Introduction to Digital

Health
92040 Autumn 2019
Primary Care in Australia
 Primary Care

What is it What is the structure What is the history The sky is falling
Organisational Units Funding Gatekeeper role Epidemics NCD / Obesity /
• Divisions -> Medicare Locals Medicare Referral / Discharge Diabetes / Heart Disease / OA
-> Primary Health Networks • MBS Continuity of care Epidemic Communicable
disease
• PBS
Definitions
Primary Care All care outside of Acute / Secondary / Tertiary

General Practice Care Provided by General Practitioners and their

teams
Acute and Unplanned Emergency and Immediately necessary care

Secondary Care Planned and referred from Primary Care

Tertiary Care Planned and referred from Secondary Care

The size of health
 The sky is falling..
Ageing Population
2001 – over 60s > than under 18s
2050 – 4 times as many needing care
At 4 times the current cost
Remember hidden costs

5
Source OPCS 2003
Healthcare Expenditure
Slightly above the world average
 Who pays for what?
Healthcare in Australia is funded by
the Australian Government, state and
territory governments, and non-
government entities such as
individuals, private health insurers,
third-party insurers and workers
compensation. These sources of
funds pay for health care across the
health system through various
funding arrangements.

In 2015–16, governments funded $115 billion of

the total health expenditure (67%) with non-
government sources funding the remaining $56
billion (33%).
Of the $115 billion government contribution in
2015–16, the Australian Government contributed
$70 billion (61%), with state and territory
governments contributing $44 billion (39%).
In 2015–16, funding by individuals was $29 billion.
This was 53% of the $56 billion in non-government
funding, or 17% of total health expenditure.
Spending on health has grown by about
50% in real terms over the past decade,
from $113 billion ($5,500 per person) in
2006–07 to $170 billion ($7,100 per
person) in 2015–16. This compares with
population growth of about 17% over
the same period.

Governments fund two-thirds (67%, or

$115 billion) of all health spending, and
non-government sources fund the rest
(33%, or $56 billion). Individuals
contribute more than half (17%, or $29
billion) of the
non-government funding.

Together, hospitals (39%) and primary

health care (35%) account for three-
quarters of all health spending.
 Financial Year State MBS Group Description Requesting Provider's Derived Major Specialty Number of Services Benefit Paid ($) Number of Patients Number of Services per Benefit Paid per Patient ($) Number of Services per Capita Benefit paid per Capita ($) Patients as per cent of Estimated Resident
Patient Population Population

2016-17 Australia Total Pathology Total 135,108,113 2,609,695,887 13,336,384 10.1 195.7 5.5 105.3 53.8% 24,781,121

2016-17 Australia Total Pathology Total GP 89,986,433 1,674,448,055 12,371,414 7.3 135.3 3.6 67.6 49.9% 24,781,121

2016-17 Australia Total Pathology Specialist 44,868,643 930,026,310 3,989,120 11.2 233.1 1.8 37.5 16.1% 24,781,121

2016-17 Australia Total Pathology Allied Health 197,372 3,675,722 42,150 4.7 87.2 0.0 0.1 0.2% 24,781,121

2016-17 Australia Total Pathology Dentist 57,176 1,741,347 18,843 3.0 92.4 0.0 0.1 0.1% 24,781,121

2016-17 Australia P1. Haematology Total 17,562,236 293,167,511 5,942,786 3.0 49.3 0.7 11.8 24.0% 24,781,121

2016-17 Australia P1. Haematology Total GP 8,750,653 139,054,532 4,510,480 1.9 30.8 0.4 5.6 18.2% 24,781,121

2016-17 Australia P1. Haematology Specialist 8,784,178 153,570,366 2,369,892 3.7 64.8 0.4 6.2 9.6% 24,781,121

2016-17 Australia P2. Chemical Total 50,288,271 1,076,518,850 10,597,076 4.7 101.6 2.0 43.4 42.8% 24,781,121

2016-17 Australia P2. Chemical Total GP 34,207,629 759,425,445 9,595,890 3.6 79.1 1.4 30.6 38.7% 24,781,121

2016-17 Australia P2. Chemical Specialist 16,004,932 315,382,024 2,858,725 5.6 110.3 0.6 12.7 11.5% 24,781,121

2016-17 Australia P3. Microbiology Total 15,622,613 448,998,119 6,537,060 2.4 68.7 0.6 18.1 26.4% 24,781,121

2016-17 Australia P3. Microbiology Total GP 12,315,027 354,338,768 5,808,021 2.1 61.0 0.5 14.3 23.4% 24,781,121

2016-17 Australia P3. Microbiology Specialist 3,264,081 93,426,099 1,352,769 2.4 69.1 0.1 3.8 5.5% 24,781,121

2016-17 Australia P4. Immunology Total 4,238,082 143,890,051 1,797,655 2.4 80.0 0.2 5.8 7.3% 24,781,121

2016-17 Australia P4. Immunology Total GP 1,901,475 63,301,961 1,268,878 1.5 49.9 0.1 2.6 5.1% 24,781,121

2016-17 Australia P4. Immunology Specialist 2,331,458 80,441,905 649,875 3.6 123.8 0.1 3.2 2.6% 24,781,121

2016-17 Australia P5. Tissue Pathology Total 3,516,438 312,252,040 2,286,831 1.5 136.5 0.1 12.6 9.2% 24,781,121

2016-17 Australia P5. Tissue Pathology Total GP 1,765,454 142,159,754 1,168,956 1.5 121.6 0.1 5.7 4.7% 24,781,121

2016-17 Australia P5. Tissue Pathology Specialist 1,737,657 168,937,743 1,254,795 1.4 134.6 0.1 6.8 5.1% 24,781,121

2016-17 Australia P6. Cytology Total 1,999,307 47,309,769 1,873,264 1.1 25.3 0.1 1.9 7.6% 24,781,121

2016-17 Australia P6. Cytology Total GP 1,633,146 32,650,988 1,585,897 1.0 20.6 0.1 1.3 6.4% 24,781,121

2016-17 Australia P6. Cytology Specialist 360,617 14,546,898 317,289 1.1 45.8 0.0 0.6 1.3% 24,781,121

2016-17 Australia P7. Genetics Total 281,268 45,770,625 240,847 1.2 190.0 0.0 1.8 1.0% 24,781,121

2016-17 Australia P7. Genetics Total GP 110,146 6,605,031 105,685 1.0 62.5 0.0 0.3 0.4% 24,781,121

2016-17 Australia P7. Genetics Specialist 171,350 39,384,845 138,266 1.2 284.8 0.0 1.6 0.6% 24,781,121

2016-17 Australia P8. Infertility and Pregnancy Tests Total 723,105 16,481,656 466,609 1.5 35.3 0.0 0.7 1.9% 24,781,121

2016-17 Australia P8. Infertility and Pregnancy Tests Total GP 497,017 11,512,339 362,146 1.4 31.8 0.0 0.5 1.5% 24,781,121

2016-17 Australia P8. Infertility and Pregnancy Tests Specialist 225,316 4,951,473 128,411 1.8 38.6 0.0 0.2 0.5% 24,781,121

2016-17 Australia P10. Patient Episode Initiation Total 40,452,393 221,619,575 13,207,290 3.1 16.8 1.6 8.9 53.3% 24,781,121

2016-17 Australia P10. Patient Episode Initiation Total GP 28,584,482 163,462,361 12,252,686 2.3 13.3 1.2 6.6 49.4% 24,781,121

2016-17 Australia P10. Patient Episode Initiation Specialist 11,787,370 57,645,615 3,832,080 3.1 15.0 0.5 2.3 15.5% 24,781,121

2016-17 Australia P11. Specimen Referred Total 424,400 3,687,691 345,972 1.2 10.7 0.0 0.1 1.4% 24,781,121

2016-17 Australia P11. Specimen Referred Total GP 221,404 1,936,875 195,769 1.1 9.9 0.0 0.1 0.8% 24,781,121

2016-17 Australia P11. Specimen Referred Specialist 201,684 1,739,343 157,074 1.3 11.1 0.0 0.1 0.6% 24,781,121
Nothing to
see here
Move along
What to we
go to the GP
for ?
We see our GP
more than any
other medical
practitioner
 No real
surprises
78% of people are registered with
a GP

87% of the population visit a GP at

least once a year
Disease Burden
Chronic Disease
 What’s
worrying
GPs?
 Some of us are seeking help
from a GP to get healthier. In
2014–15, of people aged 15
and over:
• 14% discussed reaching a
normal weight with a GP (for
adults who were obese, 31%
discussed reaching a normal
weight)
• 11% discussed eating
healthy food or improving
their diet
• 10% discussed increasing
their exercise levels.
In addition, 10% of adults who
drank more than 2 standard
drinks per day discussed
drinking
alcohol in moderation.
Inequality of
provision
Why might that be?
Indigenous
Health
Not so good…
 On average, prisoners have
poorer health and show signs of
ageing 10–15 years earlier than
the general Australian
population. Prisoners tend to face
greater socioeconomic
disadvantage than the general
adult population before they
enter prison—1 in 4 (24%) was
homeless, 1 in 4 (27%) was
unemployed in the month before
entering prison, and 2 in 3 (68%)
had an education level of
Year 10 or below.
Indigenous Australians are over-
represented in Australia’s prisons
(27% of the prison population,
compared with 3% of the adult
population).
Primary health care is typically the
first point of contact people have
with the health system.

It is often delivered by a GP but

other health professionals such as
allied health workers, community
health workers, nurse practitioners,
pharmacists, dentists, Aboriginal
health practitioners and midwives
also deliver primary care.

On average, people are receiving

more primary health
services than they were 10 years
ago.
 The Australian Government helps people pay for
nearly 300 million prescription medicines each year
under the PBS and Repatriation Pharmaceutical
Benefit Scheme (RPBS).
Nearly 1 in 3 (88.4 million) PBS prescriptions were
for cardiovascular diseases.
In 2015–16, close to $11 billion was spent on these
benefit-paid pharmaceuticals.

The Australian Government paid for most (87%) of

the cost of benefit-paid pharmaceuticals, and
individual consumers contributed the remaining
13%

However, individuals also spend money on medicines

that don’t attract a government subsidy, including
private prescriptions and over-the-counter medicines.
In 2015–16, more than $10 billion was spent on
these medicines with individual consumers paying for
most of it (93%).
 Australia’s Digital Health Strategy
Seven strategic priorities for digital health
in Australia:
• health information is available
whenever and wherever it is needed
through the My Health Record

• every health care provider can

communicate with their patients and other
health care
providers through secure digital
technologies
• high-quality data with a commonly
understood meaning can be used with
confidence
• all prescribers and pharmacists have
access to electronic prescribing and
dispensing by 2022
• maximum use is made of digital
technology to improve accessibility, quality,
safety,
and efficiency of care
• all health care professionals can
confidently and efficiently use digital health
technologies
As defined by AIHW

• Primary health care is often a person’s first contact with the health system. It comprises a
range of services that are not referred: general practice, allied health services, pharmacy
and community health.
• Various health professionals deliver these, including GPs, nurses, allied health
professionals, community pharmacists, dentists and Aboriginal and Torres Strait Islander
health workers (Department of Health 2015).
• Primary health care can also include activities related to health promotion, prevention
and early intervention, and the treatment of (and care for) acute and chronic conditions.
• Primary Health Networks are coordinating bodies that work directly with GPs, other
primary health care providers, hospitals, and the broader community to increase the
efficiency and effectiveness of health services and improve the coordination of care for
patients moving between different services or providers
• There are 31 Primary Health Networks across Australia, operating since 2015.
As defined by the
RCGP
• GPs are expert medical generalists. Every day in
our surgeries, we are managing conditions that
even a decade ago would have been
automatically referred to hospital consultants.
• We are the only doctors in the NHS who have the
skills and expertise to care for the 'whole
person', and the only doctors in the NHS who
have the opportunity and the privilege to build
up lifelong relationships with our patients.
 As defined by the RACGP
“General practice as a career
A career in general practice offers enrichment, reward, financial security, the opportunity
for personal and professional development, the opportunity for a diverse experience in
practising medicine, and collegiality.”
UK / AU / US models of General Practice
UK US Au
Gatekeeper role Strict – Single GP No Flexible – Multiple GPs

Fee for service Until 2003 Yes Yes

Fee for quality Since 2003 No No

Free at the point of care Yes No Only if bulk billed. Average

OOP $38
Co-payment for medicines £9 / $16 AUD per item Depends on your insurance PBS items $40
whatever it is but can lead to bankrupcy Non PBS full retail
Insurance may cover some if
it
Safety Net Yes No Yes (for PBS)
Unique ID Yes - NHS Number legally No IHI for MyHealth Record
enforced Medicare (not unique)
Individual state MPIs
Continuity and Out of Hours Quality Based Contract and No OOH optional
Mandatory provision of OOH Continuity not rewarded
service
Out of pocket costs
The work..
Why the difference ?
Out of Hours
in Australia
General Practice

Cares for patients in a whole of

The GP plays a central role in the In Australia, the GP: is most likely Coordinates the care of patients
person approach and in the
delivery of health care to the the first point of contact in and refers patients to other
context of their work, family and
Australian community. matters of personal health specialists
community

Performs legal processes such as

Cares for patients of all ages, both
Cares for patients over a period of Provides advice and education on certification of documents or
sexes, children and adults across
their lifetime health care provision of reports in relation to
all disease categories
motor transport or work accidents.

Fellowship entitles a GP to
practice unsupervised anywhere
General practice is a medical Entry to the speciality may be
in Australia, and to access a
speciality (in some countries called achieved by the admission to
specialist rate of remuneration
family medicine). Fellowship of the RACGP.
under Medicare, the Australian
health insurance scheme.
 Person centredness
Continuity of care
Comprehensiveness
Whole person care
Both Diagnostic and therapeutic skill

emphasise Coordination and clinical teamwork

Continuing quality improvement
Professional, clinical and ethical standards
Leadership, advocacy and equity
Continuing evolution of the discipline
Some diversity
of provision
Co-location
Co-location
with other
services
Regulation and
Registration for
Health
Practitioners
 • Pharmaceutical benefits can only be prescribed
by doctors, dentists, optometrists, midwives
Prescription and nurse practitioners who are approved to
prescribe PBS medicines under the National
medicines Health Act 1953.
• https://www.legislation.gov.au/Details/C2018C0
0410 487 pages
 • http://www.pbs.gov.au/info/healthpro/explanatory-
notes/section1/Section_1_2_Explanatory_Notes

• “Prescribers can gain access to order

PBS – Highly forms for standard and authority
prescription forms as well as computer

regulated and prescription forms by downloading the

required order form from the Department

bureaucratic
of Human Services website at
www.humanservices.gov.au.

The completed order form should be

posted to:

Prescription Pad Order Clerk….”

 1. The ability to produce a prescription
electronically
2. The ability to transmit the content of a paper
prescription electronically. The paper remains the
legal entity
E-Prescribing 3. The ability to transmit an electronic
prescription which is the legal entity released by
– 3 levels an authorised ‘token’ (which could be the paper
prescription)

Australia is at level 1 with an aspiration to

complete roll out of level 2 by 2022 - $28.2M
allocated in the 2018-19 budget
ePrescribing
eRx
Intermediate Prescription Medisecure
Exchange Services Initially incompatible but now interoperable

No single point of truth

No plans I am aware of to remove paper and replace the token

 Almost 100% have a computer in the consulting
room

Paid for by practices themselves

Digital Primary Minimal interoperability

Care
Proprietary coding or free text

Secure messaging ‘coming soon’

Significant numbers of messages are still faxes

 Why use a
controlled
terminology ?
Reasons N=709
 A national medicines

Australian Medicines database plugged into

SNOMED
Note there is NO
Terminology (AMT) knowledge or Decision
support within the
terminology
Apps vs.
Telehealth
Why is that ?
 lack of integration with concerns related to implementation costs
IT systems and current patient confidentiality

Barriers to processes/procedures and privacy

Telehealth?
lack of funding to True or False ?
support technology
adoption.
Decision Support in
Australian GP systems
A mixture of proprietary and commercially available products from
MIMS / Wolters Kluwer / Elsevier are in use. None use Stockley
Functionality includes:
• Contraindication checking – Drug / Disease Interactions
• Warnings about Drug / Impaired Renal and Liver Function as a
partial contra-indication (Reduce Dose or increase Monitoring)
• Drug Doubling
• Some indication checking and verification for Medicare PBS
purposes) and formulary checking
• PBS support to ensure right drug / formulation / duration for an
appropriate claim
• Past Use by class (can be annoying in something like Antibiotics
but useful for not appearing foolish – therapeutic options for
Diabetes / Hypertension etc.)
 The mixture of provision means that the advice
differs depending on the clinical system in use not
the actual need

[The] “Biggest problem is that

Decision despite having a range of
Decision Support (DS) tools, most
support clinicians don’t know about all
the DS tools present in the CIS
they are using, have never been
taught about them or where to
find and use them during routine
workflow …”
 Providing you know where to access them
Best Practice offers:
• BMI calculator – give a result after entering Weight and
Height – which then tells you the optimal weight range
to target
Decision • Structured Record observations – Pulse Rate, BP, Waist
measurement, Head circumference – enabled links to
Support Percentile Charts
• Cardiovascular Risk Calculator – Framingham Score
• Diabetes Risk Calculator
• Gestational Age Calculator
• INR Manager – Warfarin Dosing
• Imperial / Metric conversion
• Travel Medicine – access to database advising vaccines
and then allows you to create a schedule to give to the
patient and set reminders and recalls for follow up
Decision Support in GP systems 2
Allergies and Adverse reactions are handled differently with different datasets for each system. There is a
common model in MyHealth record but this is not completed by any system currently

Care pathways are handled by the NZ HealthPathways product which seems to have taken over
everywhere - this is a simple form-based approach with no real integration into the record.

Reminders are proprietary for each system and not shared or shareable

Dose checking
Patent State monitoring
4. Definitely not in place Pro-active decision support
Automation around Pregnancy and Breast Feeding except….MR
 Some Pathology providers allow downloads of path
reports via atomic data path – which then allows quick
access and cross reference for path test results

Decision
Some PHNs are providing to their practices a clinical
analytic tool to assist with data quality e.g. Brisbane South
PHN provides Cat 4 (free) to practices, ongoing education

Support classes for application and use and provides benchmark

reports to participating practices – refer to the
attachments for examples of both

Practices are starting to share their data but it’s very early
days. it’s what the practices learn from participating and
implementing the necessary learnings that is useful to
extend with the use of the DS
 Rudimentary in GP systems

Analytics Systems outside of GPs generally

functions less sophisticated

Outcome
health
Some Analytics PEN / Cat4
services Medicine
Insight
Garden City Medical Centre Benchmark Report
Extract Date: May 2017 Building Digital Health CAT4

Important points regarding this report:

* The Brisbane South PHN aggregated totals and percentages contained within this report include practices who provided a CAT 4 collection in
May 2017.
* Information in this report is calculated on the RACGP definition of an active patient , a patient who visits three times in the last two years. If a
patient was to make three visits to more than one practice in the last two years, then this patient could potentially be counted more than once in
the Brisbane South PHN averages.
* Information contained in this report is supplied from coded fields within clinical software. If the data is not coded correctly it may not display in
this report.
* Information in this report provides a snapshot of your data recorded for a range of areas against the available Brisbane South PHN region
averages. This information is based on coded data. Data that has not been correctly coded may not display. Use this as a guide only.

DEMOGRAPHIC PROFILE
Total Practice Population: 9,234
Number of Active Patients: 5,744
DVA Patients: 66
Aboriginal and/or Torres Strait Islander Patients: 30
Male Population: 2,237
Female Population: 3,507

DATA QUALITY AND ACCREDITATION

Measure Practice No Practice % BSPHN %
Allergy Status Recorded: 4,906 85.0% 93.5%
Patients >=18 yrs with Smoking Recorded: 5,720 99.6% 74.2%
Patients >=18 yrs with Alcohol Consumption Recorded: 3,753 65.3% 44.3%
BMI Recorded: 3,229 56.2% 54.2%
Gender Recorded: 5,744 100.0% 99.9%
Ethnicity Recorded: 5,735 99.8% 79.1%

100

90

80
% of Patients Recorded

70

60 Practice
50

40 BSPHN
30

20

10

Allergies Smoking Alcohol BMI Gender Ethnicity

The Topbar tool can assist with updating patient demographic and health information to meet the
RACGP standards for accreditation. Read more on Patient Health Records and
Health Summary requirements.

Page 1 of 2
Contrast with UK
From 15 years ago
 %

0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00

101530
72136
79330
50102
30860
79345
31444
20625
30856
92000
71105
72421
71128
1105
31443
M14
31462
72100
L13
30963
30811

Practice
79430
30885
30973
92001
72128
70580
72363
X011
Treatment with statins in IHD, April 2003 (n=473)

20607
30828
20412
72861
31447
71108
Wave 2
Wave 1

71124
31469
73381
31474
40802
 One Case
Study – 1
Million
Patients

http://www.nottingham.ac.uk/primis/documents/case-studies/west-hants-grasp-af-casestudy-interactive-v1.0.pdf
 Primary Care

What is it What is the structure What is the history The sky is falling
Organisational Units Funding Gatekeeper role Epidemics NCD / Obesity /
• Divisions -> Medicare Locals Medicare Referral / Discharge Diabetes / Heart Disease / OA
-> Primary Health Networks • MBS Continuity of care Epidemic Communicable
disease
• PBS
Introduction to Digital Health
92040 Autumn 2019

Primary Care in
Australia