Verbal with visual aides and live demonstration

Abstract

Introduction: The population in western Sydney is diverse with a high prevalence of chronic diseases and incidence of low health literacy. The workload on primary care providers is one of the highest in NSW. One major challenge in the better integration of healthcare services is improving the communication of healthcare data and pathways across primary care providers, specialists and hospitals. WentWest has developed an array of programs and systems to integrate the care of patients with chronic disease across the spectrum of healthcare providers. Two are LinkedEHR and HealthPathways. Technology Brief: Two critical aspects of integrated care are Clinical Decision Support (CDS) and shared care plans (SCP). These are potentially simpler for inpatients in hospitals with access to homogenous clinical records and more difficult in primary health care with multiple and independent providers and clinical systems. WentWest has developed a system which integrates CDS (HealthPathways) and SCP (LinkedEHR) and supports the healthcare professional’s workflow electronically. The CDS is a localised version of the NZ Canterbury District Health Board’s – HealthPathways. It is an online clinical decision support tool, populated with resources and assessment management and referral pathways agreed on by local clinicians from primary secondary and tertiary health care. HealthPathways sits on the Health Professionals desktop and is accessed via the internet. HealthPathways also provides resources for distribution to patients for action between consultations. LinkedEHR is a dynamic care plan which can be updated by GPs, nurses, allied health professionals, care integrators, specialists and hospital clinicians involved in the patient’s care. It has for each diagnosis/problem a set of goals, targets and activities with direct access to the relevant locally agreed HealthPathways. Referrals are sent securely between registered practitioners as in a Team Care Arrangement and require a response, electronically. LinkedEHR provides a simple, easy to access, web based, dynamic and secure shared care plan. The combined implementation of LinkedEHR and HealthPathways aims to provide an accessible and dynamic shared care plan informed by best practice routines. Access to the National eHealth Record (PCEHR Being cloud based it can be rolled out to other jurisdictions. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116612– http://www.ijic.org/ Implementation: Both tools were developed with the goals of improving the management of chronic disease across the healthcare delivery spectrum. LinkedEHR’s Clinical Advisory Group proposed embedding relevant HealthPathways resources in the LinkedEHR Shared Care Plan to support the effective application of problems and goals in LinkedEHR. Conclusion: This presentation will discuss the benefits of LinkedEHR and HealthPathways in integrating care in western Sydney and report on the progress to date. Lessons learnt include: • Privacy and security is possible on the Internet; • A majority of Chronic diseases fall into a group of 25 major “concept groups”; • There are common goals and targets for these chronic diseases; • Healthcare professionals appreciate improvements in workflow; • Changing people’s work practices is difficult.