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The key principles for the design and delivery of person-centred, integrated care systems.

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(1)

The key principles for the design and

delivery of person-centred,

integrated care systems.

The Blue Line connecting patient data safe and secure through the silo’s.

Jacob Hofdijk

(2)
(3)

The paradigm shift

From Supply to Demand

(4)

L

ARRIE WEED

THE FOCUS ON THE

P

ATIENT PROBLEMS

!

(5)

Person centered SOAP notes

introduced in 1965, still valid

•

Subjective

•

Objective

•

Evaluation

(6)

Approach followed when

designing collaboration in

perinatal care in Hoorn

(7)
(8)

3 leading principles Porter / Teisberg

8

Results drive

improvements

Focus health

care delivery

on full care

cycles

Improve

value for

patients

(9)
(10)

The Dutch problem oriented approach

Episode of care - dbc

Diagnosis

Health

Issue

Intake

Diagnostics

Therapy

Healthy

(11)

2003 Care standard for Diabetes

Focus on individual care in the

health network

11

Focus on prevention

Active patient , self managing Based on Guidelines and protocols

OBJECTIVE

Appropriate care for the individual patient

(12)

The integrated care approach requires

an accountable care organisation

Insurer

Care

Standard

Structure Process Outcome

Care Group

Dietary

GP

Internist

Nurse

Market 1 Market 2
(13)

From one disease ( diabetes) to managing the

population the INCA approach

(14)

Patient focused Health Issue Web

0 2 4 6 8 10 Roken Overgewicht Lichamelijke inactiviteit Ongezonde voeding Alcohol Stress Depressie Angst Somatisatie Cholesterol Bloeddruk Nefropathie Glucose Diabetische voet Neuropathie Retinopathie Longfunctie / Dyspnoe Inspanningsvermogen COPD exacerbaties 1-mrt-12 1-mrt-13

Lifestyle

PSYCHOLOGICAL VASCULAIR

COPD

DIABETES MELLITUS
(15)

Patient and provider shared decision making

0 2 4 6 8 10Roken Overgewicht Lichamelijke inactiviteit Ongezonde voeding Alcohol Stress Depressie Angst Somatisatie Cholesterol Bloeddruk Nefropathie Glucose Diabetische voet Neuropathie Retinopathie Longfunctie / Dyspnoe Inspanningsvermogen COPD exacerbaties 1-mrt-12 1-mrt-13 Individueel Behandelplan Adviezen Medicatie Verwijzingen Follow-up Leef- en behandeldoelen
(16)

16

How to connect and coordinate ?

HI S ZIS DI S LI S Laborant Diëtary AIS Pharmacist GP /POH Care Center Patiënt PIS Fysio therapist Internist Pediatrician R IS P

(17)

17

The concept of the Blue Line approach

HI S ZIS DI S LI S Laborant Diëtary AIS Pharmacist GP /POH Care Center Patiënt PIS Fysio therapist Internist Pediatrician R IS P HR

(18)
(19)

Tarlov, A.R., Public Policy Frameworks for Improving Population Health. Annals of the New York Academy of Sciences, 1999. 896(SOCIOECONOMIC STATUS AND HEALTH IN INDUSTRIAL

NATIONS: SOCIAL, PSYCHOLOGICAL, AND BIOLOGICAL PATHWAYS): p. 281-293.l

(20)

From fragmented health and social caresystems to patient centred :

the Challenge

GP

Community Nurse

Hospital

Care/Nursing Home Physiotherapy Pharmacy

Laboratory

Dentist Optician Specialist Clinics

Health

Care

Personal

Support

Housing Community Services

Home

Safety

Social

Care

Learning Needs

Leisure

Voluntary Services Private sector support

Diagram after P. Hill

(21)

HUG KISS

Technological

Interoperability

y

Semantic

Interoperability

y

Balancing

health / life goals

Society Incentive

Framework

Social Interoperability

The design of a person centred system

the Blue Line symbol for connectivity

(22)

Technological

Interoperability

y

Semantic

Interoperability

y

Social

Interoperability

Value,Priorities

Preferences

Societal Incentive Framework
(23)
(24)

Integrated Perinatal Care requires

Midwife Gynecologist Maternity

Perinatal Care Entity VSV

Delivery

Prevention Pregnancy Post natal

care

PWD Common

(25)
(26)

17 – 09 – 2015

(27)

Interoperability issues Perinatal Care

1. Organisation

VSV

Entiteit

2. Care process

Care

Pathways

3. Common language-

PWD

4. Regie information system

for care provider and

client

(28)

Several scenario’s presented, which to choose

Scenario 0: Losse systemen en een centrale data bank Scenario 1: Berichten versturen push/pull Scenario 2: Losse systemen met meta data beheer

(29)
(30)

T

Statistiek

(31)

IHE

XDS Infrastructure

Registry of the Clients Perinatal care Provider as source of data Perinatal care provider as user of data Repository Knows where to find data Perinatal Profile Based on PWD
(32)
(33)

Proof of Concept PWD , IHE-XDS

VSV West Friesland - Zorgring

VSV Amsterdam Oost-Centrum

Amsterdam-West – Sigra

(34)

The current vision on

Geboortehart

(35)

Geboortehart

is being part of the life of

the pregnant woman and her child

(36)

The proof of concept

Midwife Gynecologist Kraamzorg

Onatal Astraia HIX ISK

Orpheus

(37)

Trust , Security and Privacy Approach

Personal Information

Management Ecosystem

(38)
(39)

Involvement patient

a. Consent to share

b. Consent to view

c. View the log of the use of data

(40)

11.00 rol patiënt

a. Toestemming geven

b. Zien wie geraadpleegd heeft

(41)
(42)
(43)

Systeem interactie

Process:

Registration of consent

Registration of the pregnant woman with her BSN number in the Zorgring Registry with Consent

IT Infrastructure

Onatal

Zorgring

REGISTRY CONSENT LOGGING Midwife
(44)

t Systeem interactie

Process:

Individual Careplan

The plan agreed with the woman is recorded and published.

Onatal

Zorgring

IT Infrastructure

CONSENT LOGGING Repository Midwife

PWD Profile

REGISTRY
(45)

Systeem interactie

Process: Echo

Pregnant woman receives echo and report and images are recorded and published.

IT

Astraia

Zorgring

Midwife CONSENT LOGGING Repository

PWD Profile

& image

REGISTRY
(46)

Systeem interactie

Continuous Risc Assessment

For hypertension the

woman visits the gynaecologist

.

IT

HiX

Zorgring

PWD Profile

CONSENT LOGGING Repository REGISTRY Gynecologist
(47)

Systeem interactie

Process:

Change of plan, delivery

in the hospital.

IT

HiX

Zorgring

CONSENT LOGGING Repository REGISTRY

PWD Profile

(48)

Systeem interactie

Process

:

Postnatal care

IT

ISK

Zorgring

CONSENT LOGGING Repository REGISTRY

PWD Profile

(49)

Systeem interactie

Process: End of the journey

.

IT

Geboortehart

Zorgring

CONSENT

LOGGING

Repository REGISTRY

(50)

First the Proof of Concepts in Hoorn and

Amsterdam ,

(51)

11.15 zorgverlener

a. Verwijzen

b. Overdracht

c. Multi disciplinair overleg

d. Second opinion

(52)

Christian Lovis, MD MPH Division of Medical Information Sciences christian.lovis@hcuge.ch http://glasshospital.com/wp-content/uploads/2013/03/the-quantified-self.jpg

(53)

HUG KISS

Technological

Interoperability

y

Semantic

Interoperability

y

Balancing

health / life goals

Society Incentive

Framework

Social Interoperability

the Blue Line symbol for safe trusted

connectivity

(54)

The end of the process is a Good Start for Mother and

Child , each continuing their journey with their PHR

References

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