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Why change is needed
Why change is needed
Data
We aspire to a more proactive, connected and equitable health system, where data and evidence helps identify health needs earlier and supports better decisions at every level.
Clinicians will have timely, practical insights to identify gaps in care and support patients who may benefit from follow-up or early intervention. EMPHN and its partners will have a clearer view of how people access and move between primary care, community services and hospitals. This will help us direct investment where it is most needed, improve coordination and better understand the impact services have on people’s health.
Our ambition is to use data effectively for learning and improvement and helping primary care make its strongest possible contribution to healthier communities.
Why change is needed
EMPHN receives valuable information from general practice, commissioned services, hospitals and other parts of the health system. However, this information is often held in separate datasets and used primarily to report activity. This can make it difficult to see the comprehensive picture of people’s needs and experiences.
Population-wide results can also hide important differences between communities. Without more detailed insights, it is harder to identify people who may be missing out on care, understand where health outcomes vary or determine where earlier intervention could make the greatest difference.
We need to move beyond asking how many services were delivered to understanding whether people’s needs were met, whether their health improved and how primary care contributes to reducing avoidable demand on hospitals.
Building the future
EMPHN's data strategy
EMPHN is building a more connected data and analytics capability that brings together information from general practice, commissioned services, hospitals and relevant government datasets.
By combining this information with demographic, socioeconomic and local health insights, we will be better able to identify unmet need, understand variations in access and outcomes, and support more equitable planning and investment.
Importantly, this work is designed to turn data into action. Relevant insights will be made available to clinicians and providers in practical and meaningful ways, helping them identify care gaps, support earlier intervention and improve services.

The capability will also strengthen how EMPHN plans, commissions and evaluates services. Over time, it will help us understand what works, for whom and under what circumstances, while creating a stronger shared evidence base for collaboration across primary, community and acute care.
Data in action
Clinical Insights
Clinical Insights provides a tangible example of EMPHN’s ambition to translate data into practical support for clinicians.
Rather than limiting data use to population reporting, the underlying approach is to identify clinically relevant opportunities and return those insights to general practices. For chronic conditions such as diabetes, chronic kidney disease and heart disease, this could include identifying interventions, comparing testing and prescribing rates against best-practice standards and assisting general practitioners to improve their care.
The intention is for relevant patient-level opportunities to be flagged in a way that practices can identify within their digital practice management systems. This would allow clinical teams to review the information, apply their professional judgement and determine whether follow-up or further care is appropriate.
The broader value of this approach is the feedback loop it creates. EMPHN can identify an opportunity through analysis, make the insight available to primary care, monitor whether needs are subsequently addressed and assess the resulting short and longer-term benefits. These benefits may include improved chronic disease management, earlier intervention and reduced avoidable hospital use.
Other data-led examples
The data strategy provides a platform for data-led improvement across several areas of EMPHN’s work.
Connecting primary and acute care
We are working with our local health services to explore potential linkages between acute and primary care data sets to
develop a stronger understanding of how people interact with different parts of the health system. It can also help EMPHN examine the relationship between primary care, chronic disease management and hospital demand.
Evaluating commissioned programs
Quantitative evaluation will help EMPHN understand the outcomes achieved through its commissioned services and identify opportunities for ongoing improvement. This represents an important shift from measuring the volume of service activity towards understanding impact and value.
Informing system-level planning
A more connected data environment can help EMPHN map interactions across primary and acute care, better understand service gaps and support more coordinated planning with providers and system partners.
How data supports equity and integration
Data is central to EMPHN’s strategic commitments to equitable access, improved outcomes and stronger integration around people and practitioners.
Supporting equity
Population averages do not always reveal which communities experience the greatest barriers or poorest outcomes. By examining medical, socioeconomic and demographic information together, EMPHN can develop a more detailed understanding of health vulnerability across its catchment.
This can help EMPHN and its partners:
- Identify groups at higher risk of chronic disease
- Understand differences in access, testing and treatment
- Identify people and communities whose needs may not be met
- Focus improvement efforts on vulnerable and hardly reached populations
- Direct resources towards areas where they can have the greatest impact
- Monitor whether gaps in access and outcomes are reducing over time
Data will not be used in isolation. Clinical expertise, community experience and local knowledge remain essential to understanding what the information means and how EMPHN and its partners should respond.
Supporting integration
Linked data can provide a broader view of people’s experiences across general practice, commissioned services and hospitals. This whole-of-system perspective can help reveal how different services interact, where transitions are not working well and where better coordination could reduce gaps or duplication.
It also creates opportunities for more meaningful data sharing. During FY26, EMPHN sought advice from its Clinical and Practice Council about what data sharing could be facilitated to support better integration, what a whole-of-system view would mean in practice and what limitations clinicians may experience when using data-led insights.
By combining linked information with practitioner knowledge, EMPHN can support more coordinated approaches across primary and acute care and better demonstrate the contribution primary care makes to the broader health system.
Next steps
The next phase will focus on translating the foundations established during FY26 into practical and scalable data products.
Over time, it will enable:
Finalising and presenting general practice data analysis relating to chronic disease
Monitoring whether identified care needs are subsequently addressed
Quantifying short and longer-term changes in hospital use and other health measures
Expanding quantitative evaluation of EMPHN’s commissioned programs
Exploring appropriate and safe data-sharing opportunities with clinicians, providers and system partners.
For consumers, the goal is a care experience that feels more connected and less dependent on navigating separate programs. For providers, OneCare creates greater opportunity to collaborate, innovate and respond to local needs. For EMPHN and its funders, it provides a stronger basis for understanding impact and directing investment where it can make the greatest difference.
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