Supporting general practice to make timely decisions for better health care: a population health approach.

Primary Health Networks (PHNs) are tasked to enhance the efficiency and effectiveness of general practice. Gold Coast Primary Health Network (GCPHN) has been collecting de-identified aggregated clinical data from general practices and reporting back on areas for improvement on data coding and some clinical metrics, such as blood pressure not being recorded. However, aggregated data cannot be used to intervene at the individual patient level, and because of the collection-to-reporting time-lag, the data cannot help facilitate immediate action in the general practice. GCPHN developed a practice-based population health management approach based on mapping data from general practices to international coding classification systems, and applying evidenced-based algorithms and tools. General practices are provided with a health profile of their entire patient population, from the healthiest to the most complex comorbid patients. The information is conveyed as alerts and reports on areas including medication quality and safety, possible gaps in care and high-risk patients. The information is received based on the practice's preferences; this can be at the time of data entry, the following day or as specified. Strong clinical governance has ensured GCPHN's approach and methodologies are evidenced-based and appropriate. The consistent application of clinical governance within general practices is also needed to ensure the approach is sustainable and improves clinical outcomes.