The Use of a Web Based Chronic Disease Management Service (CDMS) for Collaborative Care

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1 The Use of a Web Based Chronic Disease Management Service (CDMS) for Collaborative Care Michael Georgeff Jon Hilton HIC 2009: Frontiers of Health Informatics Canberra August 2009

2 The Big Picture Changing Needs Infectious Diseases Hospital-based Care Collaborative Care 2

3 The Problem

4 Chronic Disease: Big and Growing Major burden on the health system: Australia $60 billion; US $1,270 billion per annum Drastic effect on quality of life, morbidity and mortality and a major economic burden in developed and developing economies: GDP Loss (2015): Australia $12B; US: $2,000B, China $75B Key to solving the problem: Collaborative, planned, continuous care involving whole care team and the patient instead of Siloed, episodic care by single GP or hospital 4

5 Wagner Chronic Care Model

6 We are not doing very well Over 50% of doctors do not follow best practice guidelines Less than 25% of chronic disease patients on collaborative care plans, less than 5% tracked for adherence 15 30% of people don t take prescribed medications 50% unnecessary acute episodes/hospitalisations from lack of knowledge of patient condition Lack of information major cause of preventable adverse events Care team operates in silos, information not shared across care team, inefficient service use No support for patient self management adhering to care plan, ensuring appointments made, visits attended, medications renewed, conditions monitored

7 Barriers to Best Practice Care Diabetes Management Inefficiency blocks uptake Missing collaboration blocks uptake Missing tracking blocks uptake Missing dynamic collaboration blocks uptake 7

8 CDMS: A Web Based Service to enable Collaborative Care

9 CDMS: How it works A collaborative web-based service to: create, share, track, monitor, and manage collaborative care plans Advise Create Distribute Edit Care Generate Start & Agree Send TCA Plan Approve Distribute Tracking Agreeement to EMR Creation TCA GPMP Patient GPMP TCA TCA Updates & Reviews Plan Updates EMR & Appts CDMS GP Care Team Reminders & Alerts Hospital Consumer Display Get ED Generate or EMR Admission && Alert Care Plan Plan

10 Team and Patient Contact Details 21/08/

11 Clinical Information from GP Desktop

12 Measurements from Full Care Team 12

13 Personalised Evidence Based Plan 13

14 Documents Automatically Generated

15 Intelligent Tracking and Alerting 15

16 Accessible Anywhere, Anytime 16

17 Results to Date

18 Care Plan Uptake Christmas Period Swine Flu Pandemic Benchmark Tasmania HealthConnect Trials: 844 patients in 2 years

19 CDM Net Uptake Benchmark Tasmania HealthConnect Trials: 30%

20 Towards Best Practice Care 200% increase in GPMPs (AND plans are best practice) 300% increase in TCAs 500% increase in GPMP Reviews Over tenfold increase in TCA Reviews Eastern Goldfields

21 Team Care Collaboration Over 60,000 total page downloads Over 20,000 involve Allied Health, pharmacist, etc Over 300 interactions per patient per year CDMS Page Downloads by Provider Type

22 Dynamic Collaborative Care GP alters meds in response Diab Ed advises meds, non conformance, need to see GP Optician advises results CDMS Notes Shared across Care Team (example taken over 6 month period) Diab Ed advises medications Diab Ed notes non conformance Diab Ed notes non attendance Podiatrist requests plan change Diab Ed advises medication GP initiates

23 Population Health and Surveillance Able to track in real time: EHR components (histories, medications, allergies, etc) Measurements, tests Actions and events Compliance Collaborations Effectiveness of care Service use Disease outbreaks and early detection

24 Data Quality Improvement Corrections Patient As clinical feed and team back data to notice is improve shared errors quality CDMS GP Care Team Barwon Health Consumer

25 By September 2009: Other Chronic Diseases Depression Chronic kidney disease Cardiovascular disease Chronic heart failure Stroke Chronic obstructive pulmonary disease Asthma Arthritis Osteoporosis

26 How does CDMS fit with Australia s Health Reform Strategies?

27 National e Health Strategy Priority Solution Drives Key Information Flows

28 Aligned with e Health Roadmap

29 Future Directions

30 Extend Collaboration Capabilities CDMS e Prescribing Health Service Bus Routing Pub/Sub Transformation Mediation Transport User Registry (Directory Service) Topics Transformation Service (HL7 pack) WSRR (Service Locator) EMPI EHR (optional) Health Services Information Exchange 32

31 Partners

32 Partners

33 Partners

34 Partners

35 Contact and Acknowledgements Michael Georgeff Precedence Health Care Phone: Mob: Jon Hilton Precedence Health Care Phone: Mob: This work is supported by funding from the Australian Government under the Clever Networks program and the Managed Health Networks program and by the Victorian Department of Innovation, Industry and Regional Development, Department of Human Services, and Multi Media Victoria.

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