Join Pen CS at Nursing Informatics International Congress 2021 ‘Informatics in Clinical Care’ Global Speaker Showcase.

Pen CS Clinical Quality Assurance Manager, Matthias Merzenich, will be speaking on ‘Nursing activation and engagement at point of care’. Read the full abstract below.

The Nursing Informatics International Congress 2021 will run from the 23 August to 2 September 2021.

View full program.

Nursing activation and engagement at point of care


Every year in Australia, poor management of chronic disease costs more than $320 million a year and in 2018, 89% of deaths were associated with 10 chronic diseases. To improve how we manage chronic disease, we need to focus on early prevention in Australia’s first line of health services or ‘primary health care’. General practice nursing is the fastest growing area in healthcare with 14,000 General Practice Nurses (GPNs) nationally and 63% of general practices employing at least one nurse. This presentation will engage GPNs on how clinical audit tools and clinical decision support systems (CDSS) can be used to support prevention and management of chronic disease in primary health care, leading to better health outcomes for patients in Australia.


How do we empower GPNs to deliver better patient outcomes? GPN engagement as part of the practice team enables a shared and collaborative responsibility to achieve this outcome. Clinical audit tools and CDSS can be utilised, by analysing data within Electronic Health Records (EHRs), to provide prompts and reminders to assist GPNs in implementing evidence-based practice at point of care.

Additionally, Bodenheimer’s ‘10 Building Blocks of High Performing Primary Care’ notes data-driven improvement as a foundation building block. Through educating GPNs to embrace clinical data to inform decision making and to champion data quality standards and interoperability will lead to better patient outcomes. Integration of clinical decision-making and reasoning into teaching was also identified as ‘the future in nursing education’.

Through engagement of GPNs with CDSS and data quality training, general practices can achieve better patient outcomes through having more complete patient records. An example of this is reflected in a case study where a GPN was able to lead the team at King Street Medical Murwillumbah to improving recording of their key data sets to achieve their goal of 80% of their patients’ ‘ethnicity’, ‘smoking’ and ‘allergy’ statuses recorded. CDSS and clinical audit tools were utilised by GPNs, GPs and practice staff to determine missing clinical and demographic data and the latter to develop monthly reports to analyse data quality improvements. Additionally, other benefits of data quality activities include evidence for practice accreditation, increased practice efficiency, improved patient care and counted as a quality improvement activity for PIP QI.

When CDSS are applied to Cardiovascular Disease (CVD) prevention, this strategy can be used to facilitate care in various ways—for example, by reminding healthcare professionals to screen for CVD risk factors, flagging cases of hypertension or hyperlipidaemia, providing information on treatment protocols and providing tailored recommendations for health behaviour changes. In June 2021, a new initiative has provided GPNs and GPs in almost 5,000 Australian general practices to have access to absolute CVD risk assessment and management templates that link patient records to CDSS tools at point of care with no extra cost. This initiative, combined with Medicare Benefits Scheme (MBS) item eligibility prompts helps to improve practice efficiency in chronic disease management and prevention. This also helps to address key barriers to integrating preventative care in general practice and supports general practice to maximise business potential.


GPN engagement and empowerment is vital to deliver better patient outcomes. Training GPNs on clinical data quality and use of clinical audit tools and clinical decision support systems (CDSS) can support both the individuals’ and general practices’ efficiency towards chronic disease management and evidence-based clinical best practice at point of care.