eHealth enabled management of chronic conditions

Introduction and background

The College has developed an education program which will assist GP's and their practice staff to integrate the sharing of health summaries via the My Health Record as a routine component of sustainable and quality practice.

The ACRRM program will assist practices develop strategies to build integrated care teams around each patient, use technology rationally, and share appropriate information through the National My Health Record System.

It has been developed by College Fellows who are "working at the coalface" of rural practice and who are leaders in implementation of Practice Improvement (Quality and Safety) strategies and in the adoption of the My Health Record and Telehealth and its use in the management of patients with complex chronic diseases.

The Clinical team was led by Dr Ewen McPhee, supported and advised by Dr Steve Hambleton, Chair of the of the Primary Health Care Advisory Group and Senior Responsible Officer of the Australian Digital Health Agency.

The Quality Improvement emphasis drew on the impressive work of the Improvement Foundation and the knowledge, skills and experience of Dr Tony Lembke and Dr Dale Ford, ACRRM also acknowledges the experience and leadership of the Aboriginal Community Controlled Health Organisations and their State Affiliates in understanding health outcomes, and progressing improvements in providing Patient - Centered Care.

The project benefited greatly from the input of the NQPHN and NCPHN.

The important role of PHNs in both supporting quality improvement process, outcomes and providing assistance to practices in engaging in the National eHealth Systems is critical, the NQPHN case study illustrates this potential.

The main target group for this education is General Practice, Primary Care Teams - Doctors, Practice Nurses, Practice Managers etc, who are interested in establishing a systematic approach to quality improvements in an ehealth enabled model of care.

This pragmatic, evidence based approach has been tested in busy rural practice to:

  1. Improve health outcomes for high need patients
  2. Improve the experience of giving care for these patients and make it easier for clinicians to deliver good care
  3. improve the practice bottom line (including meeting ePIP requirements)

The work has been supported by the Australian Digital Health Agency.


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