Collaboratives: Enhancing Patient Care Through Clinical And Business System Improvement


The health technology and software currently available to GPs provides them with enormous computing power. However using it effectively to establish and sustain patient management systems, and improvements in patient care and business efficiency, is another thing!

The $17 million Commonwealth funded Collaboratives program is helping over 500 general practices and primary health care providers Australia wide to do just that. The NPCC (National Primary Care Collaboratives), based at Flinders University in Adelaide, is working directly with general practices across the country to improve systems using an internationally acclaimed improvement model developed in the US and adapted in the UK. The program focuses on three topic areas, Diabetes, Coronary Heart Disease (CHD) and Better Access for patients to primary care.

Measurement is a vital element of this innovative improvement model and is used to provide feedback to practices on their progress. A total of 13 measures are collected by participating practices and submitted to the NPCC monthly via a secure online reporting site, in what is one of the first data collections of this type in primary care on a national level.

The CHD and Diabetes measures are collected using clinical software which initially posed a challenge for the program. To overcome this challenge, NPCC developed an extraction tool with the assistance of the Canning Division of General Practice to aggregate data and produce the NPCC measures. NPCC has also been working closely with leading software suppliers and now eight software suppliers have included NPCC reporting functionality within their software. Each month, NPCC analyse the data and provide feedback for practices, allowing them to monitor improvement. The NPCC also monitors divisional and national results and progress towards the overall aims of the program. The measures are sensitive enough to track change as practices focus on different areas of their clinical or business systems, and provide assurance that changes implemented have resulted in an improvement.

Most GPs know, for example, that a patient is taking aspirin for a CHD condition, having prescribed it themselves, or aware of the prescription from the hospital or cardiologist. However, when reports are run for the first time, often they cannot recognise or find data to produce accurate reports. This is a direct result of coding and data entry protocols adopted by GPs and the broader practice team.

One practice in the Collaboratives program reported that each GP in the practice used a different term for Diabetes, finding Type 1, IDDM, NIDDM, and Diabetes Mellitus among the codes. Another practice recalled a male patient for a gestational Diabetes review, while many others reported embarrassing and upsetting recall letters sent to spouses of deceased patients.

“Practices need to adopt a standardised approach to data capture as this allows more effective reporting, which if used appropriately, can lead to significant improvement,” said Megan Grigg, NPCC Manager of Data and Information.

Participants in the Collaboratives program have invested significant time cleaning up patient records to establish accurate registers and commence accurate measurement. By coding correctly and consistently, such as recording a patient’s BP or HbA1c results in the right area, the clinical software can produce meaningful reports. Often, after the production of accurate reports, GPs find opportunities for improvement in many areas.

A large practice in Victoria reported that in the first week of their participation in the program they archived over 20,000 patients through diligently cleaning up their systems. They not only examined their CHD and Diabetes registers but the whole practice system, archiving deceased patients and all patients who hadn’t attended the practice in 2 years. They have also noticed an increase in the speed of their software as a result.

With clean registers and effective systems GPs can know more about their patient population. They can accurately identify patients for recall and review, initiate exercise programs and diabetes education sessions, coordinate team care arrangements with allied health professionals, assess the need for a chronic disease clinic, and identify patients within high risk groups, or with increasing risk factors, for intervention and management.

General practice databases contain enormous amounts of valuable data that GPs can us to deliver proactive, systematic care, and many software packages have sophisticated tools to assist. But unless the patients are coded correctly and consistently, the software can’t retrieve the information GPs need to make informed decisions about patient care.

Posted in Australian eHealth

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