Gold Coast Integrated Care

translating the talk into action

Emma HossackHelen Cooper&

Speakers

Helen Cooper

Managing Director

Emma Hossack

Chief Executive

• President, Medical Software Industry Association

• Immediate Past-President, International Association of Privacy Professionals ANZ, Chair Strategy and Growth ANZ

• Director, ScriptWise • Chair, Australian Stem Cell Foundation

• Managing Director, Gold Coast Integrated Care, Gold Coast Hospital and Health Service

Translating the talk into action

• International Lessons - UK, Canada, Scotland.

• Professor Trish Greenhalgh – Lessons for Australia…and why we need Dead Philosophers.

• Digital Health Ecosystem – multi-layered – local – national –technical – cultural.

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EXTENSIA’S COMMUNITY

MANAGED SHARED RECORD

RADIOLOGY &

PATHOLOGY SYSTEMS

PAPER SYSTEMS

PERSONAL HEALTH APPS

GP SYSTEMS

SPECIALIST SYSTEMS

PHARMA SYSTEMS

HOSPITAL SYSTEMS

PATIENT

Australian Digital Health Ecosystem & Extensia’s Role

FLINDERS’TOOLS

e.g. HealthPathways

COMMUNITY SERVICES

Patient and Provider Benefits

Managed Shared RecordUse & Benefits

· Managed by the community, which is determined by geography, disease or specific desirable health outcomes

· Bespoke Branding, Templates, Registration process, what information is captured & reporting metrics designed by the community with results being immediately available

· Links with the national systems when users require · All providers including those without software systems to

contribute and access the record with customised templates

to improve care co-ordination

· Managed by the community, which is determined by geography, disease or specific desirable health outcomes

· Bespoke Branding, Templates, Registration process, what information is captured & reporting metrics designed by the community with results being immediately available

· Links with the national systems when users require · All providers including those without software systems to

contribute and access the record with customised templates

to improve care co-ordination

National System - PCEHRUse & Benefits· Large national database designed by the government to

achieve national health planning & bio-surveillance & reporting

· The Commonwealth Government determines what information is captured and from what systems for a nationally consistent dataset

· Automatically uploads MBS and PBS data · As a national system it is not designed for care co-ordination

– it cannot and should not be all things to all people. It forms a national foundation and allows industry to provide ongoing innovation through other parts of the digital health

ecosystem

· Large national database designed by the government to achieve national health planning & bio-surveillance & reporting

· The Commonwealth Government determines what information is captured and from what systems for a nationally consistent dataset

· Automatically uploads MBS and PBS data · As a national system it is not designed for care co-ordination

– it cannot and should not be all things to all people. It forms a national foundation and allows industry to provide ongoing innovation through other parts of the digital health

ecosystem

· Timely access to health information improves decisions· Transparency of information – empowers patients self

management & reduces risk of adverse reactions or conflicting prescriptions

· Better coordination between providers - better outcomes &

efficiencies

· Less duplication of tests & patient history is less frustrating &

saves time and money

Government‘My Health Record’

ALLIED HEALTH SYSTEMS

A new directionAustralian Digital Health Agency

Integrated Care Program

Founded on the notion that care coordination, planning and patient advocacy is best achieved in collaboration with GPs, supported by specialists, multidisciplinary teams, non government organisations and private sector allied health professionals.

A 4 year Proof of Concept

Patient and

Family

General Practice

Coordination Centre

The Gold Coast Integrated Care Population

~730kGCHHS

Patient Population

~130kGeneral Practice

Patient Population

~63kIn Network

Patients

1303Cohort

Patients

Data from 22 Jul 2016

One Care Team

24 x 7 Phone Support

Holistic Healthcare

Rapid Response

Integrated Health Records

Integrated Services

GP Managed

Holistic Healthcare

Disease

Population Risk Management

Hospitalisation

Pro

acti

veR

eact

ive

Holistic Assessment

Patient Management Dashboards

Disease Registers

Population Based

Ambulatory Care

Man

agin

g

Hospitalisation Disease

Holistic Healthcare Action Plan

Holistic Assessment

Patient Management Dashboards

Disease Registers

Population Based

Ambulatory Care

Disease exacerbationEnd stage disease

FallsDementiaCognitionNutrition

Etc.

Pre-hospitalisationMAU

Length of stayPost Discharge

DiabetesCOPDCHDCKD

Referrals ManagementRapid Response

Drive down unscheduled, avoidablehospital admissions

ofHospitalisation

The information dilemma

• There are increased risks to the delivery of healthcare as patients have to repeat their information to multiple healthcare providers across organisations as systems are not linked.

• Multiple provider centric management plans exist for a patient which leads to patient confusion.

• Many systems contain vital pieces of healthcare information however, most is not accessible at the time of healthcare delivery.

• Information in systems is not kept up to date and healthcare may be delivered based on out-dated information.

• There is no common/standard language in use throughout any of these records which means “apples” are not always compared with “apples”.

Why GCIC chose a community-based Shared Care Record• All healthcare providers and patients can see the same

information and all can contribute to, and work from, the one care plan.

• All care team members (as nominated by the patient) are able to access, view and contribute to the patient’s shared care record.

• A healthcare event summary is provided by a healthcare provider to the shared care record such that all members of the patient’s care team may view it when next delivering healthcare to that patient.

• System configuration is based on the community’s needs facilitates the integrated healthcare delivery model

2014

20152013 2014 2015

2016

5 Mar 2015 Medical at My Centre Nerang11 Mar 2015 Broadbeach Medical Centre19 Mar 2015 Gold Coast Medical Centre

30 Apr 2015 Hope Island Medical Centre30 Apr 2015 Homeworld Helensvale Medical Centre

22 May 2015 Coomera Village Medical Centre25 May 2015 Runaway Bay Doctors Surgery26 May 2015 Robina Town Centre Medical Centre28 May 2015 Gold Coast GP Super Clinic

11 Jun 2015 Health HQ26 Jun 2015 Olsen Avenue Medical Centre26 Jun 2015 Doctors At Coomera

5 Aug 2015 Labrador Park Medical Centre

Sep 2014 Business Case Approved

Timeline

2 Mar 2015 Shared Care Record Live

Longitudinal Community Health RecordRecordPoint

Integrated Health Records

General Practices14

General Practitioners110

Public Hospitals2

Ambulance Service1Other Healthcare Service Providers50

Clinical Users1444

Patients1303

Go Live: March 2015

Data as at 22 Jul 2016

As nominated by patients

Shared Care Record Content

29,788Event Summariesuploaded to the

Shared Care RecordInitial Health Summaries

General Practice Event Summaries

1,165

7,123

Structured Document Templates Configured> 90

Inbound HL7 Interface from QH Systems

Outbound Medical Objects Interface to GPs

General Practice Usage

50 – 60 General

Practitioners

20 - 25Nurses

Per Month

Patient Usage

147 of the 1303 (11.3%) Patients have accessed their record

• Some are avid readers

• Some have just looked around and not returned

Reasons

• Age of Population

• Access / Skill for technology

Hospital Use

• Hospital use remains low• Further integration with Hospital Systems is required

• The GCIC Clinical Team are the primary interface between General Practice and the Hospital

Concluding thoughts

• We are live with a community shared care record that is assisting care providers to improve patient care across the acute and primary care sectors

• Our experience over the last two and a half years is:

‘If you want to integrate care and you can build local trust, you will do it irrespective of policy and funding.’

Professor Martin Connor

Executive Director

Centre for Health Innovation GCHHS and Griffith University