Pen CS in collaboration with QLD Heart Foundation, Northern Queensland Primary Health Network (NQPHN) and QLD Health’s My health for life has implemented automated decision support in General Practice to help Doctors better manage cardiovascular disease.

The Issue

Cardiovascular disease (CVD) is one the biggest burdens on the Australian economy[1], killing one Australian every 12 minutes[2] and with 43,477 deaths attributed to CVD in Australia in 2017.

In General Practice, Doctors have a short consultation window to address the patient’s immediate concern.  Although opportune, there is little time left to focus on early identification of the patient’s risk of developing serious chronic disease. RACGP Guidelines recommend risk assessment for best practice, “In Australia, 64% of the adult population have three or more modifiable risk factors. As CVD is largely preventable, an approach focusing on comprehensive risk assessment will enable effective management of identified modifiable risk factors through lifestyle changes and, where needed, pharmacological therapy.”[3]

The Solution

Pen CS’ challenge was to support Doctors’ early identification of risk factors, contributing to CVD. The solution was to create a (Topbar) automated notification that prompts the Doctor when a presenting patient is eligible for a risk assessment and participation in My health for life. This notification supports the Doctor to ‘start a conversation’ with the patient.  There is no extra work for the Doctor and the patient benefits from extended care through the My health for life program.

For Doctors, the value is improved patient outcomes, implementation of best practice according to RACGP Guidelines and adherence for accreditation. The Topbar notification assists with meeting RACGP 5th edition Standards[4] on Preventive Health (Criterion C4.1) regarding health promotion and preventative care. Topbar notifications represent a systematic approach to preventative care.

Outcomes from the collaboration have been successful with referrals into the My health for life program growing monthly.  93 General Practices have referred to the My health for life program during its initial six month period.

From January 2018, there have been 5 referrals per month with average monthly referrals growing. 26 percent of all participants have lost some weight, while 19.8& lost greater than 5% of their weight at six months. 49.6% of participants reduced their waist circumference at six months. By session 6, 96% of participants retained their intention to change their behaviours to reduce their health risks.


[1] Australian Institute of Health and Welfare 2011. Cardiovascular disease: Australian facts 2011. Cardiovascular disease series. Cat. no. CVD 53. Canberra: AIHW.

[2] Australian Bureau of Statistics 2018, Causes of Death 2017, ABS cat. no. 3303.0, September.

[3] Guidelines for the management of Absolute cardiovascular disease risk, endorsed by RACGP, ©National Stroke Foundation 2012.