Utilisation of computers in general practice an update. Joan Henderson Graeme Miller Helena Britt

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1 Utilisation of computers in general practice an update Joan Henderson Graeme Miller Helena Britt

2 Background Integration of computers into clinical practice since 1990 s 90% of GPs used computers in 2006 Print prescriptions, test orders etc Paperless medical record use was low Large proportion used Medical Director Software Subsidised through pharmaceutical advertising Removed in 2009

Paperless medical record use was low Large proportion used Medical

3 Aims In regard to clinical computer use by GPs, to determine: Whether use of clinical functions has increased since 2005 The effect of withdrawing advertising from MD on the market distribution of software products used by GPs The influence of these factors on data quality in GP EHRs

withdrawing advertising from MD on the market distribution of software

4 Methods Secondary analysis - GP characteristic data from BEACH participants about clinical software use over time Literature review - Quality of data extracted for GP software products

5 Methods Bettering the Evaluation And Care of Health Paper based data collection National GP random sample (DoH) 1,000 GPs per year (chars of GPs + practices) 100 consecutive encounters per GP All types of encounters included Nationally representative data -100,000 encounter records p.a.

GPs + practices) 100 consecutive encounters per GP All types of

6 Methods Quality = Completeness are all the data present? Reliability are data recorded the same way at all practices, over time? Validity are the data correct? (Do they measure what they claim to measure?) (Greiver M et al, BMC Health Serv Res :116)

over time? Validity are the data correct?

7 Results GP participants: 9 years of comparable GP data mean completion rate = 78%; range 74.4% 81.0% participants (individual years) compared with national sample frame on: age, sex, State/Territory, ASGC representative of GPs across Australia

0% participants (individual years) compared with national

8 Per cent Not at all Internet Prescribing (print) eprescribing (online) Paperless records Hybrid records Paper only records GP computer use to

Email Prescribing (print) eprescribing (online) Paperless

9 * * McInnes DK, Saltman DC, Kidd MR. Med J Aust Jul 17;185(2): Per cent Medical Director Medical Spectrum MedTech 32 Genie Solutions Monet Zedmed Best Practice Other Software Product

2006 Jul 17;185(2):88 91 50 2008 09 Per cent 40 30 2009 10 2010 11 2011

10 Results NO ENFORCED STANDARDS!! Structure No problem structure for continuity of care Number of data elements Data labels and definitions No linkage of data elements Coding and classification systems Messaging languages Decision support tools technical specs and content differ Compatibility of data extraction tools

elements Data labels and definitions No linkage of data elements Coding and

11 Results Other factors Cost time and money Computer literacy / data entry skills no training Data not entered into the correct field in the record Lack of incentive No remuneration No perceived benefit for GP or patient Privacy concerns Medico-legal grey areas

field in the record Lack of incentive No remuneration No

12 Results Longitudinal data for lipid profiling 199,331 patients only 1,452 had complete lipid test information from visit 1 to visit 6 Comments routine lipid profiling may have been conducted but results not entered tracking of patients is difficult in case of consulting another GP Cannot validate the data caution should be exercised when extrapolating results to the wider Australian patient population. Carrington M, Stewart S et al; PHC Conference Proceedings, Brisbane 2011

patients is difficult in case of consulting another GP Cannot validate the data caution should be exercised when

13 Results Validation of a GP audit and data extraction tool. Comments participating sites needed to be exclusively using either MD or BP for their EHR without any use of paper or hybrid paper/electronic recording. for extraction tools to accurately collect pathology data, laboratories must submit test results in HL 7 format and assign a unique code per test. As a condition of participating we mandated that all sites have their pathology reported in HL 7 format. if a practitioner is making free text entries rather than in codable sections of the record then neither the extraction tool nor our manual case record reviewer would have detected those entries. Pieris D, et al; Aust Fam Phys (11):

for extraction tools to accurately collect pathology data, laboratories must submit test results in HL 7 format and assign a unique code per test.

14 Results Assessment of 3 data extraction tools (DETs) with 2 EHR systems. The extraction tools identified different numbers of diabetics... None provided a gold standard extraction that matches the expected 6.6% prevalence of diabetes in the study regions, as reported (elsewhere) the data models vary as there are no prescribed standards the location of key coded data varies from EHR to EHR.. it is plausible that some DETs are missing large numbers of relevant patients current DETs are not reliable and potentially unsafe. We conclude that the DET/EHR combinations did not extract similar counts of diabetics and indicators of diabetes care. This renders current DETs ineffective as tools for measuring the quality of care. Liaw S, et al; Aust Fam Phys (11):

6% prevalence of diabetes in the study regions, as reported (elsewhere) the data models vary as there are no prescribed standards the location of key coded data varies from EHR to EHR.

15 Discussion A minimum data set for GP-patient data was developed for the GPCG in 2005; GP Data Model & Core Dataset in 2000 ICPC-2 is Standard Classification for Primary care a SNOMED-CT ref set for primary care also available Secure language/messaging standards? Many practices are drowning in scanning, and every day practices are complaining about the scanning workload. The doctors have to pay staff to scan as scanning is a job now. Otto K, PulseIT, April 2014.

16 Conclusion Computerisation of GP is >98% Use varies widely impact on quality Change to MD market share mostly of benefit to BP Lack of standards impact on quality Lack of incentives/support for practices impact on quality Does it matter? Extracted data basis for financial decisions, management decisions, assessing outcomes, changing guidelines, for GP education?

incentives/support for practices impact on quality Does it matter?

17 Discussion Many thanks to the GPs BEACH

18 Discussion and endorsed by BEACH

19 Discussion Free PDF versions of the BEACH reports can be downloaded from Sydney.edu.au/medicine/fmrc (go to Publications and select Books General Practice series ) Hard copies cost $15 35 for each book Follow is on Contact us: Website: Sydney.edu.au/medicine/fmrc Phone: beach@fmrc.org.au New reports to be released on 11 th Nov

cost $15 35 for each book Follow is on twitter @Sydney_BEACH Contact us: Website: Sydney.edu.

Primary Health Care in Australia and China now and in the future. Professor Amanda Barnard Associate Dean, ANU Medical School

Primary Health Care in Australia and China now and in the future Professor Amanda Barnard Associate Dean, ANU Medical School 2 Primary Health Care General agreement that primary health care is the basis