The desire to overcome chronic disorganization of the bureaucracy through the 'adoption of computer systems is affecting all the health sector. The pace of change is proving to be excessive, however, because problems arise not provided on time, and to which the system is always ready to respond. The difficulties that arise for the compilation and delivery of electronic prescriptions, certificates of disability and illness, are for the most downloaded on the health, transformed into simple "system operators" and often threatened with severe sanctions. The project is now close, "electronic prescription", has highlighted critical issues that need to find simple solutions (doctors are not computer operators!) Before the final departure.
It said that the systems we mentioned are handled differently by different subjects, and have different characteristics. Let us examine, now, the problems associated with electronic prescriptions.
This process should be managed by the Regions and the recipes should be submitted to the Ministry 's Economy with quite different from the certification process, however managed by 'INPS.
The electronic prescriptions are being considered for some regions in charge of practical experimentation. We illustrate some problems.
Management Issues substitutes
As you know, family physicians are allowed to be represented in activity 'agreement with that mode over time, have gradually been more clearly defined:
- To replace "flash" (up to three days) and the doctor 'responsibility to inform ASL of the replacement. The substitute may be
a) belonging to another practitioner 'Association
b) a practitioner does not belong to' association,
c) NOT a doctor agreement.
In case a): the substitute recipe to your recipe
In case b) and in case c) the medical prescription on the prescription pad holder, affixing its stamp
- to replace "short" (from 4 up to thirty days) and the physician 'must give place to the ASL. The management of recipe and 'similar to the previous year.
- to replace "prolonged" (over 30 days), the substitute doctor takes a direct financial relationship with ASL, but the recipe follows the previous point
should implement a computer procedure that makes it possible and easy replacements taking into account that the replacements are very frequent "flash", if only for a few hours, and often are handled by doctors outside the conventional system. Moreover, these substitutions are frequent, systematic and continuous enough.
Recipe computer will then return both the data and those of the physician owner of the substitute, while also allowing the holder to close on or replacement as necessary, including planning in advance the duration of this
Management of diagnosis and ICD9 codes: the problem of diagnostic hypotheses
management diagnosis is very tricky, as the 'ICD9 not' always suitable to represent the conditions under which you make a prescription.
Much will depend on the solutions offered by software vendors (except the right to free choice of remaining in the range of suitable products), but some difficulties' are inherent in the system.
Background necessary: \u200b\u200bthe physician should be able to make the diagnosis "true", without "adjustments" that may be necessary to adapt to the shortcomings of the system as such behavior would be disrespectful of the truth, laws, and interests of patients, who may become severely damaged.
It should be noted in this context that the doctor and 'entitled to make the diagnosis even in a "not certain", hypotheses to be explored, suspicion or (in the case of specialist requirements or instrumental) of diagnostic questions. Ask this question and diagnostic 'of particular importance in the prescription of investigations, as it provides an indication to the specialist about what' you are looking for, and emphasizes that the diagnosis is not 'final.
However, the 'ICD9 diagnosis does not include suspected, probable, hypothetical, why inserted each diagnosis would be considered as established.
It 'obvious that some take for a disease not yet determined may distort the clinical history of 'seen that may be damaged or, conversely, may use it in certain cases to obtain allowances for which he was not entitled.
The right and duty to indicate a diagnosis 'doubtful' and 'lawful, laid down' ACN (Art. 51, 59a, art. 69, etc..) And other general rules (for all: Decree on May 18 25/10/2004 OJ 2004, in implementation of the provisions relating to monitoring of expenditure in the health sector and appropriateness of the health requirements in paragraph 2.3.1 of technical regulations).
also the recipe for the practitioner, the Court has now settled, it is be considered a public act, for some authentic material respects, including the diagnosis. See for Cass. Section VI, Judgement of 01.10.2007, No 35836, which summarizes other sentences: "The challenging ... are not simple" questions "based on reviews and assessments (diagnosis or suspected diagnosis) of a scientific nature, but, like those that contain prescription drugs (regulated by art. 23, DPR cit.) are an expression of a certification authority, because, through the underlying diagnosis, certify and operate a legally protectable interest of the citizen "
In respect of truth and the law, then, physicians should express the diagnosis in the form of certainty when it is reasonably achieved, or in the form of hypotheses or clinical question in cases of reasonable doubt, and computer systems will need to provide this facility.
Management of diagnosis and ICD9 codes: the problem of multiple diagnoses
In the recipe, the space for 'affixing of the diagnostic code allows the 'placing of a single code, but the current legislation makes it possible in a recipe up to two packs of drugs, also different.
E 'can then (and indeed, and' frequently) that the two drugs is vested in two different diseases. 'S contemporary classic example is the prescription of an anti-inflammatory and a gastroprotective, but there are countless. You should therefore enter both codes, but the recipe will provide space for one.
should therefore be possible to insert a second diagnosis.
is unacceptable the idea of \u200b\u200bprescribing only one drug per prescription, since it is an issue to be dealt with in the National Accord.
As above would appear necessary or desirable at least at present, delete the 'obligation of ICD9 coding of diagnosis, leaving only the optional possibility of diagnosing cases thus established.
The management of 'human error
As in all activities, and' anticipate a certain percentage of human error in the printing of the requirements to be the doctors (for homonyms, misrepresentation, typographical errors or force majeure). The recipe allows you to put on paper easily remedy, ripping the erroneous and rewriting again. This is not possible in the case of electronic prescriptions, especially if sent to 'Social Security in the contemporary press.
E 'then a necessary procedure to cancel any orders wrong: staying in the database they could have serious consequences for both the doctor and patient.
A trivial example might be the wrong prescription for a drug to the patient and 'intolerant remedied immediately tore the paper prescription. Although, whilst not being followed the 'recruitment, but the limitation would remain' in the database taking any error in the health check, prompting them to repeat the prescription in the belief that the drug is in use without problems.
The recipe must be removed from the database erroneous or clearly marked as "incorrect", regardless of whether it was or not withdrawn at the pharmacy.
For similar reasons, would require a procedure which allows the doctor to see what its requirements were then completed, and if some are rather outstanding. This is to also to meet any request for renewal on the grounds of loss limitation of the recipe or the like.
E 'then you may experience failures or interruptions in telephone service, or computer failure or other causes such as to prevent accidental transmission of the recipes in real time or at least on time. In these cases, the doctor provvedesse to 'send in the following days, there will be a discrepancy between the dates of those recipes on paper and sent electronically, which could lead to unpleasant consequences, especially from the legal point of view.
This may also apply to prescriptions dispensed at home after the closing day of the study: the recipes on paper would take a date other than telecommunication services, and the date, the Court has now settled, are essential elements of 'public act consists of prescription.
E ' therefore required a procedure that enables doctors to correct the 'error or report such circumstances, even in a time lag. Such a procedure is 'already' provided for certificates of illness, but within a very restricted.
Some notes on the certificates of illness, and reflections of a physician
issues quite similar to intervene in the case of the certificates of illness, except a short adjustment period of several months, in a few months should be sent to telematics' INPS. We'll talk in detail in altri articoli, ma vorremmo anticipare alcuni punti.
L' INPS ha predisposto da tempo un sistema informatico avanzato, che è in condizione, almeno in teoria, di gestire il flusso delle certificazioni. Alcuni dei problemi da noi evidenziati sopra sono stati in effetti già presi in considerazione, come ad esempio la possibilità di correggere o annullare una certificazione sbagliata, seppure con vincoli temporali ristretti (un giorno di tempo).
La certificazione telematica comporta tuttavia responsabilità assai pesanti, che costituiscono una frequente cause of dispute or complaint to the doctor.
Similar to the above for the recipes, the phase shift data, for example, even if due to causes entirely innocent, can 'be a source of serious problems, the penalties for failure to dispatch then seem entirely disproportionate and unjustified. The chronicles tell us that even the most serious health deficiencies are often less severe penalties than those provided for in these cases: termination or cancellation of the contractual relationship is frankly inconceivable if motivated by purely bureaucratic shortcomings.
The problems still encountered in the management practices of civil disability also makes us a little skeptical about the fluidity of the next steps of management of the 'huge amount (tens of times) the certificates of illness. We'll talk.
A thorough review of:
are planned and implemented a number of different procedures, with different passwords, with links to different sites, for the various tasks that arise during the same visit: a link (with password and dedicated procedure) for recipes, a different link (also 'it with their own password and procedure) for health certificate, if the patient requests the certification process for the recognition of' disability, there will be a third connection with another password and further dedicated procedure.
L 'INAIL then has its own procedure for certification of work accidents.
provides for a simplification but, reasonably, a fusion of these tasks so that the doctor, once identified and accredited to perform all its functions with a single, coordinated process. Does not provide for the need to store a set of passwords, addresses, procedures are all different.
This is, in our opinion, the real frontier of 'modernization of the health bureaucracy!
Now FNOMCeO and medical trade unions (including the same co-authors of the crime, apparently repentant) try to get some adjustments to improve them. It is hoped that reason, from the public prevail!
Daniel Zamperini - Pina Onotri
site http://www.scienzaeprofessione.it/
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