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Green Book

Setting up the practice for preventive care - Chapter 5.2

Managing patient information to support preventive care

Key point

Just as the whole practice is involved in preventive care, the practice’s physical and digital environments can be also be adapted to improve prevention.

The Green Book brings together two main themes: prevention and implementation.

Both of these sit within QI and are inherently associated with behaviour change.

Members of the clinical team routinely collect information that should be transferred to a patient’s health summary.

A complete health summary makes a useful statement of the patient’s main health issues and brings all the important information together in the one place. They are also useful reminders of what prevention interventions have been taken and to prompt for what needs to be done.1–3 This contributes to better continuity of care and patient safety within the practice and when patients seek care in other settings.

Some information may also be transferred to national registers (eg immunisation data) or state-based and territory- based systems (eg cervical screening, bowel screening or familial cancer registries) in order to improve care. Where the practice participates in national registers, patients should provide consent for the transfer of related health information to a register or be made aware that they can opt out of such registers.

Practices may also establish internal registers to flag patients with a higher priority for preventive interventions. This can be readily assisted by a practice using clinical software or additional data-mining software to reflect population-level priorities.


An example of an internal register that practices may want to establish is one related to high-risk familial cancer. Family history tends to be under-recorded and underused in general practice.

When asking about family history of cancer, it is important to identify the number of family members affected, their age when the cancer was identified and their connection to the patient. The latter is best depicted in a genogram. A number of brief screening tools can help the GP identify family history of cancer more efficiently and comprehensively. The RACGP family history screening questionnaire can assist with this.

– Assoc Prof John Litt, Green Book Editorial Committee


Three areas where registers are important, particularly for medico-legal reasons, are for patients:

  • on some form of anticoagulant (eg warfarin or novel oral anticoagulants)
  • at high risk of cancer because of their family history
  • with diabetes.

– Assoc Prof John Litt, Green Book Editorial Committee


It’s also important to identify within the practice's record software particular groups of patients who might need special preventive interventions. This may include Aboriginal and Torres Strait Islander peoples, refugees and vulnerable population groups (eg with developmental disability). This may require an adaption of the field within the records so that these patients can be readily identified for individual care and clinical audit.

This will also enable creation of a registry of each of these groups if a practice decides to use these for recall (eg for health assessments).

–  Prof Mark Harris, Green Book Editorial Committee

Practices might also use coded data collected in the practice’s clinical software (eg smoking status, diabetes register) to improve the targeting and use of prevention activities (eg smoking cessation, weight management). They may also use information collected and transferred from private pathology providers (eg diabetes screening, cervical screening).

Gathering this data is not only a QI activity (refer to the Standards, Criterion QI1.1 – Quality improvement activities); it provides a check that the practice is identifying all relevant patients for their health promotion and preventive care activities.


Letter to 49-year-olds to encourage bowel screening

General practices can send a letter to their 49-year-old patients to encourage them to complete the National Bowel Cancer Screening Program (NBCSP) test when they receive it in the mail around their 50th birthday. There is strong evidence that a letter signed by a person’s GP endorsing the faecal occult blood test (FOBT) is an effective method to increase participation in bowel cancer screening. The NBCSP has developed a template letter that GPs can use to recommend screening to patients outside regular consultations.

– Alice Creelman, Cancer and Palliative Care Branch, Population Health and Sport Division, Department of Health


Mismatch between patients with colonoscopy as coded diagnosis versus patients with recalls: Case study


My PN colleague was looking at our practice recall system and how we might streamline lists and make sure that coding was correct, in order that we could easily manage mail merge recalls and put action notification in patient files. While doing this exercise, I noted that there were very few recalls in the system for colonoscopies.

We then looked at how many patients had been coded as having a colonoscopy performed versus how many had recalls.
We also looked at how many patients had family history of bowel cancer coded. From some files of people who had had colonoscopies, we noted that there was a family history noted in free text in a patient profile but not coded in a searchable way.


We checked the files of all patients who had coded colonoscopies and read the colonoscopy reports and specialist recommendations for follow-up. We coded all those with family history of bowel cancer so that we could easily search for those patients and ensure this would appear in their medical history.

I needed to carry out some backend adjustments of the recall lists via the maintenance function in the recall system used at our Leichhardt practice, especially where the doctors had free text in the ‘reason for recall’ section or there were multiple names for the same condition.

We put recalls for surveillance on all those that were indicated as needing follow-up surveillance – whether at three years or five years.

We presented the activity at the combined staff meeting to let all staff know this was happening and to engage the team.

We put the action list in all the patient files so that any health professional opening the patient file would see the action and follow-up regarding bowel cancer testing/colonoscopy. With our clinical information system, once you have put an alert in the 'action' list, this will be the first screen to open in the patient file and you cannot navigate the file until you close the box (hopefully having read, noted and actioned the alert where necessary).

We looked at the patient registration form. This had previously been amended to include family history questions for several conditions (eg diabetes, breast and bowel cancer), but these were not always being added at the new patient visit. This process was also discussed with the team to ensure that these risks were recorded and coded in a searchable way.


Invitations were sent to all patients who required screening due to family history and risk of bowel cancer to visit their GP and discuss the issue.

Recalls were sent for those who had not been added to the initial recall but who required ongoing surveillance and were due for screening.

Recalls were added for those who required future follow-up.

Although the GPs were used to adding the coding for a procedure, they were more aware of adding recalls at the time of reviewing a specialist report.

After implementing the changes to our systems, the team was more engaged in recording a coded family history for bowel cancer. Similar exercises were carried out for family history of breast cancer risk mammogram recalls.

There were other patients picked up in this exercise, where family history was not an issue but specialist- recommended recalls for follow-up had not been added.

Our senior registrar was conducting a population health project on bowel screening, and because we had a system in place where family history was coded and recalls were in place, measuring the practice’s starting point became far easier.

– Ms Karen Booth, Green Book Editorial Committee


Using your data to improve your practice

Below is an example of how we used our practice computer system to improve our patient care while also improving our income.

With the Australian Government program to fund the shingles vaccine for all patients aged 70–79 years, our nurses have used our database to target these patients with telephone calls advising them this is available and arrange appointments for this at the same time, if they were willing.

With dedicated work, since inception of the program in November 2016, we have reached all of our patients in this age group who have not had shingles in the last year and are not on an immunosuppressant (these are contraindications) and offered them the vaccination. Our nurses performed a simple search in our practice software. With more sophisticated searches, we plan to use an extraction tool to extract data.

We started with those patients who were aged 79 years and about to turn 80 (and who then would no longer qualify under this program) and worked backwards to age 70 years. We have called everyone in this cohort and have successfully vaccinated over 70% of them, which we are informed is more than double the average for other practices Australia-wide.

Having accurate data has made things much easier. Calling these people also gave us an opportunity to tidy up our database by removing (inactivating) those patients who no longer attend. Fortunately, because we pay strict attention to inactivating deceased patients when we learn of their passing, we did not have any embarrassing calls asking if dead people wanted a vaccination!

– Dr Rob Hosking, Bacchus Marsh GP (adapted from his blog entry, posted on 21 November 2017)


Recording demographic data

Since we started routinely asking all patients if they identify as Aboriginal or Torres Strait Islander, the number registered has gone from one to 300 (over a four-year period). Recording this in the practice software demographic section enables our PNs to optimise the uptake of the Indigenous Chronic Disease Package.

– Dr Michael Fasher, GP and Adjunct Associate Professor, University of Sydney

Box 3. Reminders, recalls and prompts

Having a robust reminder and recall process supports safe, high-quality care to patients.

Reminders are used to initiate prevention, before or during the patient visit. They are ‘an offer’ to provide patients with systematic preventive care.

Recalls are a proactive follow-up to a preventive or clinical activity. These occur when it is crucial for a patient to attend the practice (eg after an abnormal test result).

Prompts (or flags) are usually computer generated, and designed to opportunistically draw attention during the consultation to a prevention or clinical activity needed by the patient.

A recall system differs from a reminder system in that reminders are used as preventive activities for patients and do not have to be followed up if the patient does not attend the practice. The patient can be removed from the reminder list, but it is recommended that the reminder is noted in the patient’s medical notes. A recall system is used to recall the patient back to the doctor for something clinically significant. Therefore, every attempt must be made to contact the patient and it is essential that the attempts are documented and initialled in the patient’s record. Any recall appointment should be marked as a ‘recall appointment’ so that you will be able to check if the patient attended the practice.4

To ensure the system is effective, fail-safe and sustainable, you could consider a team approach when coordinating the recall and reminder system for tests, test results, referrals and appointments. This includes defining the roles of GPs and other clinic staff. When using electronic recall and reminder systems, the data is only as good as what is entered. This reinforces the need to have adequate systems, policies and procedures in place. You could have a planning session with all GPs and staff to evaluate past systems and ensure they fit the criteria of being effective, fail-safe and sustainable.4


You might want to look at some of the commercially available software that bolts on to your practice management system and allows for more sophisticated on-screen prompts.

– Assoc Prof Charlotte Hespe, Green Book Editorial Committee

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