Introduction of the NZ Health IT Plan enables better gout management

INTRODUCTION OF THE NZ HEALTH IT PLAN ENABLES BETTER
GOUT MANAGEMENT
Reflections of an early adopter
Associate Professor Peter Gow BMedSci FAFRM FRACP
Rheumatologist, CMDHB
Chair, NICLG

Summary
 A person with gout, and the systems issues to be addressed
• Innovation is not just the use of new medicines, but
includes the better use of current medicine
 Health IT enablement
• As above, with better use of current and future IT
systems
 Successful models of improved care for patients with gout
• Without this, IT just makes bad care faster to achieve
 The CMDHB Rheumatology Department/MGAG Quality
Improvement Initiative
• There has to be a better cobweb

Gout-The Patients’ Perspective
Patient 1
“I would say it was worse than a broken bone.”
Patient 2
“When someone walks past me even the little wind will make my pain
worse.”
Patient 3
“When I do get gout there is a lot of throbbing in the area and feels like
the area which is red and hot like cooking a real hot sensation. When it
is really bad it feels like the flesh is trying to rip and going to burst my
skin because my skin is stretching too much.”
Patient 4
“I was bed-bound and dependent on my whanau. This caused a lot of
stress in my family. The pain was so bad that it destroyed me. I thought
I was going to die. I survived but it was so traumatic I asked my wife to
put a pillow over my head to kill me. Yes it was that bad.”

Try walking on this patient’s feet !

Gout in Counties Manukau
 Prevalence in primary care
• 14.9% Pacific men
• 9.3% Maori men
• 4.1% European men
• (2.0% women)
 > 200 admissions to MMH each year
 > 10000 patients in Counties Manukau
 Leading cause for new referrals to rheumatology clinic at CMDHB

Improving Long Term Conditions (Oranga Ki
Tua)-the need for a Whanau Ora approach
Ambition to Improve Quality
Where is your health system going?
Ordinary
Quality
Islands of excellence
within sea of ordinary
quality and safety
Transformed
organisation with
high levels of
quality and safety-everywhere
New islands
appear, others go,
but no overall
real change

Concern over proportion of
gout patients presenting to
hospital and GP with acute
gout attacks.
Auckland regional
clinical pathway for
gout prevention.
200 patients diagnosed with
gout were randomly chosen
from two GP centres.
1. Significant numbers of
gout patients do not get
regular urate estimations.
2. Almost half of patients
diagnosed with gout are
not on allopurinol despite
high urate levels.
1. The reasons for
suboptimal care and
solutions to the problem
have been identified
2. A campaign to improve
the health of gout
patients is in progress.
1. Re-audit after
intervention.
2. Consider applying
model to other chronic
disorders.
Set Goals &
Act
Identify
Problem
Set Standard
Evaluate
&
Measure
Identify
Re- deficiency
evaluate

Clinical Audit – Management of Gout
The Problem-recurrent pain, disability and work absence
• 54% of patients had an attack of acute gout in the previous 12 months
The Diagnosis-measure serum urate
• 27.5% of the 200 patients had not had a serum urate measurement within the
previous year.
The Solution-prescribe medication to normalise serum urate (curative)
• 51.2% of patients are currently not on allopurinol or other urate lowering
therapy (ULT).
The Result
• 70.5% of patients had a serum urate level ≥ 0.36 mmol/L.

Oranga Ki Tua Design Principles
1. Building engagement with the individual and their whānau
ensuring their aspirations remain at the centre of the
planning process
2. Ensure prevention of, and early intervention for, medical
long term conditions
3. Focus on proactive support of individuals and whānau
moving from dependency to responsibility including
building of health literacy
4. Function across agency and organisational
boundaries to promote collaboration, coordination and
integration of quality services
5. Build services that are evidence based, accountable and
responsive to emerging needs and trends
6. Support the concept that ‘any door is the right door’

Prerequisites of an effective health system
 Information
• National database (Atlas)
• PHO databases
 Infrastructure
• IT enablement (Clinical pathways/shared care/e-referrals
(messaging)/gout decision support /Health Navigator (education))
• Localities development (CMDHB), including long term
conditions/oranga ki tua
• Whanau ora
• Health literacy initiatives
 Incentives
• ARI contract/NHC FFP/ Community pharmacy contract
• National Health Targets (Diabetes/CVS/Smoking)

Knowledge management/Innovation:
Improvement programs

IT Enablement of Improved Healthcare
Atlas of variation (HQSC)
Problem identification, and quality improvement measurement
Patient Management Systems
Identification of those with specific conditions, their medications and laboratory based
outcomes
Gout Predict (Enigma)
Baseline data and decision support
Shared care repository (TestSafe)
Combined record of clinical data, including laboratory tests, imaging, pharmacy dispensing
etc
Clinical Pathways (Healthpoint, My Practice etc)
Systematic multidisciplinary management guidelines
Ambulatory Care (MedDocs etc )
Outpatient specialist advice to patients and healthcare providers
Transfer of Care (Orion Electronic Discharge Summary/e-referrals)
Coordination of care including advice to patients at hospital discharge/
Ambulatory care referrals including virtual reviews and messaging between providers
Patient information eg Health Navigator NZ [www.healthnavigator.org.nz]
Arthritis NZ[www.arthritis.org.nz]
Educational resources
Shared care plans(CCMS-HSA Global) and patient portals
Linkage of patient goals with multidisciplinary coordinated care, with direct patient input

Referrals Process
Faxed referral Electronic referral
 Referred 12/9 Referred/Logged 12/9
 Logged 15/9
 Graded 17/9
 Reviewed 24/9
 Letter to GP 26/9
 Received GP 28/9 Graded/Letter to GP 13/9
 Total delay 16 days 1 day

26
E Shared Care Snapshot
E-SHARED CARE VIEWS

Expected Benefits
• Patient involvement in planning and common plan with all
providers
• Communication improved within team (includes patient):
- Know who is doing what, when
- Common medications list, action list, problems
- “Virtual consult” request and fulfilment e.g. request for
medicines change, request for secondary consultation
- Team can be mobile, distributed, and still share

Ta Pasefika Pit Stop Programme Review
December 2010
 Enrolment of 128 clients, with an increase in rate of
enrolments since August 2010.
 A reduction in Uric Acid of 12.4% in those clients who have
completed 6 months in the programme. This is on track for
the target of a 10% reduction at one year.
 A reduction in the proportion of clients reporting time off
work due to gout from 55.6% at enrolment to 25% of those
clients who have completed an assessment at 6 months.
 An increase in the proportion of clients who have had a
cardiovascular risk assessment from 30.5% at enrolment to
88.9% at 6 months.

Gout Management at Ta Pasefika
 Group learning sessions for GPs and primary care nurses
 Development of a plan to improve gout management,
including the possibility of specialist learning clinics.
 Enrolment of appropriate patients in Healthy Eating –
Healthy Action programmes.
 Programmes to encourage cooperation with therapy
(individual and group), including education programmes.
 Chronic Care Management clinics.
 Access to more effective medication e.g. benzbromarone

100%
75%
50%
25%
0%
Urate Estimation
3 months
Urate Estimation
12 months
Normouricemia On Allopurinol /
URT
Pre
Post

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Normouricemia On allopurinol/URT
Pre
Post

350
300
250
200
150
100
50
0
Average Allopurinol dose
Pre Post
Average Allopurinol dose

Clinical
Screen
Lab
Screen
Clinical
Assessment
Specific Condition
Pathways
Outcomes
Demography (incl
genetic factors)
Lifestyle
Body size
Chronic conditions:
Diabetes
Hypertension
Ischaemic heart disease
Renal impairment
Gout
Glucose
HbA1C
Creatinine
Uric acid
CRP
Detailed history &
examination
CVS risk factor
score
Diabetes pathways/guidelines
CVS pathways/CHF
guidelines/shared care plans
Chronic kidney disease
pathway/guidelines
Gout pathway/guidelines/shared
care plans
Generic Lifestyle Programme
Smoking cessation
Exercise
Nutrition (including lower sugar/fructose)
Health literacy
Employment
Shared care plans
Whanau ora
Risk & Whanau Ora
assessment
Self/family management
Improved
patient care
Reduced
inequality
Reduced
hospitalisation
IT Enabled Metabolic Syndrome Best Practice
Lipids
Plus
Plus
Reduced
demand on
outpatient
clinics
Strength-based goals
ACR (Urine)

Guidelines for Use of Care Plan Headings
 The care plan will be determined by the patient
goal(s)
 Clinicians may not need to use all the headings
 Clinicians, in partnership with patients and their
whanau, should prioritise the headings so that the
most important appear at the top of the list

Care Plan Headings
 About me
• Where the patient can write anything they would like other people to know about
themselves
 Things that my care team will do
• Any action that a health professional needs to do
 Things I will do
• Any action a patient/caregiver takes to manage their own health
 Medication
• Please document any identified issues with medication
 Daily life
• Consider aspect where the patient where the patient may require further assessment or
support for them to complete their daily activities
 Lifestyle
• Any statements or concerns regarding general aspects of the patients life
 Social and mental wellbeing
• Any social, emotional, cultural or spiritual issues impacting on current health issues
 Advance Care Planning (ACP)

Management of Gout- Urate <0.36
Decrease number and severity of acute attacks
Reduce damage to joints
Reduce damage to kidneys
Reduce cardiovascular risk (stroke, heart attacks
and death)
Improve whanau ora

6. Communication
5.
Access and
Navigation
1.
Leadership
and
Management
4.
Meeting needs
of population
2.
Consumer
involvement
Health
literate
organisation
3.
Workforce

How “industrial age medicine” will invert to become “information age
healthcare” (reproduced with permission from Jennings, Miller, and
Materna)1.
Smith R BMJ 1997;314:1495
©1997 by British Medical Journal Publishing Group

Introduction of the NZ Health IT Plan enables better gout management

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Introduction of the NZ Health IT Plan enables better gout management