Primary Sense: a new population health management tool for general practice

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.

Supporting quality and safety in general practice: Response rates to computer decision support

“…The commercially available IT tools that support CQI did not meet the Gold Coast PHN (GCPHN)'s requirements to bring quality improvement into the GP's workflow during the patient's consultation, or to target patients at most risk. 11 The commercial tool GCPHN was using was also labour intensive for PHN staff, and it was challenging to produce evidence of quality improvement in general practices. To address these issues, a population health management tool with GP decision support functionality was developed with Department of Health (DoH) innovation funding, and as such, they own the intellectual property to Primary Sense.…”

Segurança do profissional e problemas éticos e bioéticos no cotidiano da atenção primária

“…Essa ferramenta permite ao profissional de saúde, em especial o enfermeiro, sinalizar em tempo real problemas de segurança, fragilidades como quedas; perda de peso e complexidade baseadas na quantidade de recursos de saúde que o paciente utiliza atualmente, a fim de apoiar, facilitar e favorecer decisões clínicas e individuais para cada paciente. Esse software reúne ainda relatórios e informações sobre condutas e atendimentos aos pacientes, tornando-se uma ferramenta de suporte segura, capaz de proporcionar melhorias, confiança e padronização nos cuidados de saúde da equipe multiprofissional (60).…”