A smart computer tool that helps GPs identify patients who are most likely to be hospitalised in the next twelve months is now available in Australia. The tool can be used by doctors to target chronically ill people most in need of preventative intervention, thereby avoiding unnecessary hospitalisation and potential disease complications.
Dr David Hansen, CEO of CSIRO’s Australian e-Health Research Centre, said: “This is the first publicly available, scientifically validated Australian risk algorithm that has been used to identify patients in GP practices who are at risk of hospitalisation. Providing this information to the GP has the potential to improve patient outcomes while reducing healthcare costs.”
The predictive risk algorithm used in the tool was developed and validated by CSIRO with the assistance of Precedence Health Care. Nearly two million de-identified patient records were used in the validation.
Precedence uses the algorithm in their smart Risk Stratification Tool (RST), initially developed for the Commonwealth’s Health Care Homes trial.
The RST connects seamlessly to GP clinical systems to extract all the information needed by the CSIRO algorithm, so GPs can be alerted to the patient’s risk of hospitalisation at the point of care. The tool can also be used to generate a report identifying the risk level for all patients in the practice.
Professor Michael Georgeff, Founder of Precedence Health Care, said: “These digital health technologies are increasingly part of a new approach to health care. They can be of enormous help to GPs who already struggle with the complexity of managing their growing population of chronically ill people.”
In addition to identifying risk using GP clinical data, the RST can also assess psycho-social issues and a patient’s readiness to change based on additional information entered by the GP or practice nurse.
Precedence’s RST has been installed in over 160 practices in the Health Care Homes trial across Australia and by a further 15 practices in the Integrated Care trials in NSW.
In the Health Care Homes trial, the CSIRO algorithm in the RST has so far identified over 7,000 patients having a greater than 9% probability of hospitalisation within twelve months. Taking into account the psycho-social and a patient readiness measures used in the RST, a third of these patients were identified as being in the top level of need and almost half were at mid-level. The different risk levels determine both the degree of intervention and the amount of Commonwealth funding for the patient.
The RST also links seamlessly to Precedence’s coordinated care platform, cdmNet. cdmNet provides identified patients with a fully digital care plan and connects them and their GP electronically to their selected care team. Over 3,000 patients in the Health Care Homes trial are already being managed using cdmNet digital care plans.
Professor Georgeff said: “This is the first time that GPs, the care team and patients can work together in a completely digital environment – targeting patients with high needs, creating fully digital care plans, tracking tasks and follow up, and collaborating across the care team. No faxes, no email, no phone tag. No-one falling between the cracks. It represents the future of health care and is here today.”
Apart from the enormous benefits to patients through potentially avoiding hospitalisation, the targeted approach provided by the RST in combination with shared care planning may help combat the ever-increasing cost of health care in Australia. Chronic illness costs the Australian health care system over $70 billion per year, much of which can be attributed to preventable complications and hospitalisations.
Precedence Health Care developed the RST using a smart connector that allows it to work with most GP clinical systems, including Best Practice, Medical Director, MedTech, ZedMed, and Communicare.
A paper co-authored by CSIRO and Precedence detailing the predictive risk algorithm has been published in Scientific Reports, a Nature journal. It will also be available to be downloaded via the Australian Government Department of Health web site. The Risk Stratification Tool is available from Precedence Ph 03 9023 0800.
About Precedence Health Care
Precedence Health Care (Precedence) is an Australian software company providing advanced digital healthcare technologies for connecting healthcare professionals and patients and facilitating the coordination of care.
Precedence is a leader in healthcare reform. Its coordinated care platform, cdmNet, currently coordinates the care of over 150,000 patients involving over 70,000 registered health care professionals, including General Practitioners, nurses, allied health professionals, pharmacists and specialists. Precedence has also developed a patient mobile app, MediTracker, to provide patients with access to their GP medical record and share this, and any self-monitored measurements, with their selected care team. Both cdmNet and MediTracker also connect to the Commonwealth’s My Health Record.
Dr Michael Georgeff is Founder and former Chief Executive Officer of Precedence and Professor in the Faculty of Medicine, Nursing, and Health Sciences at Monash University. He has been at the forefront of software innovation and commercialisation in the USA and Australia for over 40 years.
Precedence was established in Australia in 2007 and acquired by Sonic Clinical Services, the primary care division of Sonic Health Care, in late 2015.
About CSIRO
CSIRO is Australia’s national science research agency, solving the greatest challenges using innovative science and technology. CSIRO’s Australian e-Health Research Centre researches, develops and deploys leading edge digital health innovations to improve service delivery in Australian healthcare systems, and its Health Intelligence Team Leader, Senior Research Scientist Sankalp Khanna, was the lead author on this paper.
About Health Care Homes
Health Care Homes is a trial of an Australian Government strategy for tackling the enormous challenge of chronic illnesses, such as diabetes.
Around 160 Health Care Homes around Australia are enrolling patients in the trial. These practices and Aboriginal Community Controlled Health Services will provide better coordinated care for 12,000 Australians who are living with chronic and complex conditions.
The program relies on digital health technologies to identify patients most in need of care and to plan and coordinate their care.