Integrated Care Information Technology: The Care Continuum

Phil Brimacombe, CIO, Counties Manukau and Waitemata DHBs, considered the strategic use of IT to enable and to drive integrated care initiatives under three main headings:
   1. Where do we want to go?
   2. Where are we today?
   3. What are we doing?

His description of "where do we want to go" offered the vision of a happy patient and a patient-centric health system comprising community, primary and secondary sectors. Sectors would be fully integrated, offering 24-hour care and the right health care intervention delivered at the right place at the right time. Individual medical records would be patient-owned and the system would be connected to other relevant agencies such as WINZ [Work and Income], pharmacies and Plunket.

In his description of "where are we today", Brimacombe highlighted that in the primary care area many general practices are already highly computerised and clinical information systems can be better than those in hospitals. Middlemore Hospital has a number of electronic systems integrated with pharmacies and laboratories. However, the "wheel of care" is not connected or integrated. There are major gaps between parts of the health care sector and patients are at risk of "falling through the gaps".

The balance of the presentation focused on the gap between primary and secondary care.

He noted that there are some excellent clinicians in both primary and secondary care who have recognised the gap between the two groups and have tried to bridge it. However this has resulted in some tension between the groups.

He described the "silos" that primary, secondary and tertiary care operate within. Efforts to "drill" between or eliminate these silos have been largely unsuccessful. In Brimacombe’s view, an all-encompassing information system that "does everything for everyone" carries a very real risk, would be extremely expensive and wouldn’t work.

Taking a fresh look at options for achieving the desired future state, he chose the option of accepting the silos and working with them while providing "plumbing" between silos to allow information flow (refer slide 13 and slide 14). The first stage in developing this option, involved the use of electronic discharge forms, which create information flow from secondary to primary care, and the diabetes disease management system and well child projects, which promote information flow back and forth between these two sectors.

Counties Manukau DHB has 8,000 electronic discharge summaries a month. More than 95% of discharges are compliant with the system. Within 40 minutes of discharge, details including presentation, diagnosis, events, tests, drugs and follow-up advice are sent to the GP’s database.

The Otara well child pilot project used an integrated care server (I/C server) to track children in relation to immunisation status and to send alerts to well child providers if immunisation was not up to date. Within three months, there was a radical improvement in reported rates of child immunisation. Clearly an I/C server provides a useful means of tracking such "gap" children. The roll out of the pilot project involving Otara, Papakura and Franklin has about 750 children enrolled and involves 50 GP practices and 117 GPs.

The diabetes disease management project used GP practice management computer systems to capture a specific dataset about enrolled diabetes patients that is sent to an I/C server. A rules system operates based on these data and if patient management falls outside these rules the I/C server sends clinical decision support to the GP. An independent clinical audit has revealed improved status of diabetes patients involved in the project. The project has now been extended to six practices with 600 patients enrolled.

The second stage is in the development of a care continuum.

Brimacombe described integrated care IT in Counties Manukau today (refer slide 15) showing the clinical system (right hand side), GP practices with computer systems (left hand side) and the messaging network that enables information flow (centre). This exchange of information allows clinicians to manage patients in a continuum.

A key next step is the ability to initiate an electronic GP referral back to secondary care. That procedure is still being tested.

Other projects include the acute demand management project and the chronic care management (CCM) project.

Demand for acute services at Middlemore Hospital has recently shown 10% compounded growth annually. The acute demand management project involves improving patients’ primary care contact, and therefore management, such that patients do not get to acute presentation. It targets the top 1,500 patients, identified based on length-of-stay data and readmission rates, and uses individual case management to reduce readmissions.

The CCM project builds on diabetes disease management principles, incorporating these into the management of heart and respiratory diseases. The project uses IT, funding, nurse specialists and education to avoid secondary admissions.

Brimacombe concluded by setting out the key steps in getting to "where you want to go". Electronic discharge summaries are an important first step, allowing an exchange of information from secondary to primary care and assisting the GP in taking the next appropriate steps in patient care. He noted the importance of capturing the right and the relevant information; in his view a massive "catch-all" electronic patient record is not required. It is simply necessary to have the information required by an evidence-based rules system in order to generate rules using that decision support system.
[View Phil Brimacombe’s presentation Integrated Care Information Technology: The Care Continuum]