INSTRUMENTO Estrategias
5. CONCLUSIONES Y RECOMENDACIONES
Table 11: Outcomes and breakdown for Futurama (pseudonym) clinic of the calculations based on the relevant rates; total combined annual PIP payment including loading = $50,600. per doctor per practice (Medicare 2007)
E l e m e n t R e q u i r e d A c t i v i t y P r e s c r i b e d A n n u a l R a t e p e r S W P E C a l c u l a t e d A n n u a l P a y m e n t f o r S a m p l e P r a c t i c e
Tier 1 - Provide data to the Australian
Government $3.00 $12,000
1. IM/IT
Tier 2 - Use of bona fide electronic prescribing software to generate the majority of scripts
Tier 3 - the practice has on site and uses a computer/s connected to a modem to send and/or receive clinical information
$2.00 $8,000
Tier 1 - Ensuring patients have access to 24-hour care as outlined in the application form
$2.00 $8,000 (as the MDS the practice uses covers out of hours visits)*
Tier 2 - On average, the Practice covers at least 15 hours per week of its total after hours arrangements from within the practice
$2.00
Nil. Provides only 13 hours on average per week from within the practice.
2. After hours care
Tier 3 - The practice provides 24-hour coverage seven days a week from within the practice
$2.00 Nil. The Practice engages the services of an accredited deputising service.
3. Care
Planning The practice provides appropriate care planning for the target coverage level $10.00 per 65+ WPE $4,000
4. Teaching Teaching of medical students $50.00 per session Nil. No teaching undertaken
5.Quality Prescribing Initiative
Average of three activities per FTE GP,
one of which must be a clinical audit. $1.00 $4,000
6. Rurality
Loading Practice's main location is outside metropolitan area Practice is graded as a RRMA 3 location attracting a 15% loading
$6,600
The Futurama Medical Clinic is located in one of the areas of the study as a RRMA 6 practice, hence attracting a 15% Rurality loading. The practice is operated by five doctors (three of whom are full time). Between them, they perform 26,000 consultations (an amount equating to four full time equivalent GPs), and have a stable patient load of 4,000 SWPEs (practice size).
The Practice is open from 9 am to 8pm each weekday and for a morning session (9am to 12pm) on Saturdays and Sundays. At other times, an accredited deputizing service has been engaged to cover these periods.
Comparing this operating profile against the definition of "after hours" for the purposes of PIP After hours care, (being hours outside 8 am to 6pm weekdays and 8am to 12noon on Saturday) we calculate a total of 13 hours (i.e. 10 hours for Monday to Friday plus three hours for Sunday). Hence of after hours care, 13 hours is provided from within the practice.
Two of the associates are interested in clinical computing. There is a computer in each consulting room, and these are networked so that clinical records can be accessed from any room. All GPs use the standard approved prescribing software. The practice has an Internet connection with the majority of pathology reports being received electronically and communication with other GPs via email. In this regard all three elements of the Information
Management/Information Technology have been met. The practice has
not hosted a medical student placement and therefore does not qualify for the
Teaching component.
Four of the GPs have undertaken quality use of medicine activities recognised by the PIP, however the fifth GP has decided not to undertake these activities. The GPs have done four clinical audits and nine case studies for a total of 13 activities.
The practice patient profile includes 400 65+ WPEs and 60 patients within the practice have care plans. The practice therefore meets the minimum coverage rate for the Care Planning component (which is 10% in the first year). Against this background the Practice's payment level for the financial year would be $50,600. Actual payments each quarter would be $14,950 for the February and May quarters
The Practice Incentives Scheme (PIP) and this practice the following is adapted from interviews conducted in this practice 2004-05):
This practice principal does not have any difficulties when complying with the PIP and all its sub programs. This is because he is able to rely on systems
and procedures developed by the practice manager and the practice nurses. The partners decide which programs of the PIP to participate in and develop systems and procedures for use in those programs.
His opinion about the programs is they are a good idea, but are often difficult to implement, as GPs are very busy. This creates tension between obligations to paper work or to the patients. My perception of this is that the tension really exists between acute care and preventive medicine.
The initial accreditation for the practice to participate in the PIP was reported by the principal to be very demanding in administrative time. It is
administrative time that curtails fuller involvement with the PIP for the costs of compliance are seen to be high by this practice (Summary of practice documents supplied to me by the practice but developed for submission to the productivity commission 2003.)
Case Study 2
The Practice Incentives Scheme (PIP) and this practice (adapted for interviews conducted from 2004-05):
This practice describes the practice incentive scheme as bureaucracy gone mad. Although some requirements are perceived positively and allow the practice to maintain high standards, other requirements are said to be excessive. The procedure manual for instance, requires considerable time for a very limited utilization once the accreditation is complete. “I don’t think that I have looked at the manual since the accreditation, I suppose I will look at it again when our next accreditation comes up” (Practice principal 2005) It seemed to me that the accreditation process was hardest on these small practices because there is not economy of scale for them.
Furthermore, the lack of administrative staff in small practices that can be allocated only to this job when it arises makes the amount of paperwork difficult to tackle.
The practice was first accredited in 1999 after the first implementation of the PIP and then again in October 2002 and again in 2005. In the first place the PIP involved a lot of time but by the time they had done it the third time the principal did not have to spend much time as all the records were there because they had been generating them as they went along.
Everyone in this practice tries to use the computers as much as they can “To get the full value out of them”
Case study 3
The Practice Incentives Scheme (PIP) and this practice (adapted from interviews conducted from 2004-05):
The practice reports that there is a strong base of support for
computerization of this practice and the continual upgrade of the systems. “Computers have had a big impact on our practice particularly the PIP. But I would like to say that some aspects of the PIP are not worth our while” (interview 34 2005) this remark was made in regard to the accreditation process. The process is again seen by staff as negative to the mission of the practice. However the practice principal has a very different view -
I think that the first accreditation process for the PIP IT/IM was a very involved process and they could have had more practices being involved if they had not made it so detailed in terms of paperwork. We got involved early because of me you know. I have always believed in IT/IM and took the
opportunity offered by PIP. I have been chair of the local division and helped establish it. I have also been very involved in the RTO in theprovincial city not far from here. What I do there is get involved in professional development for the registrars and this involves getting them up to speed about the use of computers in general practice so that they
will be in better position to use them if and when the hospitals expand their use of IT/IM for patient discharge and after care – that’s if they ever start to directly collaborate with us GPs.( interview 35 2005)
It is interesting to speculate about the process of adoption within this
case study in regard to how one actor within the practice influences all
the activities of the practice. Fletcher 1999 suggests that perceived
power has a lot to do with influence. In the case of this practice the
principal is perceived as very powerful in terms of traditional
structures of society –i.e. traditional respect for the doctor.
In this practice adoption has occurred mainly because of this one individual and the influence he holds which can be represented by statements of employees such as - “He is the doctor you know and so we do as he wants us to do” (interview 36 2005)In returning to the interview with the practice principal a further insight to the process of adoption within this practice is gained by the following information;
“When we first started out with the IT/IM we had some difficulties installing it because of the heat here in this town, and we found that we had to build a new building that would be good for the computer system server. The practice manager works in that building now and so does the coding clerk. Going over to the fully computerised practice eventually meant that we had to move location because of the requirements of continued registration through the PIP. So the effect of computerizing can bee seen in that way as well” (interview 35 2005)
In terms of Actor Network Theory this would point out how it is very difficult to separate the actors human and non human. In a view informed by ANT,
this ability of inanimate objects to have as much influence as humans in the adoption/translation process is clearly presented by the needs of this practice to adjust to the needs of the computers and change location. Further
examples of this can be found as the practice translated through other developments
“This practice uses the Genie medical software. We do not use Medical Director as it causes problems with the way that we have our system networked here at the practice. One thing that I still find amazing is just how rapidly computers were integrated into our practice and how soon we came to treat them more or less as part of the practice. They assumed some sort of personality. I’ll explain this. Take the fact that in this practice not all of us use the computers for the same things. Some of us use them only to comply with the PIP requirements; some of the others of us use them for as many things as they can. Now those that use them as little as possible are the ones who are always reminding us about the fact that the system might crash, that we have too much information “in there”. These GPs also back up their data with paper print outs of anything they do. They also worry about the security of the data. You can tell them and explain to them again and again but it makes no difference. I think that this represents a lot of the GPs attitudes in this division. This practice does not use them right across the board – you can see that by the fact that some of us still only use them to PIP requirements. Then there is another picture at this practice –that some of us use them as much as we can. I think that our practice represents the picture right across Australia and of course across this division. (op.cit.)
Again it is clear that the level of adoption varies according to the way that computers are perceived by the practice doctors. The interplay of
computers, perceptions, ability to use the computers, the requirements from the PIP and the aspirations of the doctors are all linked in a complex
network of relationships that all play a part in the process and level of adoption. So despite the incentives supplied by the PIP and the support provided by this individual practice the adoption of computers within it is incomplete.
7.6 Conclusion
The three case studies point to a variety of influences in the way that computers were adopted, not the least of which is the influence of support and financial reward. In the case of Actor Network it can be clearly seen that the PIP was an actor in an equal way that the computer group were. While one is a financial reward the other is a political actor. The reward would not have been achieved without the other.
CHAPTER 8: THE DIVISION OF GENERAL PRACTICE AND THE ROLE OF THE IT/IM OFFICER
Aim of this Chapter: To articulate the character of the division and discuss the role of the IT/IM officer as an actor in the network of adoption. In the second part of this chapter the articulation of the role of the IT/IM officer there will be a focus on the micro-sociological aspects of power in actor networks,
8.1 Introduction
The division – establishing why it was an important player and why the placement of the IT/IM officer within it was an important move:
During the time that this research was taking place there was heated debate (Mooney, G. 2003) about the place and funding of Divisions of General Practice, going so far as to ask the question – Do divisions have a future? There was active restructure of the divisions from project based funding to longer term outcomes based funding. (2004 -05 CEO report). It was during the phase of project based funding in the life of CHDGP that achievements were made in relation to IT/IM. After this time funding ceased for the IT/IM program and it focused more on integrated projects to improve health outcomes, such as the introduction of active recall and reminder systems to support diabetes health programs. Thus the IT/IM initiatives were integrated into the wider picture. Before this the CHDGP had an IT officer who was available to general practices to assist with the implementation of IT/IM. This officer was supported by two other staff on a part time basis (they undertook other responsibilities as well). This indicates the importance that CHDGP gave to the development of IT/IM infrastructure.
The IT officer role was pivotal in the establishment of computerization
in this division. However the achievements did not come without
difficulties which in themselves created barriers to adoption of IT/IM
in the division. To get to the point above it is important to take a look
at the history and debate that was taking place in divisions at the
beginning of this research.
8.2 Some History (adapted from archives records at CHDGP; interviews with the CEO at CHDGP and staff at CHDGP):
One way that the Commonwealth Government has sought to organise general practitioners into groups, both to improve delivery and to control costs, is the creation of Divisions of General Practice. The first local Divisions were established in 1992 and about 94% of GPs are now members of a local Division of General Practice. The objectives of divisions were to deal with nationally identified issues including:
• erosion of the GPs position in the health care system,
• falling remuneration for GPs,
• GP isolation and frustration.
The initial divisions were locally based, responding to local issues. They were funded on a project basis and not on a national focus. In 1998, after a Commonwealth Government General Practice Strategy Review a recommendation was accepted that divisions be funded as the national organisation of Divisions and became known as Australian Divisions of General Practice. ADGP became one of Australia’s largest representative voices for General Practitioners.
As part of ADGP’s representation program, grass roots GPs sit on
approximately 60 key decision-making bodies in the health sector, having direct input into general practice financing, GP workforce and training, clinical practice and practice management and other key issues influencing the future of General Practice. This ensures that there is communication with Divisions of General Practice, directly or through State Based Organisations.
In 2005 the ADGP changed its name to Australian General Practice Network (AGPN) representing 119 divisions of general practice and their state-based organizations across Australia. They are now the largest voice for general practice in Australia with over 95 per cent of Australia's GPs members of their local division. Australian General Practice Network Ltd. (AGPN) is the peak national body representing 121 Divisions of General Practice
across Australia. The establishment of divisions of general practice was a response to the need for local focus on training for GPs. The aim of the AGPN is:
• be the voice of Divisions of General Practice to the Commonwealth of Australia;
• support Divisions of General Practice across Australia;
• advocate for Divisions of General Practice;
• inform the public about issues affecting General Practice;
• promote the exchange of skills, information and ideas between Divisions of General Practice.
AGPN also coordinates a number of national programs through Divisions of General Practice to improve the health of all Australians. AGPN’s programs cover a broad range of primary care issues including immunisation, youth health and practice nursing. These programs aim to strengthen primary health care to better meet the needs of the Australian community. Where appropriate AGPN works collaboratively with other organisations such as the Pharmacy Guild, to develop and coordinate a program. Many of the
programs are overseen by committees made up of GPs from Divisions and other stakeholders such as academics, allied health professionals and consumers. AGPN also works closely with the State Based Organisations and Divisions in implementing national programs to ensure they meet the local needs of their communities.
8.3 Other issues
In addition to these issues of concern to Governments is the need to better manage the health care dollar. Divisions thus provide a network to address these issues at local, State and National levels. They also enable GPs to improve primary health care in the community and work with other health providers.
AGPN receives funding from the Australian Government under the Divisions of General Practice Program. The Network has changed emphasis since acquiring its new name and delivers local heath solutions through general practice. Divisions of General Practice are the key infrastructure for integrated, quality