Chris Pearce Associate Professor in General Practice Monash University (Thursday, 10.45am, Forum Room) See associated video

1. Computers in Primary Care:
Evolution or Revolution
HINZ November 2012
Associate Professor Chris Pearce

2. The Problem? Or The Solution?
General Practice is completely computerised
» Prescribing
» Progress Notes
» Communication
» ‘Reluctance to adopt the EHR is due at least in part to fear of
change, fear of disruption to the physician–patient
relationship and perceptions of increased workload, without a
clear understanding of the benefits to be gained’1
1: Doyle et al, Family Practice 2010

3. Narrative
Fabula
Code
Personal
System
Narrative

4. Inner East Melbourne Medicare Local
» Population distribution:

5. What is the population health program?
How do we do this?
» Provide practices with access to and education in the use of
a series of data extraction tools such as PEN
CAT, PHA, IEMML tool
» Provide practices with comprehensive clinical and business
reports on a 15 month cycle
» Assist practices in making changes to they way they practice
to improve the health outcomes of their patients.

6. Data Size.
Currently we have:
» Data Warehouse 1. PHA extract – 1.1Million Patients
• Limited focus on specific chronic diseases
» Data Warehouse 2. CAT/IEMML extract – 500K Patients
• More data
• Longitudinal analysis
• Closer to the data source – 1 step removed
from the practice software rather than 2
steps (DW1)

7. What do we do with this data?
Our primary use of this data is to provide feedback
to practices on how:
» Well they code their clinical information,
» Indicate areas of potential improvement,
» How to optimise their use of MBS chronic disease and health
assessment items
» Show them how to make changes to improve practice
processes around the above items.

8. What do we present to practices?
The general layout of the clinical & business report
is:
» Patient population overview:
2011 2012
Your total population 7,232 8,198
Your cleansed population 7,118 8,067
15-month patient population 2,217 2,083
No. Patients who have not presented ≥ 3 years 3,568 3,861
Aboriginal or Torres Strait Islanders 1 1
Pensioners 492 528
DVA Patients 78 65
Patients on ≥ 5 medications 552 531

9. What do we present to practices?
» Preventative health measures and data completeness:
100%
April 2011
97% 98% 95%
August 2012
90%
IEMML Benchmark
80% 85% 85%
Recording Percentage
76%
70%
60% 64%
48%
40% 43%
38%
20%
19%
13% 12% 3% 6%
11%
0%
Allergy Status Smoking Status Alcohol Intake BMI Waist Absolute CV
Recording Recording (≥ 18 years) Measurement Risk

10. What do we present to practices?
» Co-morbidities:
Diabetes Asthma HT Mental COPD CHD Stroke Bone &
Health Joint
Disease
Diabetes 111 28 63 30 7 31 18 43
Asthma 403 107 98 30 33 26 103
Hypertension 360 101 38 120 59 32
Mental Health 360 24 28 27 100
COPD 71 27 12 10
CHD 108 84 60
Stroke 84 18
Bone & Joint Disease 329

11. What do we present to practices?
» Actual versus Potential income from MBS items:
Actual ^Estimated Estimated
Item description Earned (A) total value(B) potential new
income (B-A)
EPC Health Assessment Items $47,863 $70,453 $22,590
Diabetes GPMP/TCA/Review $13,271 $30,336 $17,066
Asthma GPMP/TCA/Review $44,834 $71,518 $26,685
Mental Health GPMP/TCA/Review $44,153 $42,720 -$1,433
CHD GPMP/TCA/Review $6,815 $10,981 $4,167
Stroke GPMP/TCA/Review $4,782 $7,628 $2,845
COPD GPMP/TCA/Review $2,485 $3,362 $877
Bone Disease GPMP/TCA/Review $12,792 $20,441 $7,648
CDM services by a Practice Nurse $3,115 $4,968 $1,853
Sub-Total $132,247 $191,954 $59,707
PNIP Subsidy (see calculator 3) $0 $25,000 $25,000
Service Incentive Program (SIP) Items $1,625 $38,801 $37,176
Medication Management Item 900 2 $1,340 $2,721 $1,381
Aged Care items Item Numbers $2,683 $5,998 $3,316
Totals $185,758 $334,928 $149,169

12. IEMML level uses
» Population profile for the catchment:
8.0% 2010-2011 IEMML Average
2011-2012 IEMML Average
7.0%
6.0%
% Total no. people
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
Age group

13. IEMML level uses
» Preventative health and data completeness benchmarks:
100%
2010-2011 Benchmark
95% 95%
2011-2012 Benchmark
80% 85%
Recording Percentage
77%
68%
60% 64%
51%
40% 43%
20%
0%
Allergy Recording Smoking Recording BMI Recording 5 Year CV Event Risk
Status Status

14. What is the warehouse comprised of?
» Local chronic disease benchmarks:
Age Standardised Prevalence
2010-2011 2010-2011 2011-2012 2011-2012 National
Condition / Morbidity
Patient Count Prevalence Patient Count Prevalence Prevalence
Asthma 9,994 7.9 9,896 8.0 9.9
COPD 1,324 0.7 1,317 0.7 2.3
CHD 5,176 2.7 4,486 2.4 5.4
Stroke 2,108 1.1 1,840 1.0 1.2
Hypertension 19,265 11.4 18,334 11.4 9.5
Diabetes 5,528 3.4 5,667 3.7 4.0
Mental Health 10,923 7.8 11,402 8.3 11.1
Bone & Joint Diseases 11,450 6.4 9,786 5.7 11.3

15. Research: Low Back Pain
example:

16. System understanding of data
‘Data Hierarchy2’
Support Clinical Interventions
Clinical Governance
Population Based Decision Support
Policy and Strategy
Research
Administration and Business Support
2: Pearce et al, Australian Family Physician 2011

17. Personal to System
Traditionally the relationship was characterised
as a dyadic one3:
But now recognised to be changing
• Black box4
• Gaze behaviours
• Information Source5
3: Middleton, J Royal College of GP 1989
4: Als, Family Practice 1997
5: Shachak, J Eval Clin Pract 2009

18. Triadic behaviours6
Actor Keys Behaviours
Doctor Unipolar/Bipolar Engaging
Disengaging
Cogitating
Patient Dyadic/Triadic Screen Watching
Screen Controlling
Screen Ignoring
Computer Active/Passive Informational
Prompting
Distracting
Pearce et al, Int J Med Info 2009

19. The ‘New’ Consultation7
Pearce et al, JAMIA 2011

20. See associated video
given in description

21. Personal
System
• Clinical Governance
• Population Based
Decision Support
• Policy and Strategy
• Research
• Administration and
Business Support

22. Questions?
Chris Pearce
cpearce@iemml.org.au