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Integrations
Communicare integrates with National and State services, external reporting solutions and utilities that expand Communicare's reporting and other capabilities.
Key Performance Indicators
Health service management personnel can collate, analyse and report on National Key Performance Indicators and state-based Key Performance Indicators using Communicare.
National Key Performance Indicators
Use this information to assist with the Indigenous primary health care key performance indicators (nKPI) and On-line Services Report (OSR) reporting within Communicare.
NKPI summary
Summary of NKPI reports.
PI 20 - Regular clients who have had the necessary risk factors assessed to enable CVD assessment
Proportion of regular clients who had CVD risk factors recorded in the previous 24 months.

Integrations
Communicare integrates with National and State services, external reporting solutions and utilities that expand Communicare's reporting and other capabilities.
- Australian Immunisation Register
  The Australian Immunisation Register (AIR) is a national register that records all vaccines given to all people in Australia.
- Data Synchronisation
  Data Synchronisation (DataSync) enables medical professionals to run clinics and deliver services in some of the most remote and isolated regions of Australia.
- Government Reporting Tool
  Use the Government Reporting Tool (GRT) to extract primary health care key performance indicators (nKPIs) for indigenous people from Communicare, analyse the data and directly upload the data to the Health Data Portal.
- HealthTracker
  Communicare can be integrated with The George Institute HealthTracker™, a decision support system developed by the researchers at The George Institute for Global Health to assist primary care health staff in best practice management and prevention of cardiovascular disease, diabetes and chronic kidney disease.
- HI Service
  The Healthcare Identifier Service (HI Service) is a module that communicates with Medicare.
- Key Performance Indicators
  Health service management personnel can collate, analyse and report on National Key Performance Indicators and state-based Key Performance Indicators using Communicare.
  - National Key Performance Indicators
    Use this information to assist with the Indigenous primary health care key performance indicators (nKPI) and On-line Services Report (OSR) reporting within Communicare.
    - Demographics overview
      Only those patients who meet the required Indigenous status, record status, patient status, age, or address are included in the reporting.
    - Identifying data required for nKPI reporting
      The nKPI reports extract data from clinical items in patient records and Medicare claims.
    - Reporting parameters
    - NKPI summary
      Summary of NKPI reports.
      - PI 01 - Indigenous babies born within the previous 12 months whose birth weight has been recorded
        Proportion of Indigenous babies born within the previous 12 months whose birth weight has been recorded.
      - PI 02 - Indigenous babies born within the previous 12 months whose birth weight results were low,normal or high
        Proportion of Indigenous babies born within the previous 12 months whose birth weight has been recorded
      - PI 03 - Regular clients for whom an MBS Health Assessment for Aboriginal and Torres Strait Islander People (MBS Item 715 or any equivalent such as 228, 92004, 92016, 92011 or 92023) was claimed
        Proportion of regular clients who received an MBS Health Assessment for Aboriginal and Torres Strait Islander People (MBS Item 715 or any equivalent such as 228, 92004, 92016, 92011 or 92023).
      - PI 05 - Regular clients with Type II diabetes who have had an HbA1c measurement result recorded
        Proportion of regular clients with Type II diabetes who have had an HbA1c measurement result recorded.
      - PI 06 - Regular clients with Type II diabetes whose HbA1c measurement result was within a specified level
        Proportion of regular clients with Type II diabetes whose HbA1c measurement result was within a specified level
      - PI 07 - Regular clients with a chronic disease for whom a GP Management Plan (MBS Item 721 or any equivalent such as 229, 92024, 92068, 92055, 92099) was claimed
        Proportion of regular clients with a chronic disease who have received a GP Management Plan (MBS Item 721 or any equivalent such as 229, 92024, 92068, 92055, 92099).
      - PI 09 - Regular clients whose smoking status has been recorded Communicare
        Proportion of regular clients whose smoking status has been recorded.
      - PI 10 - Regular clients with a smoking status result Communicare
        Proportion of regular clients whose smoking status has been recorded.
      - PI 11 - Regular clients who gave birth within the previous 12 months with a smoking status of current smoker, ex-smoker or never smoked
        Proportion of regular clients who have given birth in the previous 12 months whose smoking status has been recorded.
      - PI 12 - Regular clients who are classified as overweight or obese
        Proportion of regular clients who are classified as overweight or obese.
      - PI 13 - Regular clients who had their first antenatal care visit within specified periods
        Proportion of regular female clients who received antenatal care within specified periods.
      - PI 14 - Regular clients aged 6 months and over who are immunised against influenza
        Proportion of Indigenous patients aged 6 months and over who are immunised against influenza.
      - PI 15 - Regular clients with Type II diabetes or COPD who are immunised against influenza
        Proportion of Indigenous patients with Type II diabetes or COPD aged 15 to 49 years who are immunised against influenza.
      - PI 16 - Regular clients whose alcohol consumption status has been recorded
        Proportion of regular clients whose alcohol consumption status has been recorded.
      - PI 17 - Regular clients who had an AUDIT-C with results within specified levels
        Proportion of regular clients who had an AUDIT-C with results (score) within specified levels.
      - PI 18 - Regular clients with a selected chronic disease who have had a kidney function test
        Proportion of patients with Type II Diabetes who have a recent eGFR or ACR and the proportion of patients with CVD who have a recent eGFR.
      - PI 19 - Regular clients with a selected chronic disease who have had a kidney function test with results within specified levels
        Proportion of patients with Type II Diabetes who have a recent ACR grouped by the value of their latest ACR.
      - PI 20 - Regular clients who have had the necessary risk factors assessed to enable CVD assessment
        Proportion of regular clients who had CVD risk factors recorded in the previous 24 months.
      - PI 21 - Regular clients aged 35 to 74 years who have had an absolute cardiovascular disease risk assessment with results within specified levels
        Proportion of regular clients who had CVD risk factors recorded in the previous 24 months.
      - PI 22 - Regular clients who have had a cervical screening disaggregated by age groups
        Proportion of Indigenous women aged 25 years to 74 years who have a recorded cervical screening result, request, clinical item or qualifier within five years.
      - PI 23 - Regular clients with Type II diabetes who have had a blood pressure measurement result recorded
        Proportion of regular clients with Type II diabetes whose blood pressure has been recorded within the previous 6 months.
      - PI 24 - Regular clients with Type II diabetes whose blood pressure measurement result was less than or equal to 140/90 mmHg
        Proportion of regular clients with Type II diabetes who have a blood pressure measurement result recorded within the previous 6 months less than or equal to 140/90 mmHg.
    - OSR summary
      Summary of OSR reports.
  - NSW KPIs
    Additional information for NSW KPIs.
  - NT KPIs
    Additional information for NT KPIs.
- MeHR
  My Electronic Health Record Service (MeHR) allows Communicare users to submit details of a patient's health record and consultations to a central repository. Registered users also have access to this repository.
- My Health Record
  A My Health Record is a secure, electronic record of a patient's medical history, stored and shared in a network of connected systems, which brings key health information from a number of different systems together and presents it in a single view.
- National Cancer Screening Register
  Communicare integrates with the National Cancer Screening Register (NCSR).
- WACHS Features
  This topic provides help for WACHS-related features.

PI 20 - Regular clients who have had the necessary risk factors assessed to enable CVD assessment

Proportion of regular clients who had CVD risk factors recorded in the previous 24 months.

Notes

User may select between AIHW's definition of Regular Client (attended the OATSIH-funded primary health care service at least 3 times in 2 years), or Communicare's Current Patient status.
Patients must be recorded as Aboriginal or Torres Strait Islander or both.
Patients must have a sex and date of birth.
Patients must have the following recorded in the previous 24 months:
- Smoking status (reference qualifier with system code of SMO or SMP).
- Systolic blood pressure (numeric qualifier with system code of BPS).
- Either total cholesterol and HDL (numeric qualifiers with system codes of CHO and HDL) or cholesterol/HDL level (numeric qualifier with system code of CHR).
- For more information about qualifier system codes, see Qualifier codes.

Table 1. NKPI PI 20
Element	Description
Communicare reports	Report > National KPI > PI20 CVD Risk Factors Report > National KPI > PI20 CVD Risk Factors Patients
Numerator	All defined measures must have been recorded in the previous two years.
Denominator	Regular, Indigenous patients aged 35 years and under 75 years old at the end of the report period without a CVD diagnosis. For more information about condition codes, see Condition codes reference.
Additional data recording considerations	Note: some patients will not have all the measures recorded, but will still have an absolute CV risk recorded for indicator PI 21. This may be a data entry issue or may relate to some patients who can have a high risk inferred due to age and other conditions. For example, over 60 years with diabetes and microalbuminuria.