International Primary Care Conference March 2016 Walter Kmet

1

Innovations in connected eHealth

Adj. A/Prof Walter KmetCEO WentWest, WSPHN

IPHCRC16th March 2016

2

“One of the great challenges in healthcare technology is that

medicine is at once an enormous business and an exquisitely human endeavour; it requires the ruthless

efficiency of the modern plant and the gentle hand holding of the parish priest; it is about science, but also

about art; it is eminently quantifiable and yet stubbornly not”

Robert Wachter, The Digital Doctor

3

Innovations in connected eHealth1. Context of our work2. Role of shared care planning3. LinkedEHR4. Progress and Challenges

4

A picture of the challenges

Demand

Changing in nature

Access

Removing barriers

Equity

Social determinants

Ageing Population

Chronic

Disease

Between now and 2050 the number of older people (65 to 84 years) is expected to

double

Most chronic

diseases are

preventable

Intersection of health &

communications

5

PHN Framework: Identifying opportunities for health system improvement in western Sydney

Western Sydney PHN –

Health system

Improvement opportunities

Whole-of-system (Macro level): Enhanced structural integration across the various health services serving the population of western Sydney and covering both private and public health sectors.

Care/population groups (Meso level): Enhanced service integration for targeted health initiatives including local and national priority focus areas and/or sub-populations that have been identified as a result of PHN population needs analyses.Patient-centric integrated and coordinated care (Micro level): Improved delivery of patient-centric health services to individuals and their carers through a coordinated set of care interventions that ensure the right care is provided in the right place at the right time.

Advocacy

Commissioning

Integration

Western Sydney PHN – Health

system Improvement opportunities

6

The building blocks of a successful integrated care system

Support with Enablers

Payment Governance

Information Leadership Support

“Quadruple Aim”

Organise Delivery

Protocols

Care plans

Performancereview

Carecoordinationand delivery

Understand Needs

Low risk

Moderate risk

High risk

Very low risk

Very high risk

7

• Adoption of an evidence based approach to achieving good quality primary care for the community

• Engaging and investing in leadership at all levels – especially GP Leaders

• Linking the model to:- What we do and can do

more of- What changes are needed

and how we can make them

- A platform for integrated care

• Promoting networks of practices

• Sustaining the effort

Building Blocks for High-Performing Primary Care *

*Wllard & Bodenheimer 2012

8

The information challenge – some observations• Understanding general practice/primary care data

- Creating reliable and accurate sources• Sharing across organisational boundaries

- Even greater complexity when associated with care coordination

• Integrating, not just collating• Associating information collection with best

practice care pathways- Living documents to achieve the quadruple aim

• Up to date infrastructure• “My integration is your fragmentation”

9


10

A shared care plan is a structured, comprehensive plan developed jointly by the patient and their family/carer

and health professional(s). It may include a summary of personal health information, a person’s health goals, and the treatment and follow up care

they receive.

National Health IT Board NZ

11

Optimising the solution for consumers will mean disregarding boundaries

12

Rethinking Primary Care

Source: UCSF Center for Excellence in Primary Care.

http://cepc.ucsf.edu/

http://cepc.ucsf.edu/

13

Our vision of Primary Care for the future

“Primary care will have at its heart active collaboration between

healthcare professionals and the people they care for. This patient-

focused approach will require collaboration between professionals

and strong team working, both within and across organisational

boundaries.”

Source: Primary Care Workforce Commission UK - 2015

14

Shared care plans and teams• Direct service provision verses care coordination

- Aligning payments systems to integrated care strategies

• Primary care/general practice clinical leadership• Role definition among professionals, generalists,

specialists and sub specialists- New roles such as nurse practitioners and

physician assistants• Engaging and activating consumers through

better information transparency• Shared care planning platforms

- eHealth/EMRs aligning to clinical pathways

15


16

LinkedEHR – a shared care planning tool• It’s development was led by GP leaders who at time felt

existing products did not meet needs- Commissioned Ocean Informatics to develop for

WSydney• Ability for simultaneous viewing/updating by team caring

for the person- Uses Clinical Management System and TopBar

• Can be accessed by browser, in the GPs “neighbourhood”- Sending eRederrals, to be accessed through hospital

systems• Same security and privacy as the national MyHR• Can read a patient’s MyHR.

- Will soon be sending Shared Health Summaries to MyHR• Captures lost revenue by closing the loop for various PIPs

17

Example, dynamic shared care plan

Health Summary

Care Plan

Clinical Metrics

18

Additional Features

A comprehensive clinical decision support system (HealthPathways) embedded

By June of 2016, LinkedEHR will be integrated with the Telstra Health Gateway collecting consumer entered data and delivering an accessible SCP

A Risk Stratification feature to assesses the risk of hospitalisation being developed

19

More Information

Web Link - http://wentwest.com.au/linked-ehr

http://wentwest.com.au/linked-ehr

20


21

Building capacity and capability

There is a need for general practice to adapt rapidly so that it operates

at a scale that can provide a platform for integrated care.

(Kings Fund 2011)

Finding ways to build leadership amongst primary health care providers and working with early adopters

22

Practice Capability: steps on the journeyPen

Licences186

Practices

Pat Cat ‘Active’

120 Installed

Integrated Care Contract

s

52 Signed

LinkedEHR

Registered

218 GP 158 AHP

45 Nurse

Total421

PCMH Engaged

15 transformi

ng

15 more

engagingHealth

Pathways

4,000 new and returning users

23

Western Sydney Integrated Care Program

Mar 2016 update

GP Practices

51 (38%)

GPs 175

Enrolments – GP Practice: JanuaryGP Practices Total Number

Enrolled YTDTarget (Total)

Number of GPs Enrolled

YTDTotal 52 135 135Level 1 28 30 100Level 2 24 45 35

24

Investing in technology and innovations

OO + NT = COOJack Cochran

OS + NMC = NCM

25

Partnerships

Find common cause with partners and be prepared to share sovereignty

(Kings Fund 2013)

26

What is general practice responsible for – how we fund primary care

27

Thank you

@WKmet

28

As the Western Sydney Primary Health Network, WentWest is focused on addressing both regional and national health challenges. Together with health professionals, partners from both the health and hospital sector, consumers and the broader community, WentWest seeks to identify gaps and commission solutions for better health outcomes.

International Primary Care Conference March 2016 Walter Kmet

Healthcare