Cross-sector patient and care management
The Case Management System was initiated by the HerzNetzCenter Köln (HNC) in 2011 to further implement its successful philosophy of providing a coordination and support platform to complement conventional structures. The cornerstones of this strategy and implementation are patient proximity, individualisation, regionality, transparency, sustainability and quality. With the software, patients with different clinical pictures can be guided in different models. In addition, the data of patients, clinics, specialists, general practitioners, nurses and the Medical Service Center are centrally managed and the care of patients is centrally monitored and controlled.
The HerzNetzKöln² is a cross-sectoral supply model operated by the HNC since 2007. The central approach of HerzNetzKöln² is to improve the care situation of patients with heart failure through a structured treatment concept that includes all levels of care. Within this framework the HerzNetzKöln² pursues the following goals:
- Improvement of morbidity, quality of life and prognosis
- Guidelines Adequate care
- Favouring the outpatient care level
- Interface optimisation and exploitation of synergy options through standardised supply paths
- Involving the patient as co-therapist
- Special consideration of psychosocial and socio-medical aspects
- Increase in patient satisfaction
- Efficient use of resources
The HerzNetzCenter (HNC) functions in the HerzNetzKöln² as a coordination, information and service center, which in addition to the conventional care levels, structures the care of patients and serves as a quality assurance center.
1,750 patients are currently managed in the model
At present, well over 1,500 patients with heart failure are cared for and managed in the model, which was initially deliberately limited to Cologne. At the same time, almost all of Cologne’s general practitioners and cardiologists, with over 400 practices, are involved in the model. The aim is to ensure efficiently organized and needs-based care and treatment tailored to the individual patient. For this purpose, all services, diagnoses, self-diagnoses and visit reports must be collected and evaluated centrally. In addition, it is essential to provide transparent information to all institutions involved in the model, to coordinate their activities and to record and ensure the quality of care.
The following central requirements had to be solved in strict compliance with data protection regulations:
- Central master data administration of clinic, specialist and family doctor.
- Central management of diagnostic and therapeutic process data.
- Seamless integration of the various HIS and EPA systems.
- Automated communication with the doctors.
- Flexible mobile communication and data acquisition for patients and patient service staff, as well as for model service staff.
In the CMS, all information necessary for the cross-sectoral management of the patient in the model is centrally stored and automatically evaluated. In addition to the patient data and the family doctor and specialist in charge, these are above all the results of the examinations regularly initiated by the model. Tasks are then derived from this, if necessary, which are automatically forwarded to the responsible institution (family doctor, specialist or HNK² nurse) and whose successful processing is tracked and documented in the CMS.
“A very important component of the CMS and daily tool is the documentation of the telephone calls that the HeartNet nurses make with patients. There, in addition to the patients’ subjective self-assessments, important diagnostic key parameters are recorded, which are an indispensable basis for the successful management of patients.
Connection of the medical practices
A special challenge was the connection of the medical practices to the CMS. Practices work with a wide variety of electronic patient files, which often do not allow the connection of third-party software. In addition, an Internet connection is often not used for security reasons. To solve this complex problem, a very pragmatic approach was chosen. The practices receive a small application on an encrypted USB stick, which they can use to fill out the necessary examination reports and then print them out. These printouts are then faxed to the CMS, where they are automatically processed, read in and assigned to the patient.
Case and task management with tablets
The CMS automatically assigns tasks to the service personnel and especially to the individual cardiac nurses according to the model specifications, but also individually triggered. For example, they are reminded which of their assigned patients are currently to be visited or which other care-relevant actions are to be carried out promptly. The HerzNetzSchwestern are provided with this information on their tablets on a mobile basis and can also access all important patient data online or enter the visit documentation on site. All information automatically flows back into the CMS and is stored exclusively there.
Self-monitoring of patients with digital pen
The patient plays an important role in the care concept of the HerzNetzKöln². His active and daily participation is an important component of the care. “The average age of the patients in the model is about 70 years. It is very difficult to find a suitable technique that can be accepted and operated by the patients and that reliably provides the necessary information. The choice was made in favor of a technology that Ontaris has been successfully using for years in the field of self-monitoring of patients with diabetes mellitus.
The patient writes in his paper diary as usual with a pen containing a camera. This data is then sent from the pen (EasyPen) via a mobile phone directly into the CMS.
Cross-sector patient and care management: Further information
Would you like to receive more information about Ontaris cross-sector patient and care management? Give us a call:
Stefan Orth (GF)
Phone: +49 (202) 37155-10
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