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information systems have the capacity to produce a population list, chronic disease registers andrecall systems to support a population health approach to chronic disease prevention andmanagement.The Northern Territory Government sponsored the development of the Coordinated Care TrialInformation System (CCTIS) used in the Coordinated Care Trial sites in 1996 and went on todevelop the Primary Care Information System (PCIS) for wider use throughout the NorthernTerritory starting in 2003. Three NTDH&CS clinics in the Top End have access to the PCIScomputerised patient information system. Planning is underway to extend these to 8 sites in 2007(Bagot, Binjari, Jabiru, Nguiu, Milikapiti, Pirlangimpi, Pine Creek and Elliot Community HealthCentres).Despite the limitations of not having a computerised information system in all primary health carefacilities efforts have been made to establish population lists in each community to ensure that allmembers of the community have a valid Medicare card. The CDR II database system used byDistrict Medical Officers (DMOs) to record chronic disease clients means there is a register ofpeople with chronic disease for every community that is serviced by a DMO. Therefore for mostcommunities it is possible to produce a population and chronic disease register for targetedinterventions.b. Recall systemsA range of recall systems are being used to plan and manage the delivery of screening andchronic disease care items. Appendix 3 provides a detailed history of the development of each ofthe recall systems and the type of information collected. Table 3.1 shows the range of systemsand their use by services across the Northern Territory.Table 3.1Examples of services using different recall systems in the NTSystemCardex (manual)Total Recall card system (manual)CCTISPCISCommunicareCommunitiesCentral Australian clinicsAll Top End DH&CS health centres to varying degreesMilikapiti (now PCIS), TiwiBagot, Binjari, Jabiru, Nguiu, Milikapiti, Pirlangimpi, Pine Creek andElliot Community Health CentresKatherine West Health Board, CAAC, Danila Dilba, Sunrise,Urapuntja, Amoongoona, AnginyinyiChapter 3: Progress Against PCDS Objectives – Evaluation of the NT Preventable Chronic Disease Strategy 2007 24
Ferret Miwatj, Numbulwar, Marngarr, Laynapauy Homelands,Gapuwiyak, WurliwurlijangCDR-IIAll District Medical Officers in Darwin Rural, East Arnhem, andCentral AustraliaMedical DirectorBatchelor, Ampilatwatja, WurliwurlijangOther Proprietary Systems (eg Batchelor, Adelaide River, Titjikala, Top End Renal TeamExcel, Filemaker Pro)In June 2004, Healthy Living NT received funding from the NTDH&CS to provide education andtraining to selected non-government health clinics throughout the Northern Territory. Thisprogram ran until December 2004. Across the 11 clinics visited by the Healthy Living NTeducation program, three different recall systems were found to be in use: 3 clinics had Ferret 2 clinics had Primary Care Information System (PCIS), and 5 clinics had a paper based or manual recall system (38) .They reported a degree of confusion about the roles and capabilities of these recall systems. Forexample: one clinic said Ferret was easy to use and had a recall function; another two clinicsusing the same system reported that Ferret could not generate a recall list and that it was timeconsuming. Three of the clinics using a paper-based system were relying on the doctor to providea Chronic Disease Register to identify those due for recall. Both clinics using the PCIS felt it wasgood; one of those clinics did not have it operational due to staff turnover and lack of time (39) .In the study undertaken by Schatz in 2005, 30-40 per cent of clinics reported their recall systemsas problematic (40) . He found that in Central Australia there were mixed views regarding the userfriendliness of systems and most found them time consuming and complex. In the Top End morepeople found the systems user-friendly and easy to understand, and half said that they wereoverly time consuming.During stakeholder interviews the ACCHOs indicated that their recall systems were functioningeffectively and being used to plan service delivery. All sites interviewed reported that training inthe use of recall systems is included in orientation with most sites identifying a personresponsible for ensuring that training is provided. The Healthy for Life program has helpedidentify any issues with computerised patient information and recall systems that may behindering access to care. They have developed strategies to solve these problems.Chapter 3: Progress Against PCDS Objectives – Evaluation of the NT Preventable Chronic Disease Strategy 2007 25
Page 1 and 2: Pty LtdABN 82 147 637 101AN EVALUAT
Page 3 and 4: TABLE OF CONTENTSList of figuresLis
Page 5 and 6: 6.6 Indigenous workforce 996.7 Prev
Page 7 and 8: List of AbbreviationsABCDACCHOsACIC
Page 9 and 10: ACKNOWLEDGEMENTSWe would like to ac
Page 11 and 12: However the extraordinary number of
Page 13 and 14: the establishment of the Sunrise He
Page 15 and 16: RECOMMENDATIONSGeneral recommendati
Page 17 and 18: Exploration of joint funding arrang
Page 19 and 20: CHAPTER 1. INTRODUCTION1.1 Backgrou
Page 21 and 22: Choosing the 5 chronic conditionsTh
Page 23 and 24: Table 1.1Key Result Areas + Best Bu
Page 25 and 26: prior to the launch of NTPCDS, such
Page 27 and 28: Year * Action Outcome1999 S NT Prev
Page 29 and 30: Year * Action Outcome2005 P Aborigi
Page 31 and 32: CHAPTER 2.EVALUATION METHODOLOGYThe
Page 33 and 34: 2.2 Evaluation StagesThe NTPCDS eva
Page 35 and 36: chronic disease activities funded t
Page 37 and 38: internal project team. It was very
Page 39 and 40: Situation at Baseline1. The Guideli
Page 41: 3.1.2 Patient information and recal
Page 45 and 46: Medicare information is not for pub
Page 47 and 48: was in place in Central Australia i
Page 49 and 50: What orientation and ongoing traini
Page 51 and 52: programs focus on chronic disease p
Page 53 and 54: The information collected as part o
Page 55 and 56: Assessment against objectiveMost se
Page 57 and 58: career development, and retention i
Page 59 and 60: are. Indigenous employment is NTDH&
Page 61 and 62: NTDH&CS Programs that encourage Hea
Page 63 and 64: 2002 Aboriginal and Torres Strait I
Page 65 and 66: delivering any prevention and healt
Page 67 and 68: The Community Services Division - A
Page 69 and 70: 1 x AHW Central Australia 2001 S100
Page 71 and 72: One clinic stated it had no care pl
Page 73 and 74: Identifies priority practices to in
Page 75 and 76: There has been a significant growth
Page 77 and 78: about 25 per cent of the hospital b
Page 79 and 80: The level of funding provided by th
Page 81 and 82: Central Australia and two zones cur
Page 83 and 84: The diabetes education teams at HLN
Page 85 and 86: maintenance group for people with l
Page 87 and 88: Rebates for participating or arrang
Page 89 and 90: Use of Medicine Programmes. Althoug
Page 91 and 92: CHAPTER 4. CLINICAL OUTCOMES OF THE
Page 93 and 94:
improvements have been made to serv
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A recent ten-year follow-up of a co
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The NTDH&CS also collect birthweigh
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Figure 5.3 Vaccination coverage for
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It is also important to note that k
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eported that 50 per cent of the Ind
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The current action plan identifies
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The availability and cost of health
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Hoy et al in 1995-2000 (100) , and
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5.6 Best practice management5.6.1 P
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disease care in urban areas regardi
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PCIS was developed by NTDH&CS as th
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emote staff can access training and
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In the Top End there appeared to be
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APPENDIX 1EVALUATION OF THE NT PREV
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2.10 Generally speaking, on a scale
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4.4 Briefly recount any anecdotes y
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5.9 Generally speaking, on a scale
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Section 8 • Summary questions8.1
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Preventable Chronic Disease Program
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Year Type Background What is it? /
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Year Type Background What is it? /
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An important background to this stu
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New beliefs do not replace the old,
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Other services are provided to the
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ecame the main priority in many peo
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to be healthy, how to get rid of di
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(Draft Version - © August 2006 Jan
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References1. Dunham, H., Ministeria
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35. Smith, J.D., Progress report fo
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Research Centre for Aboriginal Heal
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114. Senior, K., 'A Gudbala Laif? h
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