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International Primary Care Conference March 2016 Walter Kmet
This document discusses innovations in connected eHealth and integrated care. It summarizes Walter Kmet's presentation on WentWest's work using shared care planning tools like LinkedEHR to facilitate collaboration between healthcare professionals and improve care coordination for patients. The presentation outlines challenges like increasing demand and changing patient needs, and emphasizes building primary care leadership and capacity through tools, partnerships, and investment in technology that can help achieve integrated care.
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International Primary Care Conference March 2016 Walter Kmet
- 1. 1 Innovations in connected eHealth Adj.A/Prof Walter Kmet CEO WentWest, WSPHN IPHCRC 16th March 2016
- 2. 2 “One of thegreat 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. 3 Innovations in connected eHealth 1.Context of our work 2. Role of shared care planning 3. LinkedEHR 4. Progress and Challenges
- 4. 4 A picture ofthe challenges Deman d Changing in nature Access Removin g barriers Equity Social determinants 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 & communicatio ns
- 5. 5 PHN Framework: Identifying opportunitiesfor 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. Advocac y Commissionin g Integration Western Sydney PHN – Health system Improvement opportunities
- 6. 6 The building blocksof a successful integrated care system Support with Enablers Payment Governance Information Leadership Support “Quadruple Aim” Organise Delivery Protocols Care plans Performance review Care coordination and delivery Understand Needs Low risk Moderate risk High risk Very low risk Very high risk
- 7. 7 • Adoption ofan 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. 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. 9 Innovations in connected eHealth 1.Context of our work 2. Role of shared care planning 3. LinkedEHR 4. Progress and Challenges
- 10. 10 A shared careplan 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. 11 Optimising the solutionfor consumers will mean disregarding boundaries
- 12. 12 Rethinking Primary Care Source:UCSF Center for Excellence in Primary Care.
- 13. 13 Our vision ofPrimary 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. 14 Shared care plansand 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. 15 Innovations in connected eHealth 1.Context of our work 2. Role of shared care planning 3. LinkedEHR 4. Progress and Challenges
- 16. 16 LinkedEHR – ashared 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. 17 Example, dynamic sharedcare plan Health Summary Care Plan Clinical Metrics
- 18. 18 Additional Features A comprehensiveclinical 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. 19 More Information Web Link- http://wentwest.com.au/linked-ehr
- 20. 20 Innovations in connected eHealth 1.Context of our work 2. Role of shared care planning 3. LinkedEHR 4. Progress and Challenges
- 21. 21 Building capacity andcapability 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. 22 Practice Capability: stepson the journeyPen Licences 186 Practices Pat Cat ‘Active’ 120 Installed Integrate d Care Contracts 52 Signed LinkedEH R Registere d 218 GP 158 AHP 45 Nurse Total 421 PCMH Engaged 15 transformin g 15 more engagin g Health Pathways 4,000 new and returning users
- 23. 23 Western Sydney Integrated Care Program Mar2016 update GP Practices 51 (38%) GPs 175 Enrolments – GP Practice: January GP Practices Total Number Enrolled YTD Target (Total) Number of GPs Enrolled YTD Total 52 135 135 Level 1 28 30 100 Level 2 24 45 35
- 24. 24 Investing in technologyand innovations OO + NT = COO Jack Cochran OS + NMC = NCM
- 25. 25 Partnerships Find common cause withpartners and be prepared to share sovereignty (Kings Fund 2013)
- 26. 26 What is generalpractice responsible for – how we fund primary care
- 27.
- 28. 28 As the WesternSydney 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.