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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 Online Services Report (OSR) reporting within Communicare.
NKPI summary
Summary of NKPI reports.
PI 07 - Chronic Disease Management Plan prepared
Proportion of regular clients with a chronic disease who have received a GP Management Plan (MBS Item 721 or any equivalent such as 229, 392, 965, 92024, 92068, 92055, 92099, 92029, 92060) or GP Management Plan Reviews from 1 July 2025 (MBS Item 393, 967, 92030, 92061).

Integrations
Communicare integrates with National and State services, external reporting solutions and utilities that expand Communicare's reporting and other capabilities.
- Services Australia
  Communicare interacts with Services Australia web services.
- 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.
- 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 Online 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 for supported encounter modes and contact types.
    - 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 - Birthweight recorded
        Proportion of Indigenous babies born within the previous 12 months whose birth weight has been recorded.
      - PI 02 - Birthweight result
        Proportion of Indigenous babies born within the previous 12 months whose birth weight has been recorded
      - PI 03 - Indigenous Health Assessment completed
        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 - HbA1c recorded
        Proportion of regular clients with Type II diabetes who have had an HbA1c measurement result recorded.
      - PI 06 - HbA1c result
        Proportion of regular clients with Type II diabetes whose HbA1c measurement result was within a specified level
      - PI 07 - Chronic Disease Management Plan prepared
        Proportion of regular clients with a chronic disease who have received a GP Management Plan (MBS Item 721 or any equivalent such as 229, 392, 965, 92024, 92068, 92055, 92099, 92029, 92060) or GP Management Plan Reviews from 1 July 2025 (MBS Item 393, 967, 92030, 92061).
      - PI 09 - Smoking status recorded
        Proportion of regular clients whose smoking status has been recorded.
      - PI 10 - Smoking status
        Proportion of regular clients whose smoking status has been recorded.
      - PI 11 - Smoking status of females who gave birth
        Proportion of regular clients who have given birth in the previous 12 months whose smoking status has been recorded.
      - PI 12 - Body mass index of clients
        Proportion of Indigenous regular clients who have a Body Mass Index (BMI) result within specified categories.
      - PI 13 - First Antenatal Visit
        Proportion of regular female clients who received antenatal care within specified periods.
      - PI 14 - Clients who are immunised against influenza
        Proportion of Indigenous patients aged 6 months and over who are immunised against influenza.
      - PI 16 - Alcohol consumption recorded
        Proportion of regular clients whose alcohol consumption status has been recorded.
      - PI 18 - Kidney Function Testing
        Proportion of Indigenous regular clients with a selected chronic disease who have a selected kidney function test result recorded.
      - PI 19 - Kidney function test result
        Proportion of First Nations regular clients with a selected chronic disease who have had a kidney function test result (eGFR and ACR) within a specified category.
      - PI 20 - CVD risk assessment factors
        Proportion of regular clients who have had the necessary risk factors assessed to enable cardiovascular disease (CVD) assessment
      - PI 21 - CVD risk assessment result
        Proportion of regular clients aged 35 to 74 years who have had an absolute cardiovascular disease (CVD) risk assessment with results within specified levels.
      - PI 22 - Female clients who have had a cervical screening (HPV) test
        Proportion of female Indigenous regular clients who have had a cervical screening (HPV) test
      - PI 23 - Blood Pressure recorded
        Proportion of regular clients with Type 2 diabetes who have had a blood pressure measurement result recorded.
      - PI 24 - Blood Pressure result
        Proportion of Indigenous regular clients with Type 2 diabetes whose blood pressure measurement result was within specified categories
      - PI 25 - STI result recorded
        Proportion of Indigenous regular clients who have a test result for one or more sexually transmissible infections (STI).
      - PI 26 - Ear Health Check
        Proportion of Indigenous regular clients ages 0-14 years who have a completed ear health check recorded.
    - OSR summary
      Summary of Online Services Report (OSR) data collection.
  - NSW KPIs
    Additional information for NSW KPIs.
  - NT AHKPIs
    Additional information for NT AHKPI.
- 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.
- MeHR
  My Electronic Health Record Service (MeHR) allows Communicare users in the Northern Territory 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).
- HealthLink SmartForms
  Communicare integrates with HealthLink SmartForms to enable you to send structured eReferrals.
- Titanium & ISOH
  Communicare can interface with the Information System for Oral Health (ISOH) or Titanium.
- Virtual health monitoring
  Communicare can be configured to integrate with virtual health monitoring applications such as My Care Manager (MCM).
- WACHS Features
  This topic provides help for WACHS-related features.
- Cardiovascular Risk
  Record cardiovascular risk in Communicare.

PI 07 - Chronic Disease Management Plan prepared

Proportion of regular clients with a chronic disease who have received a GP Management Plan (MBS Item 721 or any equivalent such as 229, 392, 965, 92024, 92068, 92055, 92099, 92029, 92060) or GP Management Plan Reviews from 1 July 2025 (MBS Item 393, 967, 92030, 92061).

Description

Proportion of Indigenous regular clients who have Type II diabetes and who have received a GP Management Plan (MBS Item 721 or any equivalent such as 229, 392, 965, 92024, 92068, 92055, 92099, 92029, 92060) within the previous 24 months, or GP Management Plan Reviews from 1 July 2025 (MBS Item 393, 967, 92030, 92061).

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.
A patient is deemed to have received a GP Management Plan if a service has the MBS item checked for claiming, regardless of whether it has been submitted or paid.

Table 1. NKPI PI 07
Element	Description
Communicare reports	Report > National KPI > PI07 Diabetes GP Management Plan Report > National KPI > PI07 Diabetes GP Management Plan Patients
Numerator	Currently this report looks for evidence of a 721 or any equivalent Medicare claim. For more information, see Medicare claims.
Denominator	Currently this indicator looks only for patients with Type II diabetes.
Additional data recording considerations	Health Services who are part of the Health Care Homes trial will not be documenting care plans with a claim for item 721 or any equivalent so will need to document these care plans with a clinical item. From June 2018 this indicator will also recognise a completed procedure with an export code of `CPA` as being evidence of a care plan being completed.

This information relates to V19.0 of the Specifications for National Key Performance Indicators and Online Services Reporting (Solving Health, Specifications for National Key Performance Indicators and Online Services Reporting V19.0. Sydney: Solving Health, August 2025). For more information, see https://www.solvinghealth.au/specifications.

20 January 2026