Information technology in primary health care
Introduction
It is now well recognised that achieving international best practice in the primary health care sector will require the development of methods based on a fundamental integration of communications and information technologies with clinical practice. This will have far reaching effects both on the pattern of medical practice and domiciliary care, and on patient outcomes.
The primary health care sector in Australia represents the base of the health care pyramid, and is formed by over 20 000 general practitioners, nurses, local area health services, community domiciliary nurses and community hospitals. This sector has a predominant role in the delivery of preventive health care and in the triaging of patients needing more expensive specialist or hospital services. Developments in health care world-wide are increasingly recognising the importance of this sector. Major advances in health care delivery over recent years have targeted; efficiency in the production of health care services and the management of health care resources; effectiveness in the selection of appropriate care services for delivery to the patient; and improvements in the quality of the services provided.
In Australia, the primary health sector is an economically important sector that controls entry into a health care system that now represents almost 8% of the gross domestic product (GDP). Integration of this sector with other specialist and local area hospital services using appropriate diagnostic and information based technologies will result in major cost efficiencies and improved public health outcomes.
The impact of national strategies both in the UK [1] and Australia [2], [3], [4] for Information Management and Technology (IM&T) on general practice are likely to be profound, but many aspects of the implementation of these policies remain unclear. The objectives are to provide information-based resources to improve patient care, promote health prevention initiatives, improve practice management and provide continuity of information transfer between primary, community and hospital services. It is not at all clear however, how the medical practitioner and nursing staff will use information management and technology to improve the quality of care delivered to patients. Nor is it clear how this technology will help the doctor diagnose, treat and manage more effectively the chronic degenerative diseases that are characteristic of an industrially developed and ageing community.
In the primary health care setting, information and communications technology has in the past been presented as a tool for management rather than as a tool for supporting, improving and making more efficient the professional practice of medicine and the delivery of health care to the patient and the community.
As a consequence, many medical practitioners continue to demonstrate the same scepticism and lack of enthusiasm that has severely inhibited the introduction of information and communications technology in general practice over the last 10 years. Although the level of computerisation in general practice in Australia is now approximately 50–60%, GPs generally use their computers for accounting, billing and simple office management. Very few use their systems for clinical purposes or patient medical records [5]. More sophisticated applications such as clinical decision support, management of longitudinal data and the interfacing of clinical measurement systems into the patient medical record, are virtually unknown.
We present a model of information management in general practice, based on the perceived needs of the practitioner. It is envisaged that elements of this model will form the basis for a telemedicine-assisted primary health care trial. This trial will have as a broad objective, the provision of continuity of patient care from the patient’s home, to the doctor’s surgery, to speciality services in hospitals and to other service providers in the health care sector. The aim of the trial will be to assess the technology, as well as assess doctor and patient satisfaction. Longer-term aims will be the assessment of changes in patient health outcomes and savings in health care expenditure.
The areas of clinical decision support, computerised clinical measurement and patient education are given particular attention as they represent novel and emerging activities in the computerisation of general practice. Methods of data exchange between these and other areas, and suppliers of patient management systems (PMS) are discussed. One simple connectivity method using file exchange is presented.
Section snippets
Information management in primary health care
The provision of information and communications technology to the primary health care sector has in the past been seen primarily from a management perspective, and even today this remains substantially the case [6]. Obviously information technology has an important role to play. From a UK perspective, the NHS IM&T [1] strategy for example, is intended to impact on general practice in a number of ways.
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Sharing more comprehensive GP data, will facilitate targeting of health care and assist
Communications and networks
For telemedicine to impact on general practice, a communications network must be in place. Interestingly, in the UK, some 40% of all activities of the NHS are associated with the handling and communications of data [1]. The NHS IM&T strategy has indeed targeted networking and the facilitation of communications between GPs, community carers and hospitals as one of its major objectives. Activity however seems to be concentrated on the establishment of standards for electronic data interchange and
Telemedicine trial
Using individual modules and the simple connectivity scheme described previously, a telemedicine trial is proposed. Plans are currently underway to produce lower cost and simpler versions of our clinical measurement modules for home use (single-lead ECG and spirometry). It is envisaged that a central service provider will automatically collect the data from the patient’s home initially via the standard telephone (PSTN) network. A database server will act as a central repository for this
Conclusions
This paper has attempted to address some of the issues involved in modelling information management in the general practice setting, and hence a telemedicine trial with a focus on continuity of care. For such a trial to be a success many other issues need to be resolved. They include:
(1) confidentiality and secure exchange of clinical data to the satisfaction of the privacy commission;
(2) tools for the assessment of the quality and provision of health care, patient satisfaction and health status,
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