Primary Sense: a new population health management tool for general practice
Deborah DaviesGold Coast Primary Health Network, 1/14 Edgewater Court, Robina, Qld 4226, Australia. Email: debbied@gcphn.com.au; markndeb123@bigpond.com
Australian Journal of Primary Health 26(3) 212-215 https://doi.org/10.1071/PY19205
Submitted: 28 January 2020 Accepted: 30 March 2020 Published: 12 June 2020
Journal Compilation © La Trobe University 2020 Open Access CC BY-NC-ND
Abstract
Primary Sense is a new data extraction, analysis and reporting tool that the Gold Coast Primary Health Network (GCPHN) has developed to enable practical and effective population health management in general practice and also on a regional level. Once installed, the tool de-identifies data within the practice before running it through various clinical risk algorithms to create practical information that can easily be actioned within the general practice business model in at least two ways. The first is to generate up-to-date reports of patients who are most likely to benefit from specific interventions or occasions of service. The second is to identify potentially serious medication safety issues, alerting clinicians in real time at point of prescribing. Formal live testing of the system was completed in nine practices where 22 managers and nurses and 42 GPs used the tool over a 5-month period in 2019. The live test monitored the use of reports and alerts, and regular feedback from users enabled small but important improvements to the tool. Practice teams successfully used the reports to target specific groups of patients with outstanding care needs or who were at greatest risk of adverse health outcomes. The results of the live test showed that users found Primary Sense to be easy to use and beneficial to general practice. The next phase of this project is now underway to further trial the scalability and change management requirements for full implementation of Primary Sense. As more and more practices adopt the tool, the aggregated data will increasingly help to support population health planning, commissioning of local services, active health surveillance and other related activities.
Additional keywords: evidence-based practice, medication systems, primary health care, point-of-care systems.
References
Advisory Board (2018) 4 steps for managing rising-risk patients. (Advisory Board: Washington, DC, USA) Available at https://www.advisory.com/research/care-transformation-center/care-transformation-center-blog/2018/02/risk-management [Verified 23 August 2019]Agency for Clinical Innovation (ACI) (2015) Risk stratification in NSW. (ACI: Sydney, NSW, Australia) Available at https://www.aci.health.nsw.gov.au/resources/chronic-care/aci/risk-stratification-program [Verified 23 August 2019]
Australian Commission on Safety and Quality in Health Care (ACSQHC) (2012) National safety and quality health service standards Sydney. ACSQHC, Sydney, NSW, Australia.
Australian Digital Health Agency (2017) Safe, seamless and secure: evolving health and care to meet the needs of modern Australia. Australia’s National Digital Health Strategy. Available at https://conversation.digitalhealth.gov.au/australias-national-digital-health-strategy [Verified 12 August 2019]
Australian Healthcare and Hospitals Association (AHHA) (2015) Population health. AHHA Primary Health Network discussion paper series: paper four. (AHHA: Canberra, ACT, Australia) Available at https://ahha.asn.au/sites/default/files/images/phn_discussion_paper_four_-_population_health.pdf [Verified 23 August 2019]
Australian Institute of Health and Welfare (AIHW) (2016) Australian Burden of Disease Study: impact and causes of illness and death in Australia 2011. Australian Burden of Disease Study series no. 3. BOD 4. AIHW, Canberra, ACT, Australia.
Australian Medical Association (AMA) (2017) General practice in primary health care. (AMA: Canberra, ACT, Australia) Available at https://ama.com.au/position-statement/general-practice-primary-health-care-2016 [Verified 25 June 2019]
Berwick DM, Nolan T, Whittington J (2008) The Triple Aim: care, health, and cost. Health Affairs 27, 759–769.
| The Triple Aim: care, health, and cost.Crossref | GoogleScholarGoogle Scholar | 18474969PubMed |
Biggs A (2016) A new way to address chronic disease in primary care. (Parliament of Australia: Canberra, ACT, Australia) Available at https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/BriefingBook45p/ChronicDisease [Verified 9 August 2019]
Britt H, Miller GC, Henderson J, Bayram C, Harrison C, Valenti L, Wong C, Gordon J, Pollack AJ, Pan Y, Charles J (2015) General practice activity in Australia 2014–15. General practice series no. 38. Sydney University Press, Sydney, NSW, Australia.
Buchan H, Duggan A, Hargreaves J, Scott I, Slawomirski L (2016) Health care variation: time to act. The Medical Journal of Australia 205, S30–S33.
Council of Australian Governments (COAG) (2012) National Healthcare Agreement 2012. (COAG: Canberra, ACT, Australia) Available at http://www.federalfinancialrelations.gov.au/content/npa/health/_archive/healthcare_national-agreement.pdf [Verified 12 August 2019]
Davies D (2018) Supporting general practice to make timely decisions for better health care: a population health approach. Australian Journal of Primary Health 24, 368–371.
| Supporting general practice to make timely decisions for better health care: a population health approach.Crossref | GoogleScholarGoogle Scholar | 29898816PubMed |
Department of Health (2018) PHN practice support, frequently asked questions. (Department of Health: Canberra, ACT, Australia) Available at https://www1.health.gov.au/internet/main/publishing.nsf/Content/Fact+Sheet-PHN-Practice-Support+ [Verified 8 August 2019]
Department of Health (2019) Primary Health Networks (PHNs). (Department of Health: Canberra, ACT, Australia) Available at https://www.health.gov.au/internet/main/publishing.nsf/Content/PHN-Home [Verified 12 August 2019]
Duggan A, Koff E, Marshall V (2016) Clinical variation: why it matters. The Medical Journal of Australia 205, S3–S4.
Galbraith K, Ward A, Heneghan C (2017) A real-world approach to evidence-based medicine in general practice: a competency framework derived from a systematic review and Delphi process. BioMedCentral Medical Education 17, 78
Gordon J, Miller G, Britt H (2016) Reality check - reliable national data from general practice electronic health records. Deeble Institute Issues Brief number 18. (Australian Healthcare and Hospitals Association: Canberra, ACT, Australia) Available at https://ahha.asn.au/publication/issue-briefs/deeble-institute-issues-brief-no-18-reality-check-reliable-national-data [Verified 13 August 2019]
Leotsakos AZheng HCroteau RLoeb JSherman HHoffman CMorganstein LO’Leary DBruneau CLee PDuguid MThomeczek CVan der Schrieck-De Loos EMunier B (2014 )
Lyons A (2017) Doubts remain over funding for Health Care Homes trial. (newsGP, RACGP: Melbourne, Vic., Australia) Available at https://www1.racgp.org.au/newsgp/racgp/doubts-remain-about-funding-for-health-care-homes [Verified 8 August 2019]
Mehta N, Panditb A (2018) Concurrence of big data analytics and healthcare: a systematic review. International Journal of Medical Informatics 114, 57–65.
| Concurrence of big data analytics and healthcare: a systematic review.Crossref | GoogleScholarGoogle Scholar | 29673604PubMed |
Phillips C, Hall S, Pearce C, Travaglia J, de Lusignan S, Love T, Kljakovic M (2010a) Improving quality through clinical governance in primary health care. (Australian Primary Health Care Institute: Canberra, ACT, Australia) Available at https://pdfs.semanticscholar.org/e22c/32db88fbd7bcda853dcaf31d362170b90778.pdf [Verified 13 August 2019]
Phillips C, Hall S, Pearce C, Travaglia J, de Lusignan S, Love T, Kljakovic M (2010b) Improving quality through clinical governance in primary health care. (Australian Primary Health Care Institute: Canberra, ACT, Australia) Available at https://pdfs.semanticscholar.org/e22c/32db88fbd7bcda853dcaf31d362170b90778.pdf [Verified 13 August 2019]
Sansoni J (2016) Health outcomes: an overview from an Australian perspective. (Australian Health Outcomes Collaboration, Australian Health Services Research Institute, University of Wollongong: Wollongong, NSW, Australia) Available at https://ahsri.uow.edu.au/content/groups/public/@web/@chsd/documents/doc/uow217836.pdf [Verified 8 August 2019]
Swerissen H, Duckett S, Moran G (2018) Mapping primary care in Australia. (Grattan Institute: Melbourne, Vic., Australia) Available at https://grattan.edu.au/wp-content/uploads/2018/07/906-Mapping-primary-care.pdf [Verified 8 August 2019]
The King’s Fund (2011) Improving the quality of care in general practice. Report of an independent inquiry commissioned by The King’s Fund, London. (The King’s Fund: London, UK) Available at https://www.kingsfund.org.uk/sites/default/files/improving-quality-of-care-general-practice-independent-inquiry-report-kings-fund-march-2011_0.pdf [Verified 13 August 2019]
World Health Organization (WHO) (2005) Chronic diseases are the major cause of death and disability worldwide. Fact sheet. (WHO: Geneva, Switzerland) Available at https://www.who.int/chp/chronic_disease_report/media/Factsheet1.pdf [Verified 22 August 2019]
