Chronic disease coordinated care planning: flexible, task-centered decision support

SA HealthPlus is a trial of coordinated care enrolling 4000 high use patients in South Australia in ten groups including diabetes, cardiac, aged care and lung disease. These patients each have a designated general practitioner (GP) care coordinator who formulates an individualised care plan designed to keep them as healthy as possible. An online interface to SA HealthPlus has been developed for the care coordinators. The Care Plan On-Line (CPOL) system provides a single coherent source whereby the GP can review the available information on a HealthPlus patient in the context of devising a care plan of prospective services and medications. In the same application environment CPOL provides access to care guidelines tailored for SA HealthPlus. The guidelines are linked to the HealthPlus services and to key clinical observations (e.g., blood pressure, cholesterol, weight). The system graphically flags services and observation when it reasons that the GP should consider the relevant guideline. CPOL provides a consistent interface across the various chronic disease classes, rather than several disease-specific decision support systems. This is especially important in light of the many complex patients with multiple major diseases and the fact that GPs need to deal with a range of illnesses. The system architecture provides separation of guideline knowledge and database resources from the user interface itself, while maintaining a coherent face to the user, resulting in system that is cohesive but also modifiable and expandable.