership benefit, MIPS continue to support a number of educational stakeholders around Australia by providing MIPS risk education. An example of this is MIPS providing additional opportunities for IMGs through the Victorian Medical Postgraduate Foundation.

Premium Support Scheme – mandatory risk education

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Are you a medical practitioner with limited registration? This year many healthcare practitioners with limited registration will renew their membership for the third year since the national laws changed in July 2010. Practitioners in a limited registration (public interest - occasional practice) type are only allowed to renew it three times - beyond that if they would like to stay registered they need to transfer to another registration type or alternatively their registration will lapse.

Additionally, MIPS members who do transfer to general registration need to ensure they have the contemporary skills for the services they intend to provide and meet their continuing professional development (CPD) requirements. Keep an eye out for MIPS risk education opportunities!

The limited registration (public interest - occasional practice) registration type is a closed category– so no practitioner can opt-in for this registration type. There are around 1,000 practitioners with a limited registration including about 600 who are due to have their registration expire in September 2013. The remaining practitioners will have their registration expire before September 2014.

• their work impacts on safe, effective

The National Law provides medical practitioners with limited registration (public interest-occasional practice) with three options: 1. make a new application for general registration 2. make a new application for non-practising registration 3. let their registration lapse. This means any MIPS members who are in the limited registration (public interest - occasional practice) registration type need to weigh up whether they would like to continue with their current practice. For any MIPS members who elect to transfer to general or non-practising registration or let their registration lapse, it is likely that your MIPS membership category will need to change. If you are in this situation you should refer to the Membership Benefits Handbook for guidance on an appropriate category or call MIPS on 1800 061 113.

For roles beyond patient care, the Medical Board recommends practitioners be registered when: delivery of healthcare to individuals • they are directing/supervising/

advising other health practitioners about the healthcare of an individual • their employer/employers professional indemnity insurer requires that person to be registered • professional peers and the community would expect a person in that role to comply with the Board’s standards (CPD, recency of practice etc) and/or • they are required to be registered under any law to undertake any specific activity.

There are however a number of activities which the Medical Board of Australia has advised can be undertaken without the need for general registration. Amongst these are where the practitioner is: • an examiner/assessor of medical

students or graduates, where the student/graduate is not treating patients as part of the assessment and provided that the organisation on whose behalf they are acting believes that current practising registration is not necessary for the scope of the activity

• a tutor/teacher working in settings

that involve simulated patient or settings in which there are no patients present, provided that the organisation on whose behalf they are acting believes that current practising registration is not necessary for the scope of the activity • a researcher whose work does not include any human subjects and whose research facility does not require them to be registered • a person who speaks publicly about health or medical related topics and who will not be giving any individual patient advice • a person serving on a board or committee or accreditation body, where their appointment is not dependent on their status as a ‘registered medical practitioner’ • a person who may be using skills and knowledge gained from an approved qualification but is not using a protected title, nor claiming or holding themselves out to be registered, such as a person in an advisory or policy role • a medical practitioner who is registered overseas and is visiting for any role not involved in providing treatment or opinion about the physical or mental health of an individual. If you hold a limited registration (public interest – occasional practice) registration type and would like to transfer, AHPRA have provided a guide: Information sheet: Maintaining registration with limited registration (public interest - occasional practice). For further details see the news article on AHPRA’s website.