Sharing Excellence
Prompt - Online Evidence-based Guidelines for Cardiovascular Disease
ProCare Health Limited
Cardiovascular disease is the single largest cause of death throughout the world. Yet it is often difficult for GPs to know what the best possible care option for every patient is. Prompt replaces growing volumes of paper-based guidelines and adds value by providing on-the-spot responses during patient consultations and statistical data for profiling the big picture. The clinical and technical teams have not only ensured that this decision support tool is robust, but have agreed that the clinical content will be placed in the public domain and some technical protocols will be published.
About ProCare
ProCare is a Primary Health Organisation (PHO). With 370 GP members representing about 200 medical practices, ProCare is one of New Zealand’s largest PHOs, looking after the health needs of almost 600,000 Aucklanders. It is actually a combination of four individual groups - two in South Auckland, one in central Auckland and one covering the north and west - corresponding to the areas covered by Auckland’s District Health Boards.
| Prompt is used to manage a patient’s
cardiovascular risk |
What were the needs?
Auckland-based ProCare Health Ltd has half a million registered patients. Of these, four to five thousand will have a significant cardiovascular disease event this year. Comparing this with diabetes deaths, suicide, and breast and cervical cancer registrations combined, a cardiovascular disease event is about 10 times more likely.
Cardiovascular disease is a blanket term for a number of afflictions of the heart and blood vessels of the body, including coronary heart disease, angina and stroke. The disease affects the heart or blood vessels by restricting the flow of blood. This occurs when a build-up of cells, fat and cholesterol clogs the arteries, impeding the free flow of blood. Over time the blood vessels become blocked, and a heart attack or stroke can occur.
Even though cardiovascular disease accounts for the single largest cause of death, GPs say they are not sure what the best possible treatment option is, and which patients most need it. Yet evidence suggests that for every 20 patients treated, one premature cardiovascular event can be prevented over a five-year period.
GPs have shelves groaning with paper-based guidelines, and nine more new guidelines for cardiovascular management will be released over the next 12 months. ProCare’s information systems manager Ken Leech claims it is impossible for GPs to stay up to date. ‘Accurate and consistent risk assessments will remain difficult’, he continues, ‘unless automated tools are made available’.
How the needs were met
ProCare and its partners – including The University of Auckland, Health Technology and Enigma Publishing – decided to design an Internet-based decision-support tool called Prompt to help screen patients for cardiovascular risk and then manage the risk. Prompt delivers the latest evidence-based guidelines tailored specifically for the patient at the time of consultation. GPs can ensure that the best possible evidence is used to manage the risk.
GPs will benefit from having more time during patient consultations, the capacity to apply consistent and comprehensive treatment, and the ability to model ‘what if ’ scenarios with their patients. Finally, the health system should benefit from better targeting of treatment and health promotion, a reduction in the number of cardiovascular events, and a reduction in the total cost of patient care.
Prompt also helps to improve ProCare’s understanding of:
- barriers to the acceptance of new technology by GPs
- the applicability of decision-support tools
- issues around the integration of central services with distributed practice management systems
- issues around getting agreement from large groups of clinicians about the most appropriate ways of managing disease.
Prompt links data on patient profiles, risks, management and outcomes, and provides feedback and support planning. It also enables the collection of information for statistical purposes that may allow New Zealand to build its own risk model for cardiovascular disease, particularly for Maori and Pacific patients.
What are the expected health outcomes?
Leech asserts that patients will benefit because they will avoid unnecessary treatment, and the probability of early detection and treatment where the risk is high will increase. Evidence suggests there will be significant patient benefits from screening patients, and then managing those who are at high risk of cardiovascular disease.
What technology was used?
The system brings together secure Internet technology and practice management system applications using XML communications protocols – a critical ingredient in peer-to-peer information-sharing schemes that makes data digestible no matter what type of computer or other device people use. It allows practice management systems to integrate with a central server in a way that makes access to Prompt seamless for the GP.
The service can be provided through a virtual private network – a way to use the Internet to provide remote offices or individual users with secure access to their organisation’s network.
This central server approach is an advantage over similar tools within a local practice. It is independent from any particular practice management system, so the rules that determine the most appropriate disease management recommendations are defined and maintained centrally and consistently. In addition, the central server approach enables the use of resources such as other systems, large databases and faster processors that may not be easily implemented in local practices.
How policies served the project
ProCare designed its system to be consistent with national policies. The WAVE report has contributed to its development, particularly regarding integration and gathering primary care information.
However, Leech asserts that more can be done to develop standards for electronic guidelines and interfaces. ProCare has agreed that the clinical content within the decision-support tool will be in the public domain and the XML protocols will be published.
Some critical issues and how they were managed
Involvement of, and acceptance by, key stakeholders
The involvement of key stakeholders including GPs, the National Heart Foundation, the New Zealand Guidelines Group, the University of Auckland and others was critical, and has contributed to the clinical information and technological quality. The communication among ProCare’s registered GPs was vital to ensure their uptake and support. They needed to be assured of technical safety when using the Internet, and of privacy matters. No identifiable information about a patient is stored on the server, and information such as National Health Index (NHI) numbers are encrypted, preventing anyone from identifying a patient.
It is also important to ensure good clinical support, and that the information is clinically robust and has a sound evidence base. | Dr Dean MacKay discusses Prompt findings with patient Kristine Reid |
Reaching patients most at risk
The overall objective of the project is to ensure that treatment for cardiovascular risk is directed to the patients that are most at risk. ProCare has had to communicate the benefits to GPs and explain that there will be an additional workload as more complete information will be required. It stresses, however, that it will hopefully add significant value to the management of their patients by:
- increasing the number of patients treated for cardiovascular risk
- reducing the number of premature cardiovascular events
- refining the cardiovascular risk assessment model
- building an infrastructure that provides for additional services to be added later.
What lessons were learned?
The project team advise:
- Identify possible barriers to acceptance by GPs early and ensure communication is ongoing and clear.
- Alleviate concerns about technical safety and privacy when connected via the Internet by ensuring the technical solutions are robust and safe. Communicate this to the users.
- The workload for GPs increases when the collection of outdated or missing additional information about the patient is required by a new system. It is important to communicate the benefits to these users.
What were the costs of the project?
The investment by ProCare so far is $0.3 million. There are significant costs for a GP to access the server, most notably the cost of connecting to the Internet via a high-speed connection.
ProCare has taken the cost burden into account by subsidising the cost of connecting to the Internet and remunerating GPs for the additional effort required to assess the patient for cardiovascular risk.
How transferable is the project?
Prompt is designed for widespread use by any organisation. The practice management system chosen to work alongside Prompt is currently used by 70 percent of GPs in New Zealand. There are plans to provide access from other practice management systems.
Where to next?
The initial scope of the project is constrained to the assessment of cardiovascular risk. The system has scope for additional services in the future, including disease management modules for chronic conditions such as diabetes, need assessment modules, and access to referred services.
Leech concludes that ProCare’s desire for the future is that Prompt is the beginning, not the end, and reiterates that they foresee that a wide range of diseases can be supported using this tool.
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General Practioners regularly screen patients for cardiovascular diseases | |
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