Automating faxes was just the start: Inala Primary Care and Digital Health

Driving through the streets of Inala, a south-west Brisbane suburb, is always memorable. The 1950s style brick-and-stucco housing is clear evidence of Inala’s origins as a post-war social housing experiment. Through the decades, disadvantage has continued to dominate the area, populated by the elderly and predominantly African, Middle Eastern and Asian communities – in particular Vietnamese, who were among Australia’s first wave of ‘Boat People’ and made Inala their home. Indigenous art work in the local parks reflect one of Queensland’s largest agglomerations of Aboriginal, Torres Strait Island and Pacific Island peoples.

Standing adjacent to Inala's main shopping precinct is a Centrelink, legal service offices and an array of healthcare providers, including a discoloured Whitlam-era community health building – buried at the back of which is Inala Primary Care, or  'IPC' for short.  A charitable general practice, IPC won the Australian General Practice (AGPAL Accreditation) of the Year in May 2016, not from benefits derived from the latest design and building scale of its Indigenous Health neighbour, nor from being the recipient of a ‘Closing the Gap’ largesse or government ownership.  I believe that the prestigious acknowledgment was the result of IPC's reliance on the development and innovation of its digital systems.

The needs of IPC's patients are simply too complex for doctors to employ old fashioned methods of service. Less than two per cent are privately insured, 70 percent have either a pensioner concession or healthcare card and 29 per cent are on five or more medicines. Nearly 1000 of IPC's 3500 patients have been diagnosed with diabetes, and the practice also has one of the highest rates of mental health diagnosis in its PHN region. IPC serves patients from 119 ethnicities and delivers one in seven of its consultations with assistance from an interpreter. A further one in six consultations are delivered using the language skills of bi-lingual doctors. In the past, this complex, marginalised and often voiceless group have been supported through a fragmented healthcare system.  Many were consistently frustrated by communication gaps in their health journey. With so many patients unable to manage good health, it's not surprising that IPC is looking at systems to help patients and their care team achieve better outcomes. Digital health is a significant part of their answer, a strategy well received by patients who have quickly embraced it as a way to bridge gaps.

On 4 September 2012, IPC uploaded Australia's first Shared Health Summary to our truly national electronic health record.  This milestone came after several years participating in various eHealth pilot and wave initiatives, which led to the deployment of the system we now call the My Health Record system.  With many patients under the care of varying clinicians, this single source of truth is fundamental to delivering effective care, given it enables access to up-to-date, accurate healthcare information, medicines reconciliation, tracking of contact with the healthcare system and increasingly, visibility for end of life wishes.  It’s all there in one convenient, secure record. 

Digital systems also enable shared care within IPC. Many of the GPs and providers at the practice work part-time. Frequent flier patients usually have two doctors (within a medical team of 23) who they would name as their primary carers. With this reality, IPC identified that clinical benchmarks and practice dashboards must support ongoing practice management and clinical governance. In live time, the practice can generate a variety of reports, all using visual formats, to analyse the current state. In addition, IPC was an early adopter of the NPS MedicineWise’s MedicineInsight system and in the last 12 months, a benchmarking process underpinned by the PenCS suite, which is coordinated by the Brisbane South PHN. Use of the PenCAT tool to generate lists, update registers, do audits and assess demand for new services is a fortnightly occurrence. Such reliance on data analytics requires quality data and standardised business processes.

Uploading Shared Health Summaries and Event Summaries, or updating medicine lists, is something which can be accommodated in the routine nurse and GP workflow. When the e-PIP measures changed to a measure of meaningful use, the practice easily met the target despite experiencing periodic downtime with the uploading function from software provider Best Practice to My Health Record. The biggest challenge so far has been maintaining patient and clinician interest in a system which seems to have proceeded at a slow pace, and when so many dates for upgrade have been missed. The practice continues to advocate for greater standardisation of secure messaging across healthcare systems so that interoperability improves. 

The latest announcement by the RACGP of the ‘Fax Off’ initiative is seen by IPC as a worthwhile and overdue process. Four years ago, the practice worked with Sharp to generate code which would automate the feed from faxes received by a new multi-function work centre into Best Practice. This saved boxes of paper each week and reduced the workload for reception significantly. Consequently, the practice patient volume has doubled over the period with marginal increases to reception staffing. Sharp has since marketed this solution to many other practices nationwide.

Ms Tracey Johnson is CEO of IPC and has recently been appointed to the Healthcare Homes Evaluation Advisory Group. After studying health systems in five countries over several months in 2015, she is a strong advocate for continued improvement in our digital health infrastructure. Managing tiers of chronic disease patients under new funding models will require a radical shift in practice systems to sort, manage and review sub-populations. Managing patients will increasingly occur through teams of care providers, not all of whom will reside in the one practice setting. Therefore, being able to access and update patient records efficiently will become even more important. Developing patient health literacy and increasing their engagement in care will also be necessary if we’re to continue to negate rising costs. A variety of digital health interventions and infrastructure will enable this transition to more patient-centred care. To this end, IPC is already preparing for a world in which only very sick patients physically attend the practice. Having deployed tablets during home visits more than eight years ago, the team is keen to build models of care where phone, email, videoconference, telehealth, home monitoring and digital screening in reception can complement the traditional role of physicians laying hands on patients. Such a world will only be possible when accessing histories is as readily available as biomarker feeds, and all are captured for the entire care team in one reliable and accessible digital space – the My Health Record.

IPC has already developed integrated models of care with several partner hospital for complex diabetes, chronic renal disease and attention deficit hyperactivity disorder. A bug bear for each is the need for the double entry of patient information into practice and hospital management systems. Such duplication of data always involves skilled clinicians such as nurses who will, over time, be of increasing value and in short supply. Savings on repeat pathology are only meaningful if a primary care nurse does not have to check the hospital data to see whether particular tests have been completed in the secondary or tertiary sector. Identification of patients for complex care will occur more accurately and earlier in their disease progression if algorithms can run using both practice and secondary care provider data. Therefore, an urgency exists to develop digital solutions which mean both primary and secondary providers can access the same digital clinical information in a timely way.

The Commonwealth has started a conversation about the future of the Practice Incentive Program (PIP).  In line with other health systems around the world, a focus on quality and ongoing improvement will most likely be the emphasis of any revamped program. Managing greater percentages of patients to a larger number of evidence-based targets, tracking gains over time and generally using data to stimulate innovation at practice and regional level are all worthy ambitions – but they will only be possible if practices have accurate, up-to-date and meaningful data at hand. 

Of course, the next evolution could be to incentivise change in 30, 60 and 90 day hospital re-admissions. In our current world, practices like IPC often receive first notification of an admission a month after it has occurred.  In future, a My Health Record which flags an emergency department contact or admission, provides timely detail on discharge and any required follow-up would be of significant benefit.

Then there is the world of research. Whilst primary care receives six percent of government health expenditure, it treats the vast majority of the population. A digital health world can potentially make better use of this funding. Data would be at the point of care in such volumes that studies regarding health services and even medicines necessary to protect an increasingly multi-morbid population could be far easier than before. IPC has been a research active practice since its inception. Improving data quality, developing skills in data capture and analysis has underpinned research into novel models of care. Digital windows into the patient journey and clinical outcomes can only enrich our understanding of what works for patients, funders and providers.

Taking the variance out of patient care and the stress out of clinician work can be achieved through greater input from patients and the entire care team associated with any individual. Such connectivity is best digital, especially when, in practices like those at Inala, the patients do not speak the language or have such limited health literacy that their capacity to engage with their healthcare team is limited. Making our system work on behalf of such persistent and demanding users as those in disadvantaged catchments is the ultimate test of how many savings digital health can reap.

Dr John Aloizos AM is a Senior Clinical Reference Lead at the Australian Digital Health Agency and the Chair of Inala Primary Care Ltd since June 2007.

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To have your say on the national digital health strategy, go to website https://conversation.digitalhealth.gov.au/