The Bettering the Evaluation and Care of Health (BEACH) program: where to from here?

The Bettering the Evaluation and Care of Health (BEACH) program, which began in 1998, is a continuous, national, cross-sectional survey of the clinical activity of general practitioners.1 The survey collects information from rolling random samples of GPs with the aim of gaining an understanding of the characteristics of the GPs themselves, the content of GP–patient encounters, and the services and treatments provided.

General practice has changed dramatically since BEACH began. In 2012 the profession was older (41% of GPs aged 55 years and over, versus 25% in 1998), more feminised (41% women, versus 30% in 1998), with fewer Australian graduates (66%, versus 77% in 1998) and more Fellows of the Royal Australian College of General Practitioners (57%, versus 27% in 1998).2 Only 12% of GPs now practise solo (compared with 18% in 1998), with the movement to larger practices encouraged by government financial incentives, shared infrastructure costs and increased flexibility of working hours — on average, GPs now work 3 fewer face-to-face clinical hours per week than they did in 2001–2002. However, government-claimable consultations have consistently averaged 15 minutes,2 perhaps reflecting reliance on a fee-for-service system that pays more to the GP per minute for multiple shorter consultations than for longer consultations.

Yet consultations have become more complex. Middle-aged and older people are making up an increasing proportion of patient encounters (from 47% in 1998 to 57% in 2012), resulting in the management of more (particularly chronic) problems, more clinical treatments, procedures, tests and investigations, and referrals to specialists and allied health professionals. GPs face more demands on their time with an ageing population, improved primary prevention, early diagnosis of chronic disease and therefore more need for longer-term management.

BEACH also measures changes in the management of specific conditions in response to new evidence, pharmacological and other products, screening and diagnostic tests, and government policies and incentives. This relies on the GPs’ direct linkage of management to the patient problem, a linkage that is facilitated by the structure of the BEACH encounter form. In addition to extensive BEACH publications,3 commissioned BEACH reports (over 100 per year) are used by the government (particularly during formulation of the primary care reform strategy), professional organisations, non-government organisations and industry to guide policy and practice.

BEACH researchers rely on the generosity and hard work of GPs in completing details of encounters on structured paper forms. The survey remains the most reliable national source of data on GP activity. However, its cross-sectional design precludes comparison of outcomes of different approaches to care. For this we need a randomised sample of general practice-based longitudinal records of patient care and outcomes, which could then be used to assess “real world” practice-based evidence of effectiveness of care among ambulatory patients.

Theoretically, this should be possible — in 2012, based on BEACH data, we estimated that 96% of practising GPs used a computer at their desk for some clinical purpose, although some used it only for prescribing or ordering pathology tests. Others were paperless, so all of their patient data should be in the electronic health record (EHR). However, most electronic systems lack the structured problem orientation that provides reliable linkage of management actions to a patient problem,4 even though this structure was introduced and widely adopted for paper records in Australia in the 1970s.

Some groundwork has been done, but there remain no nationally agreed standards for the EHR — including structure, systems of terminology and classification, data elements and definitions. There is also no compulsory minimum dataset to standardise which patient data should be collected.5 Specifications for EHRs were developed by the Family Medicine Research Centre in the 1990s, and were found by independent reviewers to be excellent.5,6 A functional requirements specification for both clinical and administrative general practice computer systems was developed by IBM in 1997.5,7 In 2000, we worked with Simsion Bowles and Associates, GPs and other stakeholders to develop a general practice data model and core dataset.5,8 These projects were funded by the Department of Health and Ageing, but their outcomes were not adopted, and the government did not proceed with developing standards for electronic data recording. Perhaps there was a lack of perceived cost-effectiveness and benefits by government, vendors and other stakeholders.

The International Classification of Primary Care (ICPC–2)9 was recommended as the standard for classifying patient-reported and GP-recorded morbidity data in 2003 — another standard that was never mandated.5

In 2005, the National E-Health Transition Authority (NEHTA) was established, and other dedicated government funding of IT development in general practice was stopped. NEHTA focused on developing the Personally Controlled Electronic Health Record (PCEHR),5 which, due to lack of EHR standards, does not link the patient problem with subsequent management and outcome. Yet, a large government financial investment was made to provide incentives to vendors and GPs to roll out the PCEHR.

Therefore, we now have a variety of EHR systems with inconsistent structures, data elements and terminologies.5 The absence of compulsory basic standards has three negative effects. First, it makes it extremely difficult to transfer patient data to other general practices and health providers. Second, it makes it hard for practices to change to a different EHR system because transfer of patient data to a new system, with different data structures and coding systems, is unreliable. Last, it makes it impossible to obtain reliable national information about the care provided to individuals and the population through passive data collection from GPs’ computers. This is unacceptable when in 2011–2012 there were 125 million GP services provided at a cost to government of about $5 billion.5

We have learned much from BEACH about general practice and how it has changed in the past 14 years.3,5 The program has provided valuable input into primary care reform and GP professional development. So much more could be achieved if standards and minimum datasets were finalised and mandated — so that we could collect reliable, high-quality, longitudinal patient-based data from GP EHRs.5

How much longer do we have to wait?