(Albert Einstein, 2008)
Figure 11 - STAGE ONE: Chapter 4 - Context and Practical Experience
Introduction
Chapter two provided the theoretical foundation, the methodology to be used and the research design of the study. Chapter three provides a literature review on chronic conditions, health information systems and proceeded to expand into the literature
regarding information systems in general practice and the issues that affect the adoption of information systems in chronic condition care. It culminated by identifying a number of factors and constructs from the literature that could potentially inform an emerging information system implementation framework for the prevention and management of chronic conditions in general practice.
This chapter’s overall aim is to frame the case study. Three distinct sections provide the necessary content to achieve this unified aim. The first section provides the context in which the study took place (Part One). The second complements and enhances the findings in Chapter Three in the form of practical knowledge acquired as part of practical chronic diseases information systems implementations in general practices (Part two). The third section provides a background to the implementation framework that was carried out before the study begun (Part Three).
Another purpose, as the methodology chapter indicated (Chapter Two), by appropriately documenting the study’s context and protocols so that another investigator can follow the documented procedures, is that reliability is expected to be increased (Yin, 2003). As well as creating a ‘chain of evidence’ by allowing the reader to follow the derivation of this evidence from initial propositions to conclusions (Yin, 2003).
Another subtle outcome of this chapter is to make explicit any conscious or unconscious ‘world views’ that are guiding the researcher —in his double role as IT/IM officer at CHGPN. As explained in the methodology chapter, these ‘world views’ influence the researcher’s arguments and conclusions by determining the choice of background material, theories and research techniques (theoretical framework) used or omitted in the study (Darlaston-Jones, 2007; Flood, 1990; Lindsay, 1995; Reich, 1994). Therefore, when the thesis is written, it is the researcher's exposition of their own ‘world views’ that enable readers and examiners to follow the researcher’s arguments, and reach the same
conclusions (Phillips & Pugh, 1992). This is achieved by providing a background to the implementer and the implementation process before the study began.
Part One: Context of the study
This section of the chapter provides a brief overview of the broader Australian Health systems context, General Practitioners and Divisions of General Practices; and specifically the context around Central Highlands General Practice Network as the key stakeholder and partner organisation in which the study took place (the Case Study). This section also includes chronic diseases baseline data, and activities that relate to the practical implementations knowledge used in the study.
Australian Health System
Since 1901 Australia has been an independent nation having a federal system of
government, with its origins in the British system of government and law. The Constitution established a Commonwealth (federal) Government, giving its Parliament powers in
specified fields. Each of the six States and two Territories within the Commonwealth has a parliament; in the States these parliaments have powers in all areas not specified in the constitution as Commonwealth powers. Within States there are local governments such as municipal and shire councils (Medicare Australia, 2008c).
The Commonwealth currently has a leadership role in policy making and particularly in national issues like public health, research and national information management, and it
funds most medical services out of hospital, and most health research. The
Commonwealth, States and Territories jointly fund public hospitals and community care for aged and disabled persons.
The States and Territories deliver public acute and psychiatric hospital services and a wide range of community and public health services including school health, dental health, maternal and child health and environmental health programs (Medicare Australia, 2008c). The aim of the national health care funding system is to give universal access to health care while allowing choice for individuals through a substantial private sector involvement in delivery and financing.
The major part of the national health care system is called ‘Medicare’. Medicare provides high quality health care which is both affordable and accessible to all Australians, often provided free of charge at the point of care. It is financed largely from general taxation revenue, which includes a Medicare levy based on a person’s taxable income (Medicare Australia, 2008c).
The Federal Government’s Department of Health and Ageing (DoHA) is responsible for the policy development of Medicare and the Medicare Benefits Schedule (MBS)
(subsidised Medicare services listing). Medicare Australia (formally known as Health Insurance Commission - HIC) is responsible for:
• Ensuring Medicare benefits are paid to eligible health care consumers for services provided by eligible medical practitioners, and
• Assessing and paying Medicare benefits for a range of medical services, whether provided in or out of hospital, based on a schedule of fees determined by DoHA in consultation with professional bodies (Medicare Australia, 2008b).
General Practitioners
In Australia, the majority of general Practitioners (GPs) are self-employed and work in private businesses called General Practices in which they are employed or own outright. A small proportion consists of salaried employees of Commonwealth, State or local
governments. Salaried specialist doctors in public hospitals often have rights to treat some patients in these hospitals as private patients, charging fees to those patients and usually contributing some of their fee income to the hospital. Other doctors may contract with public hospitals to provide medical services. There are many independent pathology and diagnostic imaging services operated by doctors (Medicare Australia, 2008a).
The Divisions of General Practice Program
In 1992, the Australian Government Department of Health and Ageing funded 10
demonstration Divisions of General Practices, these were formalised local networks of GPs working within the same geographic area. The success of these demonstration projects meant that funding was extended with the Divisions of General Practice Program covering the whole of Australia. Current funding for the Divisions Program extends to 2012. The aims of the Divisions of General Practice Program have remained the same since the inception of the program. Its main aim is to improve health outcomes for patients by encouraging GPs to work together and link with other health professionals to upgrade the quality of health service delivery at the local level.
The Divisions Program also supports such common aims such as:
• Providing a mechanism for individuals and groups to contact local GPs and for GPs to respond as a group in local health issues;
• Allowing GPs to be involved in health policy decision making at the local level; • Improving the quality of health service delivery at the local level in order to
provide better access to available and appropriate health services;
• Addressing local issues to meet the special needs of groups such as Aboriginal and Torres Strait Islander peoples (these are local indigenous groups), people from non- English speaking cultures and people with low incomes;
• Facilitating the introduction of other elements of the general practice strategy e.g. accreditation, peer review and training initiatives;
• Enhancing the quality of educational and professional development opportunities for GPs and undergraduates; and
• Improving the cost effectiveness of service delivery at the local level thereby contributing to a more appropriate allocation of Commonwealth funding
(Primary Health Care Research & Information Service, 2008b) Divisions are supported by State-Based Organisations (SBOs) and the Australian General Practice Network (AGPN). At 30 June 2007, there were 119 Divisions of General Practice covering all of Australia (123 in 2000). Table 12 below, provides an organisational chart of the Division’s network. Headed by a national body, Australian General Practice Network (AGPN) that connects to the Federal Government and State Based Organisation (SBOs) (one in every state) and a number of divisions in each state that work with their SBOs. Divisions vary greatly in geographical size, number of general practitioners and population in their area, as well as in resources, infrastructure and their activities (Department of Health and Ageing, 2008).
Figure 12- Division of General Practice -Organisational chart
(Department of Health and Ageing, 2008) Central Highlands General Practice Network
The Central Highlands General Practice Network (CHGPN), formally known as Central Highlands General Practice (CHDGP) is one of the 119 Divisions around Australia. The Central Highlands General Practice Network includes the areas to the north, north-west and west of Melbourne in the State of Victoria; and covers an area of approximately 6000 square kilometres (see Table 13 below).
Figure 13 - Central Highlands General Practice Network - Geographical position
This Division (CHGPN) commenced formal operations in November 1993 and established its offices in January 1994. The Division is managed by a Board of Governance made up of elected local GPs.
The GP Network includes two large suburban satellite towns (Sunbury and Melton), a number of provincial centres and towns (Castlemaine, Seymour, Kilmore, Broadford, Gisborne, Woodend, Mt Macedon, Trentham, Riddells Creek, Romsey, Lancefield, Daylesford, Kyneton, Wallan and Wandong), as well as smaller rural communities. It boasts a population of more than one hundred and seventy thousand inhabitants; more than two hundred GPs and more than forty general practices; five hospital and seven
community health centres (see Table 14).
The industries at CHGPN have traditionally included mixed farming, light industrial and service industries. Many of the residents in the southern and western areas of CHGPN commute to the Melbourne metropolitan area for employment. The area is well served by major state highways including the Hume, Calder and Western Highways (CHGPN, 2008). Figure 14- CHGPN - Summary Profile - 2008
Population in
the region 173,261 (2001 ABS census) Number of
GPs 245 (full, part-time and includes GP registrars/GPs in training) Number of
Practices 43
Nature A mixture of rural, provincial and outer-urban towns Hospitals Five Public Hospitals
Community
Health Seven Community Health Centres Pharmacies 34
Health Status
Trends in Mortality above State or National rates include Heart Disease, Diabetes Mellitus, Suicide, Stroke, Some Cancers, Chronic Bronchitis, Emphysema, Asthma, Neuroses, and Dementia. High patient load with complexity of rural management
Socio- Economic Status
Generally matches state & national averages but is up to 1% lower in certain areas.
CHGPN: Context Data (2002/2003)
While the previous section provided a snapshot of the current (2008) profile of the CHGPN Division; the following data present the contextual data in which the practical
implementation begun to take place in 2002/2003.
Back in 2002/03 the Division profile was somewhat different; less population totalling just over one hundred and fifty thousand inhabitants and less GPs as is to be expected
following normal population growth trends. The number of practices however, has dropped and this was due to a number of amalgamations between smaller practices and the
retirement of older GPs. The result is less general practices but larger in size; the rest remained somewhat constant over the following years; see Table 15 for more details.
Figure 15 - CHGPN Summary Profile 2002/03 Population in
the region 155,324 Number of
GPs 186 (full, part-time and includes GP registrars) Number of
Practices 49
Nature A mixture of rural, provincial and outer-urban towns Hospitals Five Public Hospitals
Community
Health Seven Community Health Centres Pharmacies 34
Health Status
Trends in Mortality above State or National rates include Heart Disease, Diabetes Mellitus, Suicide, Stroke, Some Cancers, Chronic Bronchitis, Emphysema, Asthma, Neuroses, and Dementia. High patient load with complexity of rural management
Socio- Economic Status
Generally matches state & national averages but is up to 1% lower in certain areas.
(Primary Health Care Research & Information Service, 2004) Chronic Diseases Data 2002/03
The following data are a summary of baseline data as reported by the then Health Insurance Commission (HIC) (now Medicare Australia) in 2002/03 (General Practice Victoria, 2003). HIC data, for a number of reasons does not always reflect measures accurately. To improve understanding of the HIC data, the IT/IM Officer’s ‘insider’ knowledge is presented in a text box and in Italics to help the reader interpret the data.
For example: Of the 46 practices reported in the above profile, during the Period
November 2001 to June 2002, only 30 practices were actually accredited (regulations and performance indicators necessary to be deemed worthy of certification as a reputable general practice), and therefore eligible, for the Government’s Practice Incentives program (PIP) program already explained in Chapter Three. Further information on the specific Medicare Benefit Schedule (MBS) item numbers used by general practices can be seen below in Figure 14.
The lack of accreditation meant that no data was collected by the HIC from these
practices, and that these practices had no access to the financial incentives (PIP). This was (and still is) a misinterpretation of the reality, as some of these non-accredited practices were either not providing orthodox GP services (instead delivering alternative medical services like naturopathy, acupuncture, an so on and so forth) or these practices were ‘satellite’ practices belonging to other central general practice sites already accredited, but could not claim payments as they are not registered as a ‘separate’ business (general practice) on their own. Other reasons for not seeking accreditation are the imminent retirement of GP business owners or the intent of merging the business with other
provider. Red-tape (time consuming and complex paper-work) was often another reason.
Even then out of those 30 practices, not all chose to sign on for all PIPs; for example, HIC data for the period August-October 2003 Quarter (Table 4): only 29 (comprising of a total of 148 GPs) chose to register for the Cervical Screening PIP programs (93%) and 27 (90%) for the Diabetes component. The baseline data for the three major chronic conditions relevant to this study were as follows:
Cervical Screening: Of the 148 GPs only 43% used the Practice Incentives Program (PIP) item numbers averaging 3.1 items during the six monthly terms, well below the State average of 4.5 items per GP. While the low (43%) number of GPs can be explained by the fact that not all GPs in a practice do Cervical Smears, female GPs (only +38%) are more likely to engage and be favoured by female patients to do smears. Worst of all, the practice coverage rate at the Division at the time was a low 31%, when the government benchmark was 65% over two years (later changed to 50% as the target was more appropriate). To give an indication of the deficiencies, one of the ‘lighthouse’ practices (term describing high achievers) had, according to the HIC, a cervical screening rate of 31% in 2003
Table 16.
This was not just a localised or State wide problem. According to Australian Institute of Health and Welfare (2007) national figures showed that two-year participation rates had peaked at 63.4% in 1998–1999 but had significantly declined to 60.7% in 2002–2003. Furthermore, from 1996–1997 to 2004–2005 it showed that there was a steady decline in participation among women aged less than 35 years and continued improvement in participation for women aged 40 years and over (Australian Institute of Health and Welfare, 2007). Moreover, women aged 20–69 years from regional and remote locations experienced higher incidence and mortality rates for cervical cancer compared with women in major cities (Australian Institute of Health and Welfare, 2007) .
Diabetes: Of 148 providers (GPs) only 34% —not necessarily a bad figure as not all GPs treat Diabetics, had an average item use of 10.4 per term as opposed to 13.4 State averages. Although no data was available for the 2001/2 period, data from the November 2003 Quarter report –a year later- when the effects of system implementation were already taking effect, was showing a Division average covering rate of no more than 17%; needing to be a minimum of 20% per quarter to satisfy the 80% annual minimum benchmark (Table 4).
Asthma: At this time, only 29 GPs (20%) out of 148 provided a total of 268 services for the semester at an average of 9.2 services; and although this is a very low figure this was higher than the state average of 6.3 (Table 4)
Table 4 below provides information to each Victorian division of general practice for the period August-October 2003 Quarter. The first column denotes the name of the Division by their assigned number (from 301 to 332 – total of 32) in the state. The second column represents the number of practices accredited at each Division. The next grouping of two columns refers to the Sign-On activity for Asthma, Cervical Screening and Diabetes (showing the percentage of practice participation and the SWPEs (statistical derived number of patients) covered by the participating practices for each condition. The next two groups of columns refer to Outcomes payments for Cervical Screening and Diabetes respectively; representing the number of practices signed-on for the scheme, the number of
practices already receiving payments, practice participation rates, the number of patients covered and the last column the percentage of patients covered.
(General Practice Victoria, 2003) Error! Reference source not found. below further details the key information from the above table that is relevant to the study. This data represents the thirty Victorian Divisions’ ranking in the uptake of government incentives. The shaded cells show CHGPN’s 2003 outcomes for the Service Incentives Payments (SIPs) for the three main chronic conditions (Cervical Screening, Diabetes, Asthma) as component of the Practice Incentives Program (PIP) already outlined in Chapter 3, section five.
Table 17 – Service Incentives Programs (SIPs) outcomes for CHGPN 2003 below shows the Division’s baseline data at the time of the initial implementations (2003). For example, column one (% signed on practices with SIPs) shows CHGPN to be at the 27th position out of the then 30 Victorian Divisions, and represents the percentage of practices participating in the Cervical Screening incentive (SIP) scheme. The second set of two column, shows the similar measurements but for Diabetes (column 3) and the percentage of practice participation (column 2). And so on with the third set of columns (4 and 5).
(General Practice Victoria, 2003) This is the baseline data from HIC (now Medicare) and will help determine the impact of the implementations when compared to the outcomes in later years at the end of the study.
While the then Health Insurance Commission (HIC) —now Medicare Australia, provided less than up-to-date - and difficult to interpret data, they will be used as the official measuring instrument to compare outcomes in this study. Most of the inaccuracies are due to lack of Division specific data due to the fact that CHGPN shares boundaries and
practices in them with five other Divisions; and data from those practices in boundary town were not necessarily reflected in HIC reports for CHGPN. To make matters worse, the Division’s boundaries do not align with any of the statistical areas (by shire, or health area) that are used in calculating these tables. Therefore, most of the data are statistically inferred (by the HIC) by the percentage assigned of each boundary practice to the
Division, even though the implementations were wholly the labour of CHGPN; and vice versa with programs delivered by other Divisions to our shared practices.
It is important to note that the fact that Practices or GPs were not claiming PIP incentives does not mean that the delivery of care was not being provided to patients. Rather, that it wasn’t being monitored by HIC without this process.
CHGPN Activities 2002
Divisions provide funding providers (Department of Health and Ageing) yearly activity reports. And this primary documentation resource will be quoted to set the
implementations in context.
During 2002, the only instance where a chronic condition (Diabetes) was mentioned as an activity was under the heading: ‘SERVICES TO GPS’; where the education goal was to: ‘support quality prescribing’; to this account: 45 GPs (41 for group case study and 4 for 1on 1) were visited for Diabetes educational visit (process); where 44% (12) of GPs visited reported they had been prompted to change their management of Type 2 diabetes
(impact)(Primary Health Care Research & Information Service, 2008a).