Integrated Care 

Ocean's Integrated Care application, known as LinkedEHR, is a comprehensive tool that connects patients with their carers across a continuum of care – from the community to the hospital - underpinned by a comprehensive care planning tool.

Built in partnership with Western Sydney Primary Health Network (WentWest), LinkedEHR provides a single, dynamic shared care plan that is accessible by the entire care team.  It enables General Practitioners, allied health providers, specialists and hospital-based clinicians insight to the complete range of care activities that are planned or being carried out for their most complex patients as they move between each participating healthcare provider.  

In most clinical situations, the patient's usual GP creates a care plan, based on national best practice and evidence-based care pathways. The care plan is a transparent way to coordinate and integrate care amongst a group of healthcare providers with different skills and in a viariety of locations, to ensure that all identified care requirements for the patient are delivered. The patient themselves is critical to this approach - they have access to their own online care plan and associated health record through a web portal or mobile apps.  Over time, as the patient interacts with their care providers, the care plan is updated and effectively becomes a single living, breathing view of the patient's care status - the whole care team is aware of every aspect of the patient’s care and are working together to optimise care outcomes.

LinkedEHR meets the Healthcare Homes (Integrated Health) Minimum Criteria

  • Create, view and change a shared care plan in real time.
  • Create a shared care plan which includes core elements required to coordinate chronic disease care, including:
    • target goals and, if appropriate, measurable success criteria for each goal
    • activities and timeframes to achieve each goal
    • roles and responsibilities of members of the care team in order to help achieve goals
    • care plan conditions, i.e., clinical reasons or concerns for the care plan, including comorbidities
    • the ability to review the status of a care share plan.
  • Give patients and external healthcare providers access to view the entire shared care plan. Health Care Homes will also be able to assign role-based permissions that allow patients and external healthcare providers to edit and upload to specific elements of the plan. Patients and external healthcare providers should have access to the shared care plan in real time via a web portal (optional apps/programs are also appropriate).
  • Send patients and providers reminders and notifications regarding follow-up referrals or reviews of specific goals.
  • Audit and track the creation and modification of each care plan goal; and review the progress of each goal.
  • Track usage, reviews of shared care plans and clinical metrics over time.
  • Extract data from existing clinical management systems to produce a shared care plan.
  • Secure all information so that the privacy of patients is maintained. Controls allow access to authorised persons only. The creation, deletion and accessing of clinical information and documentation can be tracked to individual users.
  • Access vendor support and training for the practice.
Healthcare Homes RequirementCriteriaLinkedEHR Complies
A central element of Health Care Homes is shared care planning.    
A shared care plan is designed to:    
 
  • Get patients more involved in their own care
 
  • Improve the coordination of the services they receive inside and outside the Health Care Home.
 
  • Together, the patient and the care team at the Health Care Home will develop and use a shared care plan.
 
  • All Health Care Home patients must have a shared care plan that can be shared electronically between health care providers.
Principles for developing a shared care plan    
 
  • Patients agree to develop a shared care plan and agree to share their records with their care team.
 
  • A patient’s privacy is maintained to the highest standard.
 
  • Robust processes ensure that information is always added to the correct patient’s record.
 
  • Vendors commit to integrating shared care plan software as far as possible with the My Health Record system.
 
  • If care pathways are available, they are considered when the shared care plan is being developed.
Minimum requirements for shared care planning software    
Many practices and ACCHS around Australia are already using shared care planning tools.    
The department has developed a set of minimum requirements for shared care planning software for stage one.    
Health Care Homes can choose any software program that allows them to:    
 
  • Create, view and change a shared care plan in real time.
 
  • Create a shared care plan which includes core elements required to coordinate chronic disease care, including:
    • Target goals and, if appropriate, measurable success criteria for each goal
    • Activities and timeframes to achieve each goal
    • Roles and responsibilities of members of the care team in order to help achieve goals
    • Care plan conditions, i.e., clinical reasons or concerns for the care plan, including comorbidities
    • The ability to review the status of a care share plan.
 
  • Give patients and external healthcare providers access to view the entire shared care plan.
 
  • Health Care Homes will also be able to assign role-based permissions that allow patients and external healthcare providers to edit and upload to specific elements of the plan.
 
  • Patients and external healthcare providers should have access to the shared care plan in real time via a web portal (optional apps/programs are also appropriate).
 
  • Send patients and providers reminders and notifications regarding follow-up referrals or reviews of specific goals.
 
  • Audit and track the creation and modification of each care plan goal; and review the progress of each goal.
 
  • Track usage, reviews of shared care plans and clinical metrics over time.
 
  • Extract data from existing clinical management systems to produce a shared care plan.
 
  • Secure all information so that the privacy of patients is maintained. Controls allow access to authorised persons only. The creation, deletion and accessing of clinical information and documentation can be tracked to individual users.
 
  • Access vendor support and training for the practice.

 

Benefits

The Patient at the Centre

Research shows that when patients are included in their care plan and are part of their own care team, health outcomes are better and targets are more likely to be met.

General Practitioner-friendly

Care planning begins with the patient's usual GP and is designed to help them create comprehensive, cohesive and evidence-based care plans, without disrupting their normal clinical workflow.  GPs enjoy the benefits of being able to easily refer to other care team members and get notified of referral acceptances and any changes to care activities that occur.

Multidisciplinary approach

In most health environments today, clinicians find that patient information is not easily shared as patients move between different parts of the health system. This leads to wastage of healthcare resources and often there is also poorer outcomes for patients.  Ocean's online Care Planning tool enables GPs to create a care team that is tailored to a patient’s specific needs and allows that care team to coordinate easily and communicate effectively - wherever they are - enabling the streamlined sharing of information at every important step.

Based on a shared electronic health record

Ocean Care Planning is built upon the OceanEHR platform - an open, standards-based electronic health record which provides high-availability and high-scaleability. OceanEHR has built-in security, privacy and integration functions and is able to be rapidly deployed to cloud or local servers, plus is easily customised to meet individual requirements.

 

Key Features

  • Integration - Seamlessly integrates with GP and other community systems to enable clinicians to efficiently coordinate care of their patients.
  • Mobile connectivity - Mobile phone and tablets connect to enable clinicians and patients to view and update the care plan wherever they are.
  • Shared Care Plan - Enables clinicians to create a single, best practice care plan for their patients with one click. The ability to easily request that other clinicians become part of the care team is an added benefit. All the care team can see and be notified of changes and updates to the care plan as they happen.
  • Security and Privacy - All privacy and security features are built-in, so that only those providers who should have access to a patient’s record, do have access.
  • MyHealthRecord - Seamlessly connected to the Australia's national My Health Record to enable viewing of all documents that have been uploaded there.