Care planning

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The care plan sets the patient goals for their health, wellbeing, and lifestyle. To achieve the goals, the plan sets out the activities that need to be done. These activities are usually done by the patient, with help from their care coordinator.

Practices involved in Health Care Homes are required to use a shared care planning tool that meets the minimum requirements.

Matrix of shared care planning products

  • The products in this matrix are mostly those that are listed on the MSIA website. Others have been included as they either meet the requirements or aspire to.
  • Asterisked (*) requirements are not part of the minimum requirements.
  • This matrix helps you do your own assessment. A valid assessment is much more likely if subjectivity is decreased by applying a consistent comparison method. The most effective assessment technique is to witness a demonstration of predetermined scenarios in two or more products. This guide to choosing software has more detail.
  • Suggested use of this matrix is to copy and paste the data into an Excel spreadsheet, remove columns you don't need, and add ratings/notes.
  • The weighting should be used. Simply multiply the weighting by the rating.
cdmNet Extensia LinkedEHR WhiteBoard Carelink Episoft Intrahealth KindredPHR PrimaryClinic VisualOutcomes
Requirement Suggested weighting Rating Note Rating Note Rating Note Rating Note Rating Note Rating Note Rating Note Rating Note Rating Note Rating Note
Care coordinator can create care plan

Consider: Workflow. E.g. who develops goals and timelines with patient?

5 Nurse can initiate.

Doctor must approve.

Care plans can be auto-generated using templates based on guidelines. Once generated, care plan can be changed so it is person-centred.

Yes. Requires template to be created by the clinic. Care plan template not included by default. Must be started by a doctor.

Do settings allow Nurse to complete?

Care plan template is included by default.  Must be started by a doctor. Nurse can develop. Doctor must complete. In development Care plan template not included by default.
Care coordinator can view care plan

Consider: To be effective, does the coordinator have access to all information?

5 Yes. Care team members can apply filters as needed. Not plan but record of care Yes Can view an imported plan
Care coordinator can change care plan

Consider: Workflow. E.g. who approves updates?

5 Yes. Only user logged in as GP can approve updates. Not plan but record of care Yes In development
Contains target goals

Consider: Aims of patient-centred care

5 Yes. Pre-populated from templates and can edit. Tasks can be assigned to specific care team member/s. Requires template to be created by the clinic. Yes In development
Contains measurable success criteria

Consider: Terminology. Can the patient understand?

5 Targets pre-populated for clinical measures. Can be edited. Requires template to be created by the clinic. Yes In development
Contains patient goals*

Consider: What terminology is used? Is it patient-centred?

5 Pre-fills goals from guidelines, can be edited to enable patient-centred goal setting. Requires template to be created by the clinic. GP agrees goals with patient and sets. In development
Contains activities and time frames

Consider: Who can update? Is there a difference between internal & external access?

5 Pre-populated from templates, editable and free text available Requires template to be created by the clinic. Notifications can be modified In development
External care team members can access (based on setting of roles/permissions) 5 Assigned tasks are editable (based on access permissions) through web-based portal. Yes. But dependent on what is set in the clinic's template. Role setting also sets what can and cannot be done. Password controlled. In development If provider has a subscription
Contains conditions

Consider: How are these entered?

5 Imported from clinical software. Can be edited. Non-coded conditions (i.e. free text) cannot be imported. If included by clinic (drawn from clinical software) and is set in the clinic's template. Imported from clinical software In development
Contains comorbidities

Consider: How are these entered?

5 Imported from clinical software. Non-coded conditions (i.e. free text) cannot be imported. If included by clinic (drawn from clinical software) and is set in the clinic's template. Imported from clinical software In development
Patient access

Consider: Is the terminology patient friendly?

5 Patients have free access to their cdmNet care plan via the web portal. Simpler view available in MediTrackerapp (MediTracker subscription is $5.95) Yes. No extra cost. Web application (suitable for mobile phone as well as desktop) In development
Patient ability to add/change elements

Consider: Will the patient understand relevance of elements?

5 Yes, If permission is set. Only GP can make changes to care plan. Patient can add comments but not change plan items.
Patient access to add observations/data* 3 MediTracker app imports from wearable devices (MediTracker subscription is $5.95) Web application (suitable for mobile phone as well as desktop)
External HCP access to view entire plan

Consider: Are the roles & expectations defined?

5 Free for AHPs.

Subscription required for GPs.

Level of access for external care team members is controlled by roles, but GP must approve changes.

Yes. But dependent on what is set in the clinic's template. GP manages referrals, can give permission to others to view, edit, and upload.

Free to GPs and AHPs.

Can view an imported plan If allowed in user access If provider has a subscription
External HCP access to edit and upload to specific elements

Consider: Workflow. E.g. how is the coordinator informed of changes?

5 Level of access for external care team members is controlled by roles, but GP must approve changes. Yes. But dependent on what is set in the clinic's template. Comments and documents can be added.

These are read-only to other care team members.

Need to upload new plan (i.e. cannot change individual items) If provider has a subscription
Access in real time

This means: Do you see the latest updates? Or do you have to do something to make that happen?

5 Yes Yes Yes Real-time updates and motifications of changes to medical record (email or in–app
Integrates with My Health Record

On principle, vendors must commit to integrating.

5 Reads MyHR

data from MyHR available to all team members. Cannot upload.

0 Does not connect to MyHR Reads MyHR, and uploads Shared Health Summaries.

Includes enhanced SHS (can add more data than standard SHS)

Reads MyHR, and uploads Shared Health & Event Summaries 0 Does not connect to MyHR 0 Does not connect to MyHR Intrahealth's Profile system integrates with MyHR 0 Does not connect to MyHR Reads MyHR and can upload Event and Shared Health Summaries 0 Does not connect to MyHR. Connection is in development.
Interoperable with other care planning systems* 5 0 Has APIs to allow data exchange with another system. Functions specific to care planning are not interoperable. 0 Not interoperable 0 Not interoperable 0 Not interoperable 0 Not interoperable 0 Not interoperable 0 Not interoperable 0 Not interoperable 0 Not interoperable 0 Not interoperable
Send patient reminders/notifications

Consider: Are their options for notifications? Are they convenient to the patient?

5 Email, SMS, and mobile app. Yes, by an authorised person in the clinic configuring 'business rules'. App is in development. SMS appointment reminders only SMS and email
Send HCP notifications 5 Notifications via email, fax, SMS, and in-app. Can be set automatically, or manually generated.

Includes instant messaging.

Only on initiation. Yes, by an authorised person in the clinic configuring 'business rules'. Team care case  conference via instant messaging Only via secure messaging Via secure messaging.
Audit/track modification of goals and review progress toward goal 5 Yes, with auto alerts. Yes All data is logged and history can be retrieved. Timeline shows progress towards goal. Need to upload new plan (i.e. cannot change individual items)
Track usage and reviews 5 Yes. Review triggered based on guidelines and HCH tiers Yes Access by anyone is logged and traceable. Can track, and has instant message function
Track clinical metrics

Consider: Where is this data entered/obtained? Does someone have to transcribe data?

5 Yes. Data from GP clinical software and patient wearable devices. AHP can input. Metrics can be tracked against set targets. Yes. Data from GP clinical software. 11 clinical metrics are tracked plus: demographics, allergies, medications, immunisations, family history, social history Only if used as primary clinical software
Extract clinical data from existing clinical systems

Consider: Where is this data entered/obtained? Does someone have to transcribe data?

5 Yes. Integrates with MD, BP, ZedMed, MedTech, Communicare and Monet. Auto-update of coded data on opening patient record. Yes. Data from GP clinical software. Yes. Data from GP clinical software. Can view entire report, not single results Integrates with results and reports, saves letters and documents 0 Does not extract data.
Secure information for privacy, and tracks individual users 5 Yes. ISO certified. Audits to individual level. Secure and encrypted. Secure and encrypted. User access password protected
Vendor support and training access

Consider: How to support providers external to HCH?

5 Mon-Fri 08:30-20:00.

Online training and webinars.

Yes. Various media. Training included in standard pricing. Train the trainer available for PHN staff. Online training packages available on request.
Guideline source* 3 Includes guidelines from Cancer Council, Heart Foundation, Arthritis Foundation, etc HealthPathways If Doctors Control Panel is installed
Patient information links* 3 Includes guidelines from Cancer Council, Heart Foundation, Arthritis Foundation, etc

Links to Better Health Channel

HealthPathways

Patient information available to patient.

Compatibility* 5 BP, MD, Zedmed, MedTech, Communicare, Monet. BP, MD, Communicare, Practix, StatHealth, ZedMed (Genie integration in development) BP, MD BP, MD, Zedmed 0 Standalone EHR, does not integrate 0 Standalone EHR, does not integrate 0 Standalone EHR, does not integrate 0 Standalone EHR, does not integrate 0 Standalone EHR, does not integrate 0 Standalone EHR, does not integrate
Advance Care Directive* 2 PDF of ACD can be uploaded (and viewed by others in the the team). Included in documents from clinical software Included in documents from clinical software
QI reporting* 4 Yes. Customised and standard reporting templates for QI and revenue.

Notes

cdmNet Extensia LinkedEHR WhiteBoard Carelink Episoft Intrahealth KindredPHR PrimaryClinic VisualOutcomes
no use of tier information, creator must alter dates for review according to tier or clinical guidelines Integrated with Livecare (videoconsultation solution) Client management system, designed for community health Links to Livecare (videoconsultation solution)