Building one world class system for Gold Coast Primary Health Network (GCPHN) provides support to general practice, the cornerstone of healthcare, to remain a hub of clinical excellence
GCPHN has developed Primary Sense to address the needs of general practice. Primary Sense creates practical reporting to support the practice in population health management, supporting the GPs, nurses and practice managers to deliver evidenced based, optimised care.
GCPHN has worked closely with local GPs and researchers to develop Primary Sense to ensure reports and medication safety alerts are both high quality and practical in a general practice setting, and align with RACGP Standards and advice.
Beyond Data Mining
Primary Sense ensures that the reports generated support actionable, evidenced based care in general practice. Medication safety alerts link to optimising care reports for patients. The system highlights potential quality and safety of care issues for your clinical consideration as well as linking to recommended interventions in a seamless way.
Primary Sense is fully automated and can be tailored by the individual user, with the ability to opt patients in and out their request.
While general practice may know the health needs of patients who attend frequently, they may not know the status of those patients who are more infrequent attenders. This is especially important for those with increasing complexity. Primary Sense provides patient information delivered as timely, actionable reports. This allows clinicians to plan and coordinate care in an efficient and effective way.
Timely and Convenient
The pseudonymised data is collected from the practice, analysed and the specific reports the practice has requested are produced on demand. When viewed in the practice, the report links with the software to provide the patients’ details as an actionable lists.
Incorporating the ACG® System
Characterised by excellence in both research and practice, the Johns Hopkins ACG® System has been used in performing risk measurement and case-mix categorisation for more than 30 years. Using data from the practice, the program provides a multi-morbidity framework for assessing patient complexity, providing estimates of costs, and predicting future health needs, including risk of hospitalisation
Primary Sense provides an opportunity to more effectively monitor complex patients as they move around the health system, supporting practices to arrange enhanced and integrated care.
As a patient why this is important
General practices are very busy, often providing care to thousands of patients, and it’s not always easy to predict which patients are most at risk of poor health. When a general practice shares health information with GCPHN the data is analysed, using a tool called Primary Sense, to find patients who might benefit from extra attention.
The patient’s name, full date of birth or address are not shared with GCPHN as these are not necessary for the analysis.
GCPHN uses evidence based guidelines and state of the art IT tools to provide the practice with resources and support to deliver quality health care to patients. GCPHN also uses the information for planning, research and evaluation to improve the health care services available on the Gold Coast.
Primary Sense could see that one practice had more patients with kidney disease than other similar sized practices. The practice is informed of the patients potentially most at risk. In addition GCPHN provides education and resources to general practice so staff can better manage this condition in primary care.
Patients often see more than one GP. This means that the treating GP may not have the full medical history, which can reduce the quality of care.
To overcome this, with appropriate consent, Primary Sense can share key data between participating practices to notify the treating GP on issues such as
- an abnormal test result that could cause harm
- mixing medications that could cause harm
- a diagnosis that may have implications for current treatment
John has recently moved to a new practice where the GP suggests he take a medication to help prevent a heart attack. John forgets to tell the GP that he has had a stomach ulcer in the past. Primary Sense has found a history of this at his other practice, and while prescribing the heart medication, the GP is alerted that John has had a stomach ulcer and may need a second medication to protect him.
Only data to improve the quality and safety of care is shared.
This is a new initiative in early stages of implementation and development will continue to provide greater functionality into the future.