The Journey from a Chronic Care Program toward an Integrated Health and Social Care Model

1. ICT Strategy in
The Catalan HealthCareand SocialCare
System
ICT Services

2. Table of contents
TicSalut Foundation
Catalan Healthcare System
Electronic Health Record in Primary Healthcare
iSIS.Cat. Integration Health and Social Care
1
2
3
4

3. TicSalut: Technology, Innovation & Health
Founded in 2006, TicSalut Foundation is an agency within the
Ministry of Health that works to promote the development and
use of ICT in the health and social care domain, acts as a trends,
innovations and emerging initiatives observatory, and provides
services for the standardisation and accreditation of products.

4. The Catalan Healthcare System
Health Plan

5. Current System
The Catalan healthcare model is a multi-
provider one integrated in a unique public
network.
It enhances the autonomous management
of each provider.
Providers are free to select their
information systems; however 85% of the
primary care centers have the same
system (eCAP)
Interoperability among systems must be
guaranteed.
Decentralized System

6. Catalan Healthcare System
Insurance Services
USER
CATALAN
HEALTHCARE
SERVICE
CONTRACTED
PROVIDERS
100%
DEPARTMENT OF HEALTH: Draws up Health Plan and Transfers
economic resources Plans
Governance
 The history of the Catalan healthcare
system, made it highly fragmented at a
healthcare supply level:
 Around 80% of the specialized care
and around the 20% of the primary
care is provided by suppliers not
belonging to the Department of
Health
 Inexistent common Information System
for all the healthcare suppliers due to the
healthcare system diversification
ICT’s Strategic component of the Healthcare System
20%
Supplementary
Private Insurers
CATALAN
INSTITUTE OF
HEALTH
Private Centres
20%
70%
10%

7. Goals and health programs
Chronic care patients orientation
Integrated care system
Quality and equitry in tertiary care
Focused in patients and families
Outcome-based commissioning
Clinical and professional knowledge management
System governance and participation
Shared information, transparency and evaluation eHealth Plan
Citizen
centered
healthcare
HEALTH PLAN

8. 97%
Hospitals
98%
Primary
Care
82%
Long-term
care
67%
Mental
health
Catalonia
Spain
USA
27 hospitals 6
EMRAM
2013
Current Situation. Some Figures

9. VIDEO

10. 1.8m docs/month
23%
Current model
121.390 access/month
64%
New model
BPM
Rules
CDSS
IS
Web services
Care processes
Health intelligence
Messaging
platform
BI/visor
Future model: ISISS.cat Health and social integration
Healthcare
processes
integration
Integration Health Data

11. The Shared Medical Record – Look & Feel

12. Adding Value through ICT: From documents to cooperation
 Adds “value” to
professionals
 Enables continuity of
care
Sharing Documents
Images Publishing
 Professionals share
knowledge
 Serving continuity of care
Exchanging Information
ePrescripcion
 Clinical practice is
connected with ALL the
agents demanding a
change in behaviour
 Increase of quality of care
Collaborative Model
eHealth

13. Folder
Information
Digital certificate
Documents
Channel
Communication
Robust password
Services
CITIZENS ACCES TO DATA

14. Home Diagnosis ePrescription Vaccination Connect My controlsReports
Search by:
- Report type
- Date
- Center
Report search results:
- Date
- Report type
- Diagnostic
- Service
- Health Center
PHC: Clinical reports

15. Active health
problem
Non active
health problem
Home Diagnosis ePrescription Vaccination Connect My controlsReports
PHC: Diagnosis control

16. Online: always updated
Printable
PHC: ePrescription – Available and printable
medication and chronic treatment
Home Diagnosis ePrescription Vaccination Connect My controlsReports

17. Reported from provider center
Reported from vaccination book
Reported verbally from patient
Duplicated
PHC: Vaccination – Reports vaccines supplied
Home Diagnosis ePrescription Vaccination Connect My controlsReports

18. o Blood donors
o Public procedures
desk
o Other reference
health centers
PHC: Connect
Home Diagnosis ePrescription Vaccination Connect My controlsReports

19. Telemonitoring
- Controlling of diabetic disease
- Preventive medicine (SISO)
PHC: My controls
Home Diagnosis ePrescription Vaccination Connect My controlsReports

20. Health care environment
Budget reduction + Increase
chronicity
Guarantee the
quality of the
service
+ =
Challenge: manage
efficiently the
resources assigned to
chronic patients
Information TechnologiesProcess & OrganizationCurrent environment
• Systems oriented to the medical
act.
• Low personalization of complex
cases
• Low consensus level of
agreement in the patient
treatment
• High traditional units activity:
A&E
• Reactive system
• Difficulties for the treatment
adherence
• Low integration with palliatives
units
• No patient centric vision
• Systems oriented to treat the pathology
not the patient (clinical pathways,
processes…)
• No case management role extended
• No transversal care plan treatment
• Low culture of homecare
• Low telemedicine processes
• No alternative units for A&E
treatments.
• No integration with social services
• No integration with intermediate care
attention
• Systems with low level of
integration
• No 360º vision of patient
• No proactive systems for
given support to the
professionals.
• No clinical pathways
implemented in all
healthcare levels (partial
implementation).
• Difficulties to measure the
KPIs
• No mobiles development
solutions

21. i-SISS.Cat
Strategic plan for the implementation and
deployment of the platform for the management of
healthcare and social Processes in Catalonia

22. BENEFITS
Gestiódel
coneixement
Modelsde
predicció
Anàlisi impacte
pacient
Mesurade
resultatsen
termesde salut
Analítica
Avançada
Model de Interoperabilitat i
regles de negoci
Model de gestió
de processos
clínics integrats
Gestióde processos
Guies clíniques
Monitorització del servei
Gestió d’acords de servei
Integració
Publicació catàleg de serveisd’informació pacient
Missatgeria entre proveïdors
Estàndards del sector i de país (HL7, WIFIS)
Gestióde regles
Ruta al territori
Events del pacient
Protocols
Govern
Visió programes
Gestió oferta –demanda
Control econòmic/consum
Professionals
Visió 360
Gestió del procés
Entorn de col·laboració /
educació
Alarmes
Pacients– Canal de
Salut
Interacció amb el sistema
sanitari
Educació
Pacient expert
Gestiód’informació HCE Continguts
iSALUT
Motortràmits
Access
informació
clínicapersonal
Accésa apps.
Telemonitoritza
ció
Modelde
col·laborac
ió amb el
ciutadà -
Canalde
Salut
AQuAS- VISC
• Distributionand source of
informationwith different
level of detail
• Evaluationof care processes
• PredictionModel
• Internationalprojects.Pilots
Citizen
• Proactivity
• Non-face-careModel
• CPS – follow-upof the process
• Co-responsability
• APPs
• Personalizedmedicine
Department
• Comply with the
objectivesof the health
care plan
• Gettinghealth policies
to citizens
• Integrationwith other
departments
Professionals
• Continuumof care
• Vision and process monitoring
• mhealth
• Collaborativemodel
• Proactiveand predictive medicine
Supplier
• Integrationsinto their systems of
information
• Common Model
• Processmanagement
• Interconsultes
• Definitionof rules of derivation –
supply & emand control systems
for clinical decision support
• Facilitatethe adaptiation to the
new billing models among other
introduceds
DGORS
• Integrationwith the
history of the Center
• Accreditations.Quality
managementof the
Center
• Patientcollaborative
environments
CatSalut
• Model Government
• Common Model Standardization
• Informationon line
• Monitoringof regional healthcare
processes
• Proactivity.Have data, don’t ask for them
• Demand control
• Adjustmentof payment models
• Proforma Invoice: identificationof clinical
processes
• Integrationwith 061CatSalut Respon
Public Health
• Suitabilityof prevention
programmes
• Integrationwith SSII asistencials
• Prescribehealth tips
• Library of Consells de Salut and
mobility
• Integrlvision of citizen
information
• Epidemicpredictive models
DG Planning
• Decisionson-line
• Design stage based on
activity
• Alliance Planning
• Trainingmaterial linked
with clinical processes
• Telemedicineand
telemonitoring
• PPAC and Pacient Expert

23. Governance of
the program
Holistic view
of the
patient
Integral vision
of healthcare
processes
Integral
vision of
the citizen
Government programs:
Summary of
Processes
Governance
i-SISS.Cat
•Creation of programs and tracking key
performance indicators (KPIs).
•Allocation of KPIs for each program.
•Display of results for program and service
provider.
360 °view of the patient:
• Access to the broad view of the patient and
the process (the supplier can decide to use
this functionality or not).
• Environments of collaboration between
professionals.
Healthcare process integration:
• Social and health-related information
sharing of the patient by the definition of
integral processes.
• Unique file generation and healthcare.
Integral vision of the citizen:
• Platform that will allow us to expand
the coverage to other social benefits
and giving coverage to the unique
social, labour and health record.

24. 360 °view of the patient:
• Access to the broad view of the patient and
the process (the supplier can decide to use
this functionality or not).
• Environments of collaboration between
professionals.
Integració procés sociosanitari:
• 306º view of the patient.
• collaborative environment of
professionals.

25. • Management the different clinical processes included in the Healthcare Plan
• Govern the health model in terms of efficiency and direct towards processes
• Facilitate the adoption of new models for health care providers billing
• Fit the new models of purchase without adding complexity to the supplier
• Self-management. Customized of the clinic processes to the reality of each of the
territories and suppliers..
• Integrate suppliers at different levels: processes, information and management tool at
the discretion of the level of evolution that they have their systems of information
• Make interoperability between different providers, unifying the model of integration
and sharing of information
• Measure the relevant indicators established within the Health Plan
• Co-responsible for the patient in the management of their health and the health
system itself
The solution i-SISS.Cat should allow

26. Thank you
Jordi Martínez
Chief Innovation Officer, TicSalut Foundation