LinkedEHR the IT centrepiece for NSW integrated care trial

Western Sydney is trialling a new model of care for patients with chronic illnesses involving GP-led shared care planning, hospital-based rapid access and stabilisation clinics and nurse-led care facilitation, all powered by a web-based, dynamically updated, shared care plan.

The trial is part of the four-year, $120 million Integrated Care in NSW strategy announced by Health Minister Jillian Skinner in March 2014. Designed to shift the traditional focus on hospitals as the centre of healthcare to encompass primary and community care as well, Ms Skinner described the idea of integrated care as a “transformative step” for healthcare in the state.

Part of the strategy is to establish demonstrator sites at three Local Health Districts (LHDs) – Western NSW, Central Coast and Western Sydney – to implement and pilot new integrated care demonstrator models. Under the Western Sydney demonstrator model, clinicians who normally work in silos within the primary and acute care settings will come together to co-manage enrolled integrated care patients.

GPs will create and manage a shared care plan, hospital specialists will update it with action plans, and nurses will facilitate the plan by working with patients, GPs and speciality services to ensure its recommendations and goals are carried through.

At the heart of the project is the LinkedEHR shared care planning system first developed by the Western Sydney Medicare Local (WentWest) in association with Ocean Informatics, which went live in early 2014.

LinkedEHR is currently a free solution for GPs that is hosted by WentWest and is designed to facilitate better team care arrangements between GPs, specialists and allied health practitioners in the primary care setting. It has also been integrated with WentWest's HealthPathways web-based clinical decision support portal and the PCEHR.

As part of the integrated care demonstrator site, LinkedEHR is being used as the IT centrepiece of a new model of care that will see quite a radical change in the normal divide between primary and acute care.

The Western Sydney Integrated Care Program (WSICP) demonstrator is a joint partnership between the Medicare Local and the LHD, which have committed to resourcing the necessary components within LinkedEHR to achieve the links across primary care and hospital services, and to provide access to LinkedEHR through the acute care Cerner electronic medical record to allow hospital clinicians to view the care plan.

In addition, the WSICP demonstrator is supporting building capacity in primary care to better manage chronic disease, providing care facilitators for the registered integrated care patients, staffing rapid access and stabilisation clinics, and providing advice to GPs through a dedicated phone support line.

GPs in the Medicare Local catchment, which overlaps the LHD, will be recruited to identify patients with complex needs who would benefit from shared care planning and care facilitation, as well as to do more intensive treatment in their own practices with the idea of preventing hospital readmissions. GPs in the catchment already have access to the LinkedEHR system, but they will also be equipped with an eReferral system currently being built into LinkedEHR.

Shared care planning

WSICP clinical lead Michael Crampton said the wider strategy was to deliver more timely and appropriate health services to complex patients across the spectrum of care settings, with the intention of improving the integration of their care.

Dr Crampton, the 2014 RACGP GP of the Year and a well-known advocate for using eHealth to better care for patients, said the project will focus on people with four specific chronic diseases: diabetes, chronic heart failure, ischaemic heart disease and chronic obstructive pulmonary disease.

“We are focusing on patients with those or a combination of those chronic diseases,” Dr Crampton said. “They are the people who on any kind of risk assessment are more likely to have more complex care needs, greater problems and greater potential for hospitalisation."

The integration of their care will involve four areas of focus, he said. The first is to develop a shared care plan for each patient using LinkedEHR that is accessible to multiple providers and the patient and is constantly kept up to date.

The second is to encourage GPs to focus on maintaining and regularly reviewing the care needs of the patient and their care plan, with specialists updating it with their own action plans following each specialist consult.

The third is the appointment of a care facilitator who will be assigned to a number of practices and will assist the GPs to keep an eye on each patient's plan and ensure the items on the care plan are being delivered. The care facilitator will work across the primary, community and hospital services to ensure the patients’ needs and care plans are addressed and where possible streamlined for the patient.

The final focus is the development of new services in the hospital setting. This will involve the establishment of rapid access and stabilisation clinics that are staffed by specialists, senior registrars, nurses and appropriate allied health clinicians who will be quickly available to integrated care patients and to GPs.

GPs will be able to use the support line to talk to a specialist about the patient and if the specialist thinks it appropriate to see them, they will be able to bypass the emergency department or normal outpatients’ clinics and be seen quickly to have their immediate healthcare need attended to and a treatment plan amended if necessary.

“The stabilisation clinics will work as a kind of short-cycle outpatient clinic for those people,” Dr Crampton said. “They might have just been discharged from hospital so the specialist can see them for one or two visits or get the allied health people to see them, just to enhance their care in those particular areas before being transferred for care back in the primary care sector.”

Part of the notion of setting up a GP support line is to encourage the GPs to provide more treatment in their own practice rather than feeling their only option is to send the patient to the hospital emergency department.

“The specialists on the end of the line know that they have staff allocated to the rapid access clinic during specified time periods,” Dr Crampton said.

“They may say that you can do this for the patient now and we'll see them later today or tomorrow. If the clinicians mutually decide the patient is too sick for the GP to manage or too sick to wait for whatever period of time, then they still have the option of referring the patient to come in through emergency.”

The project will also focus on building capacity in general practice by giving GPs more access to specialist knowledge for their integrated care patients through regular communication and case conferencing, which in turn will up-skill practice teams and allow them to use that knowledge on their other patients.

“If this all works wonderfully well, it's going to be brilliant, but needless to say it's going to take a lot of time to get everything in place,” Dr Crampton said. “We can bring lots of these individual components online at different points, so we have appointed our first care facilitator and the signing of our first general practices and the eHealth components are coming together.

“We are achieving individual bits and pieces along the way but it's probably going to be some months before we can say we've joined all the dots.”

ICT infrastructure

LinkedEHR has been provided for free to GPs and allied health professionals in WentWest’s catchment for some time, and access will now be extended to the hospitals as well. Western Sydney LHD has agreed to extend the electronic medical record system in outpatients so specialists can write action plans for the patient that will be sent back to the GP electronically.

Hospital specialists will have a view of the LinkedEHR shared care plan through Cerner, and the project team is also creating a specific eReferral within LinkedEHR that can be sent to the hospital in support of an appointment in one of the appropriate clinics.

“From an IT point of view, the main principle that we are trying to have is visible, comprehensive and current information between the care providers,” Dr Crampton said. “The hospital specialist teams, the GP, the care facilitator and allied health in the community can get access to the care plan.

“The patient can also have a view of the care plan. If the patient wants to carry it around on their tablet or their smartphone, then they can also call up their own care plan and show it to anyone that they want to.”

WentWest's Paul Campbell, the eHealth lead for the project, said NSW Health's HealtheNet program is also involved. HealtheNet was first established as part of the PCEHR implementation and is being rolled out statewide to allow hospital clinicians to view patient information held not just in the PCEHR but in the state's clinical data repositories, no matter which hospital the patient attended.

“There are some things that HealtheNet is doing for the Western Sydney Integrated Care project and the LHD is doing for the project as well,” Mr Campbell said. “One major step is for a specialist to be able to send an action plan electronically to a GP after a patient is seen in a clinic as well as a letter to be given to the patient.

“To be able to receive electronic referrals from LinkedEHR and process it, something has to be built to receive it at the hospital clinic. The state is also involved in looking at the specialist letter, which is a NEHTA document, and starting to review the possibility of sending this as well as the action plan out to the GP.

“All of this is starting to happen. The project and IT aspects will be evaluated to demonstrate learnings and potential for transferability and scalability across the state. We are aiming to make this something that is useful beyond just this demonstrator site.”

Care facilitation

In addition to the IT infrastructure, one of the core elements of the project is the appointment of care facilitators. They are registered nurses with experience in looking after patients with chronic diseases, and the idea is that they will facilitate the care planning rather than be responsible for delivering it.

“[Delivery] is primarily through the general practice and the hospital teams,” Dr Crampton said. “We don't want the care facilitators to become the independent care providers – we want them to be helping the practitioners and improving the care plans through advice and having expert knowledge of the range of healthcare services, rather than becoming the owners or deliverer of the care plans.

“Their job is to work primarily in the community with the practices and across hospital services to support these integrated care patients.”

He said the care facilitators will have three main roles. “One is to facilitate some of the patient's care requirements like education services, so the facilitator may be involved at the practice or community level in delivering or arranging that.

“The second thing is the care facilitators will independently and cooperatively with the GP and other healthcare providers keep an eye on things due on the care plan. They will be helping to make sure that the patient is having the items on the care plan delivered and moving towards achieving the goals on the care plan.

“The third thing that the facilitator will be expert in the range of services that the LHD provides. The care facilitators will become in effect advocates for patients and advisers to the GPs for aspects of the care plan. They can advise for example that as you have a patient with this condition, did you know that these various services are available as well? That will improve the quality of what goes into the care plan.

“Having a team of clinicians involved in creating and monitoring the care plan, the GP, specialist and the care facilitator, brings potential for better quality care planning.”

The project will recruit patients from both the primary and acute ends of the care spectrum. For example, patients with the specified clinical conditions who have had multiple and unplanned hospital attendances will become eligible to reduce or eliminate readmission.

In general practice, the idea is to use resources like the Pen CAT tool to identify patients with the specific conditions, particularly if they have several of them. Once those patients have a care plan in LinkedEHR, the system will then automatically calculate a 'risk of hospitalisation' score.

“This higher risk patient group is being called 'next year's admissions' – by doing good work with this group, we hope to cut down on next year's admissions,” Dr Crampton said. “We can actually keep an eye on people who have got care plans in LinkedEHR about their hospitalisation risk and focus on those that have the highest risk.”

GP and patient engagement

According to Mr Campbell, of the 325 general practices in the ML catchment, about 80 don't use clinical software, but the other 245 are almost all eHealth ready. In terms of individual GPs, about 170 are using LinkedEHR, along with a similar amount of allied health practitioners.

This is a good start, but as general practices are independent businesses, there has been a realisation that those practices will face change management costs and will need some funding to offset those costs and encourage them to take part. Dr Crampton said further discussion is required on the possibility of changes to the current MBS funding system to look at outcome measures as opposed to fee for service.

With a good number of GPs already using LinkedEHR, the project is now moving on to arranging for access to it for hospital clinicians through Cerner and also to the care facilitators.

LinkedEHR is currently being modified to provide a dashboard for the care facilitators so they can see all of the patients that have been allocated to the program’s GPs, but with some filtering options so they can quickly see if there have been any changes. The LHD IT team is also building a similar patient flag and view at the hospital end.

The build with Cerner is now taking place, Dr Crampton said, and over the next few months the project will begin engaging with patients. Having presented the idea to many GPs, Dr Crampton said they were enthusiastic about the new clinic services in the hospitals.

As the project progresses, there will be more improvements made to LinkedEHR, including the ability to automatically update clinical parameters and details within a care plan. While patients can view their care plans on their mobile devices, in the future there is also the potential to more actively engage them, Mr Campbell said.

“This will not be in the first or the second year, but we are gathering data from various sources about home monitoring devices for weight, blood sugar, pulmonary tests and blood pressure, and linking that into the record for self-management at home,” he said. “We've got that on the radar but it is a couple of years away.”

Posted in Australian eHealth

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