The Cardiac Analytics and Innovation (CardiacAI) Data Repository: An Australian data resource for translational cardiovascular research

In Australia, cardiovascular diseases (CVD) are managed in a complex and fragmented healthcare system across multiple providers. A data repository that links data sources, and enables advanced analytics and big data technologies, will generate novel insights, and allow development of translational tools that can improve patient care and outcomes. The Cardiac Analytics and Innovation (CardiacAI) project has established a research-ready electronic medical records data resource to enable collaborative and translational cardiovascular research. The CardiacAI data repository prospectively extracts de-identified electronic medical record (EMR) data from two local health districts (LHD) in New South Wales (NSW), Australia. These data are linked with Australian population health data to ascertain longitudinal hospitalisation and death outcomes. The data are stored within a secure, cloud-based storage and analytics platform. The CardiacAI data repository is a not-for-profit data resource that promotes collaboration and responsible sharing of data. The CardiacAI data repository is a resource for Australian healthcare providers, clinicians and researchers seeking to improve cardiovascular care. The project is expanding to include data from stroke hospitalisations and two additional NSW LHDs, and is actively exploring linkage with ECG signal data, medical imaging data and community-based healthcare. The CardiacAI project has the potential to unlock a wealth of novel insights and translational tools that improve secondary prevention and treatment of CVD.Comment: Author Notes: Blanca Gallego and Sze-Yuan Ooi are co-senior authors of this paper. Blanca Gallego is the senior technical author and Sze-Yuan Ooi is the senior clinical autho

Administration of the Australian Childhood Immunisation Register

This audit examined the effectiveness of the Department of Human Services’ administration of the Australian Childhood Immunisation Register. Audit objective, criteria and scope The audit objective was to examine the effectiveness of the Department of Human Services’ (Human Services) administration of the Australian Childhood Immunisation Register (ACIR). To form a conclusion against the objective, the ANAO adopted the following high-level criteria: Human Services has established effective policies and procedures to support the administration of ACIR; Human Services has adequate procedures and controls in place for the collection, use and management of ACIR information, including to maintain the integrity of data in ACIR; and Human Services has sound reporting processes which support the timely, accurate and authorised dissemination of ACIR information. The audit focused on Human Services’ administration of ACIR and did not include an assessment of the broader National Immunisation Program or its overall administration by the Department of Health. ACIR is largely populated using data from the Medicare customer database, which was the subject of a previous ANAO performance audit. The integrity of the Medicare customer database has not been examined again as part of the current audit. However, where relevant, the findings of the previous audit are noted in this report. Overall conclusion The Australian Childhood Immunisation Register (ACIR or the Register) records the immunisation details for over 2.25 million children under the age of seven. The Register is a key public health resource used to measure and monitor immunisation coverage rates for policy and planning purposes, and to inform parents and immunisation providers of a child’s immunisation status. Information from the Register is also used to confirm a parent’s eligibility for certain family assistance payments as part of an Australian Government policy to encourage childhood immunisation, as well as for authorised research purposes. The Department of Health (Health) has responsibility for the overall management of ACIR in the context of the National Immunisation Program (NIP) agreed by Australian Governments, while the Department of Human Services (Human Services) is responsible for establishing and maintaining ACIR. A business agreement between the departments documents key aspects of Human Services’ day-to-day administration of the Register. The ACIR contributes to the overall success of the NIP and the health status of individual children, and in April 2015 the Australian Government announced its intention to also establish an Australian School Vaccination Register for adolescents. Australian governments use data from the current Register to inform immunisation policy and planning including, most recently, a policy response to growing levels of conscientious objections to immunisation. Parents and immunisation providers have also come to rely on the Register as a source of information on the immunisation status of children under seven years of age, including for the administration of essential vaccines in accordance with the NIP schedule. Children will generally receive vaccinations for different diseases over a number of years, potentially from different providers, and a key challenge for Human Services is to maintain the Register’s integrity through accurate and timely data entry and revision. In its administration of ACIR, Human Services relies on information received from parents and providers, and on the reliable exchange of data between ACIR and other departmental ICT systems—the Medicare Consumer Directory (MCD) and the Centrelink program’s Income Security Integrated System (ISIS). Overall, Human Services’ administration of ACIR has been generally effective. The department has generally met or exceeded performance targets established in its business agreement with Health, and maintains a range of communication channels to facilitate parents’ and immunisation providers’ access to child immunisation records. System controls to maintain the integrity of data on the Register have been implemented and are generally operating as intended, although there remains scope to strengthen the ACIR quality and control framework. In particular, known impediments to the automated exchange of information between ACIR and other departmental ICT systems mean that the department must manually reconcile certain records on a daily basis—an ongoing administrative overhead. Further, while information on the Register can be added or revised on the basis of telephone advice received from immunisation providers, there is no process for monitoring ACIR telephony services for quality control purposes; and the department has not clearly communicated its expectations on the key role played by parents and immunisation providers in maintaining the integrity of ACIR data holdings. Between 2011–12 and 2013–14, the ANAO’s analysis of Human Services’ documentation indicated that the department generally met or exceeded the ACIR performance targets set out in its Business Agreement with Health. During this period, the department provided 100 per cent of financial reports to stakeholders within five working days of the specified time, exceeding its target of 90 per cent. The department also exceeded its target of making 90 per cent of immunisation provider payments within seven days before the end of the month, with 100 per cent of payments made within the required timeframe. In 2013–14, some 92.5 per cent of immunisation information was processed within 10 working days, against a target of 95 per cent. Human Services has also established a number of useful communication channels for stakeholders, including a dedicated website and telephone lines, and outreach officers for Indigenous and multicultural customers. The Register is a key public health information resource, and effective communication channels facilitate parental access to their child’s Immunisation History Statement (IHS) and enable immunisation providers to interrogate ACIR regarding their patients’ immunisation status. However, maintaining ACIR data quality remains an ongoing business risk for the department. Limited interoperability between Human Services’ ICT systems (ACIR, MCD and ISIS) and external providers’ practice management software (PMS) makes it necessary for the department to supplement automated data exchange processes with daily manual data cleansing and matching activities. For instance, departmental operational reports of transactions between ACIR and MCD indicate that some 4 900 records required manual resolution over a two month period. Many electronic transactions between ACIR and immunisation providers also required manual investigation during this period, as did transactions between ACIR and ISIS. To contribute to ACIR data integrity and improve the efficiency of information processing, Human Services should establish a pathway for the resolution of persistent and known data synchronisation issues between ACIR and other departmental ICT systems, incorporating a planned process and timetable. There would also be benefit in the department working with PMS suppliers to identify options for addressing errors arising during data exchanges between the ACIR and provider systems. The department relies on the experience of its Service Officers (SOs), supported by documented procedures, to maintain the quality of its manual reconciliation processes. However, there is currently no systematic quality control process in place to provide departmental management with additional assurance regarding the accuracy of these resource-intensive manual processes. There would be merit in the department introducing a quality control framework for manual reconciliation and review processes applying to data exchanged between ACIR and other ICT systems. Similarly, no quality control process applies to ACIR telephone calls from parents and immunisation providers, which can result in updates to information kept on the Register. Consistent with many other services provided by Human Services, the department should also apply quality call listening processes to ACIR-related telephone calls, to provide additional assurance that the Register is updated in accordance with relevant procedures. Human Services advised the ANAO that in addition to its own quality control processes, it relies on parents and immunisation providers to assist in maintaining the accuracy of the Register. In particular, the department expects that parents will check that details recorded on their child’s IHS are correct, and will advise the department of any errors. The department also expects that immunisation providers will review their monthly payment summaries to check that vaccines they administered have been accurately recorded, and that payments made to them are correct. However, Human Services’ expectations in respect to maintaining the accuracy of the Register are not clearly and consistently communicated to parents and providers, and the department should include a statement to this effect in relevant communication materials, including the IHS sent to parents and the monthly payment summaries sent to providers. The ANAO has made three recommendations to strengthen the ACIR quality and control framework, focusing on Human Services: establishing a pathway to resolve known impediments to the automated exchange of information between ACIR and other departmental ICT systems; introducing a process to monitor the quality of ACIR telephony services and manual data reconciliation activities on a sample basis; and clearly conveying departmental expectations relating to the role played by parents and immunisation providers in maintaining the accuracy of the Register. As mentioned, the current Register contributes to the overall success of the NIP, and informs ongoing policy responses to immunisation issues—such as the $26 million 2015–16 Budget measure foreshadowed by the Australian Government in April 2015. As part of that measure, the Government proposes to establish an Australian School Vaccination Register for adolescents. The findings and recommendations of this audit of ACIR may also inform responsible entities in the implementation and operation of the proposed school vaccination register

Healthy Environments

This issue of Early Childhood in Focus draws attention to some key global challenges in providing healthy environments for young children. Section 1 recognises that multisectoral policy responses are needed to ensure adequate housing and improved water and sanitation, as well as recreational spaces. For young children, physical spaces are closely intertwined with emotional security and feelings of well-being. Section 2 explores the opportunities and challenges of living in urban environments. Young children are especially vulnerable to the physical harm that urban environments create from pollution in the air, toxins in the ground, contaminated water and waste dumps, traffic, and unsafe housing. Their homes, as well as their neighbourhoods, may be unhealthy places to grow up in. Section 3 is about the design of environments specifically for young children, including innovative ‘democratic spaces’, and ‘child-friendly spaces’ in areas affected by disasters and emergencies

Integration and Continuity of Primary Care: Polyclinics and Alternatives, a Patient-Centred Analysis of How Organisation Constrains Care Coordination

Background An ageing population, increasingly specialised of clinical services and diverse healthcare provider ownership make the coordination and continuity of complex care increasingly problematic. The way in which the provision of complex healthcare is coordinated produces – or fails to – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational, relational). Care coordination is accomplished by a combination of activities by: patients themselves; provider organisations; care networks coordinating the separate provider organisations; and overall health system governance. This research examines how far organisational integration might promote care coordination at the clinical level. Objectives To examine: 1. What differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical coordination of care. 2. What difference provider ownership (corporate, partnership, public) makes. 3. How much scope either structure allows for managerial discretion and ‘performance’. 4. Differences between networked and hierarchical governance regarding the continuity and integration of primary care. 5. The implications of the above for managerial practice in primary care. Methods Multiple-methods design combining: 1. Assembly of an analytic framework by non-systematic review. 2. Framework analysis of patients’ experiences of the continuities of care. 3. Systematic comparison of organisational case studies made in the same study sites. 4. A cross-country comparison of care coordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics. 5. Analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute in-patient care. Results Starting from data about patients' experiences of the coordination or under-coordination of care we identified: 1. Five care coordination mechanisms present in both the integrated organisations and the care networks. 2. Four main obstacles to care coordination within the integrated organisations, of which two were also present in the care networks. 3. Seven main obstacles to care coordination that were specific to the care networks. 4. Nine care coordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than were care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care coordination because of its impact on GP workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care coordination, and therefore continuities of care, than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings

Regional data exchange to improve care for veterans after non-VA hospitalization: a randomized controlled trial

BACKGROUND: Coordination of care, especially after a patient experiences an acute care event, is a challenge for many health systems. Event notification is a form of health information exchange (HIE) which has the potential to support care coordination by alerting primary care providers when a patient experiences an acute care event. While promising, there exists little evidence on the impact of event notification in support of reengagement into primary care. The objectives of this study are to 1) examine the effectiveness of event notification on health outcomes for older adults who experience acute care events, and 2) compare approaches to how providers respond to event notifications. METHODS: In a cluster randomized trial conducted across two medical centers within the U.S. Veterans Health Administration (VHA) system, we plan to enroll older patients (≥ 65 years of age) who utilize both VHA and non-VHA providers. Patients will be enrolled into one of three arms: 1) usual care; 2) event notifications only; or 3) event notifications plus a care transitions intervention. In the event notification arms, following a non-VHA acute care encounter, an HIE-based intervention will send an event notification to VHA providers. Patients in the event notification plus care transitions arm will also receive 30 days of care transition support from a social worker. The primary outcome measure is 90-day readmission rate. Secondary outcomes will be high risk medication discrepancies as well as care transitions processes within the VHA health system. Qualitative assessments of the intervention will inform VHA system-wide implementation. DISCUSSION: While HIE has been evaluated in other contexts, little evidence exists on HIE-enabled event notification interventions. Furthermore, this trial offers the opportunity to examine the use of event notifications that trigger a care transitions intervention to further support coordination of care. TRIAL REGISTRATION: ClinicalTrials.gov NCT02689076. "Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization." Registered 23 February 2016

How can rural health be improved through community participation?

Executive summary Rural Australians generally experience poorer health than their city counterparts. Rural Australia is a vast geographical region, with significant diversity, where there is good health and prosperity, as well as disadvantage. The purpose of this issue brief is to provide evidence on how the health of rural Australians can be improved through community participation initiatives, which are currently being funded and delivered by health services and networks. Rural Australians need innovative health services that are tailored to the local context and meet increasing healthcare demands, without increases to expenditure. There are community participation approaches supported by research that can improve existing practice. Avoiding duplication, including the current work of Medicare Locals and Local Hospital Networks, is important for ensuring good outcomes from community participation initiatives. The following recommendations are made to improve practice: New ways to contract and pay for health services are needed, which use ideas developed with communities, within current budgets State and federal government competitive grants and tenders should prioritise proposals that demonstrate effective community participation approaches Community-based services, such as community health centres, Medicare Locals and Local Health Networks, have an important role to play in facilitating community participation, including: Building partnerships between existing services and leveraging existing participation strategies, rather than developing new services or standalone initiatives—to leverage available funds and maximise outcomes Employment of a jointly-appointed, paid community leadership position across existing community-based health services, to avoid duplication and overcome barriers of over-consultation and volunteer fatigue Formal and robust evaluation of initiatives is necessary to guide future policy and research A national innovative online knowledge sharing portal is required to share best practice in rural community participation, save time and money on ineffective approaches, and to support the rural health workforce

Understanding Contrasting Approaches to Nationwide Implementations of Electronic Health Record Systems:England, the USA and Australia

As governments commit to national electronic health record (EHR) systems, there is increasing international interest in identifying effective implementation strategies. We draw on Coiera's typology of national programmes - ‘top-down’, ‘bottom-up’ and ‘middle-out’ - to review EHR implementation strategies in three exemplar countries: England, the USA and Australia. In comparing and contrasting three approaches, we show how different healthcare systems, national policy contexts and anticipated benefits have shaped initial strategies. We reflect on progress and likely developments in the face of continually changing circumstances. Our review shows that irrespective of the initial strategy, over time there is likely to be convergence on the negotiated, devolved middle-out approach, which aims to balance the interests and responsibilities of local healthcare constituencies and national government to achieve national connectivity. We conclude that, accepting the current lack of empirical evidence, the flexibility offered by the middle-out approach may make this the best initial national strategy

Integration and continuity of primary care: polyclinics and alternatives - a patient-centred analysis of how organisation constrains care co-ordination

Background An ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level. Objectives To examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care. Methods Multiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care. Results Starting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care

Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development

OBJECTIVE: Internationally, primary care practice had to transform in response to the COVID pandemic. Informatics issues included access, privacy, and security, as well as patient concerns of equity, safety, quality, and trust. This paper describes progress and lessons learned. METHODS: IMIA Primary Care Informatics Working Group members from Australia, Canada, United Kingdom and United States developed a standardised template for collection of information. The template guided a rapid literature review. We also included experiential learning from primary care and public health perspectives. RESULTS: All countries responded rapidly. Common themes included rapid reductions then transformation to virtual visits, pausing of non-COVID related informatics projects, all against a background of non-standardized digital development and disparate territory or state regulations and guidance. Common barriers in these four and in less-resourced countries included disparities in internet access and availability including bandwidth limitations when internet access was available, initial lack of coding standards, and fears of primary care clinicians that patients were delaying care despite the availability of televisits. CONCLUSIONS: Primary care clinicians were able to respond to the COVID crisis through telehealth and electronic record enabled change. However, the lack of coordinated national strategies and regulation, assurance of financial viability, and working in silos remained limitations. The potential for primary care informatics to transform current practice was highlighted. More research is needed to confirm preliminary observations and trends noted