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Protocol to guide the scoping review that aims to map the evidence of spread and scale within Integrated Care.

Additional file 1.

Additional file 1 Table S1 Topics, lessons and learning objectives of the six modules. Fig. S1 Examples of the course screens. Table S2 Response to an open-ended question on what participants liked most about the course (n = 160). Table S3 Responses to an open-ended question on what participants would like to see changed in the course (n = 98).

Context: Pharmaceutical opioid (PO) use has increased four-fold in Australia with increased deaths, mostly by accidental overdose. Pharmaceutical claims showed that 10-20% of the population visited at least four prescribers or three dispensing pharmacies, or obtained at least 20 dispensing. Three (3.1%) percent of the population met all 3 criteria. Doctor-shoppers are believed to have twice the risk of drug-related mortality and opioid-related hospital admissions. Objective: To identify the demographics and drug-seeking behaviour of doctor-shoppers. Design: Identification of patients who have been prescribed at least one opioid between 2000-2017 in the data repository of the UNSW electronic Practice Based Research Network (ePBRN). The prescription strength and dose was used to calculate oral Morphine Equivalent Dose (oMED); visit information to calculate usual provider of care (UPC), Doctor Shopping Quantity (DSQ) and Doctor Shopping Indicator (DSI). Associations with demographic and clinical data of the opioid cohort were examined. Setting: SW Sydney Participants: Fourteen general practices, 200+ GPs and 60,637 active patients. Findings: A cohort of 13, 492 patients (prescribed at least one opioid between 2000-2017) was identified. There was no gender bias. Most were aged 41-70 years, followed by the 21-40 age group. A quarter of the cohort (25%) had mental health co-morbidities. Most opioid users visited only one practice, but often see different providers within the practice. Only a handful visited more than 2 practices. Values for UPC, oMED, DSQ and DSI will be discussed at the conference. Implications for practice: Observational EHR data can be used for timely identification, assessment and monitoring of selected cohorts and, in this case, associations of opioid abuse with cohort characteristics.

This poster describes the process of harmonising primary care Electronic Health Records (EHR) data by converting it into the OMOP Common Data Model (CDM). The poster discusses the advantages and disadvantages of the OMOP CDM and challenges faced during vocabulary mapping with initial results of demographics concepts mappings. This poster was presented at HIC 2018.

Disease registries derived from Electronic Health Records (EHRs) are widely used for chronic disease management (CDM). However, unlike national registries which are specialised data collections, they are usually specific to an EHR or organization such as a medical home. We approached registries from the perspective of integrated care in a health neighbourhood, considering data quality issues such as semantic interoperability (consistency), accuracy, completeness and duplication. Our proposition is that a realist ontological approach is required to systematically and accurately identify patients in an EHR or data repository of EHRs, assess intrinsic data quality and fitness for use by members of the multidisciplinary integrated care team. We report on this approach as applied to routinely collected data in an electronic practice based research network in Australia.

Introduction : Primary Health Care Limited (Primary), is an Australian corporate organisation with 71 medical centres nationally, providing primary healthcare services to 2 million patients per annum. All Primary medical centres include a range of co-located services that support a Patient Centred Medical Home (PCMH), such as GPs, Specialists, Allied Health, Pathology Collection, Diagnostic Imaging and Pharmacies onsite. Due to high patient numbers and the demands placed on the health care practitioners (HCPs) there has been a tradition of focussing on episodic care. Many Primary medical centres are located in low socioeconomic areas where patients have multiple chronic complex conditions. Episodic care fails the long term management of those patients. Short description of practice change implemented : Using Bodenheimer’s 10 building blocks of high performing primary care, and developing a PCMH model for diabetes care, Chronic Care Co-ordinators have been commenced to implement workflows and progress GP management plans and team care arrangements as well as preventative care and health coaching programs. GP small group meeting were commenced fortnightly to review the workflows, the referral programs as well as interconectivity within the centres Gps, specialists and allied health practitioners. A baseline data analysis of the completion of diabetic annual health assessments, including biometric analysis, cycles of care, GP management programs and team based programs will be reviewed on a de-identified practitioner and discussed at the GP small group meetings on a monthly basis. Education on the use of the AUSDisk audit tool for assessing the risk levels of developing diabetes in the high risk undiagnosed diabetic population. This will trigger health assessments by the CCC, as well as investigations to determine a diagnosis of current diabetes in that patient population. Interconnectivity has been provided by a Centre level Medical software solution where all health practitioners on site will have access to the documentation of any conferencing, patients notes, test results, prescriptions and external hospital or specialist reports. On the completion of the program a Patient satisfaction and GP approval assessment will be undertaken. This is a program to focus on the change management process for diabetics and pre-diabetics as well as a review of the patient outcomes within the Fairfield Centre. Aim and the theory of change : The aim is to establish a chronic care workflow protocol for diabetes care, which could be transferred to other chronic conditions presenting in Primary’s Fairfield Medical Centre. This could then be transposed into as many as possible of the 71 Primary medical centres. Targeted population and stakeholders : Initially the diabetic patients in the Fairfield Medical Centre database are targeted to identify failure to initiate comprehensive care in accordance with the Royal Australian College of General Practice (RACGP) best practice guidelines. Currently this entails 1800 patients. Thresholds for workflow referrals have been developed. Timeline : The program commenced 1st Oct 2016 and the program assessment will be completed in April 2017. Highlights : This project has supported the interconnectivity between the GPs, Specialists and Allied Health care practitioners resulting in the formation of a comprehensive PCMH Diabetes clinic in a socially disadvantaged region where healthcare traditionally has been episodic rather than part of an organised chronic care program. Conclusions: Bodenheimer’s 10 building blocks of high performing primary care has been the basis of the development of a PCMH for diabetes care at the Fairfield Medical Centre. In a clinical corporate setting, the principles of change management and interprofessional and interorganisational trust have supported the progress of this project. Discussion : Primary’s PCMH model for diabetes care has formalised a workflow and interconnectivity culture where the model can be expanded to become a generic chronic care management tool. This can be transposed into other Primary Medical Centres. Once the Fairfield program has been fully developed and implemented then a program of integrating with the local Primary Health Networks, Local Area Health and local Government Council can be commenced where life coaching, healthy life and community programs will be promoted.

Objective To identify the categories of problems with information technology (IT), which affect patient safety in general practice.Design General practitioners (GPs) reported incidents online or by telephone between May2012 and November 2013. Incidents were reviewed against an existing classification for problems associated with IT and the clinical process impacted.Participants and setting 87 GPs across Australia.Main outcome measure Types of problems,consequences and clinical processes.Results GPs reported 90 incidents involving IT which had an observable impact on the delivery of care, including actual patient harm as well as near miss events. Practice systems and medications were the most affected clinical processes. Problems with IT disrupted clinical workflow, wasted time and caused frustration.Issues with user interfaces, routine updates to software packages and drug databases, and the migration of records from one package to another generated clinical errors that were unique to IT; some could affect many patients at once. Human factors issues gave rise to some errors that have always existed with paper records but are more likely to occur and cause harm with IT. Such errors were linked to slips in concentration, multitasking, distractions and interruptions. Problems with patient identification and hybrid records generated errors that were in principle no different to paper records.Conclusions Problems associated with IT include perennial risks with paper records, but additional disruptions in workflow and hazards for patients unique to IT, occasionally affecting multiple patients. Surveillance for such hazards may have general utility, but particularly in the context of migrating historical records to new systems and software updates to existing systems. Refereed/Peer-reviewed

Background: Severe hypertension (SHT) (Blood Pressure, BP ≥ 180/110 mmHg) is associated with considerable morbidity and mortality, yet little is known about how it is managed. The purpose of this study is to examine the management of SHT by Australian general practitioners (GPs) and to explore its variance across patient characteristics and clinical practices. Conclusions: Most patients with SHT had at least one follow-up visit and 72% had initiation of, or changes to, antihypertensive drug treatment. Although most of the patients experienced some improvement, blood pressure control was poor. Some clinics showed better performance. Suggestions are made for the development of clinical standards to facilitate appropriate management of this dangerous condition. Methods: Review of electronic medical records for a year before and after a recorded measure of SHT in 7,499 patients by 436 GPs in 167 clinics throughout Australia during 2008-2009. Outcome measures included follow-up, referral, changes to antihypertensive drug treatment, and BP control (normotensive reading, BP