Long Term Conditions
Delivering relevant clinical information to healthcare professionals
Challenge
Chronic disease now accounts for 78% of all spending on health care in the United
Kingdom, and this percentage will rise with an increasingly ageing population. Finding
effective ways to treat people with long term conditions, and aid self management
of Long Term Conditions, is becoming a major priority for most NHS Organisations.
The health care provision of long term conditions is often fragmented and simultaneously
managed by several specialist health services such as GPs, community services and
hospitals.
Disparate health records spread across primary, secondary and community care, contribute
to care fragmentation and inefficiency especially when it comes to developing a
structured care plan for patients. There is a real need to share appropriate clinical
information amongst health care professionals so that care planning and health surveillance
are integrated.
The NHS strategy for 2010-2015 'from good to great: preventative, people centred,
productive' highlights the importance of patient centred care, with a main priority
being to 'integrate information around the patient, deliver relevant information
at the right time to clinicians and use technology to drive efficiency for both
patients and clinicians'.
Solution
The Graphnet Long Term Conditions solution enables high quality cost effective care
for patients suffering from Diabetes, CHD, CKD, Stroke and other long term conditions.
Graphnet deliver a patient centric record for those with long term conditions which,
with consent to view, can be accessed by care professionals involved in the patients
care.
The Graphnet system pulls together clinical patient information such as letters,
notes and test results from GP encounters, A&E activity and inpatient/outpatient
activity. This information is aggregated to form a single patient record that can
be shared and accessed by care professionals across the local health economy.
The aggregation of this clinical data is key to improving care delivery, as a clinician
has access to all the information they require at the point of need and patients
have an up to date picture of their condition which aids self management.
The information collated can also be used for a wide variety of reporting and analysis,
including NSF reporting.
Key Features
- Patient Allergies
- Current Medications (Issues or repeats in the last 12 months)
- Relevant Health Issues (e.g. Long Term Conditions)
- GP contact ( in the last month)
- Clinical Letters and Discharge Summaries
- Lab Results (Eg. Pathology Results)
- Care Plans (for the last month)
- Observations and Assessments (e.g. Blood Pressure, BMI, Alcohol)
- X-rays (from the last year)
- Microbiology Results (from the last month)
Benefits
- Enables multidisciplinary and multi-location working
- Supports service delivery closer to patient
- Improves patient safety and service efficiency
- Supports call-recall for community wide programmes such as diabetes foot-care and
retinopathy screening.