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Acute Care Management
For patients with Diabetes and CKD, complications that may lead to hospital admissions can occur. In Reality Apps, we can track acute admissions and use algorithms to detect Acute Kidney injury. These patients will be marked and alerted to linked staff members using ToDo:
- Diabetic emergencies and hospital admissions tracked via our app theMAP
- CKD patients with AKI/Nephrotic Syndrome automatically changed to AKI modality
- Chronic patients with end-organ emergencies
- AKI and Acutes as a subgroup classification
- Alerts/Acutes linked associated Staff ToDo list via our Task Manager tool
.jpeg "Add more action plans to the CarePlan algorithms to guide care workers")
Task Manager: the ToDo list
As part of the "vertical integration" of our processes that starts with checking bloods and algorithm-driven alerts until the patient is seen again - the staff linked to each patient should be an integral part of the ownership and accountability model we are rolling out in 2023:
- Staff use REMINDERS for themself and staff
- Referrals to other services for patients
- Alerts and Appointments from CarePlans
- Messages intended for patients can be sent
- Closing the loop through check-box/comments
- Auto-escalation from team to group/center level
Optimum Scheduled Care
Using a patient TRAFFIC reporting tool where individualized care plans are used to direct patients to the correct person, place, and time. Based on the color-coded alert and time frame generated by algorithms - Reality Apps will have up-to-date patient lists to guide users:
- Each patient got a well-defined time-frame and service to be seen
- These reports can be updated every 20 mins
- Booking services time frame to do scheduling
- SimcartRosters, our scheduling software, can match capacity
- The level of service contact can be granulated to match demand
.jpeg "Run more frequent Eclair runs to efficiently update of resu")
Data Form management
Structured data entry (SDE) is a data entry method that interacts with pre-defined forms. Compared with free text data entry, SDE can constrain clinical data entry behavior and improve data quality, readability, etc. To improve this feature in 2023, we are planning to roll out the following:
- Standardized Social assessment forms for Diabetes and CKD
- Refine forms for Kaitautoko Mate Huka services
- Create a ListView feature for forms with critical data tracking
- Printing of blank and completed Forms for paper-based use
- Track progress variables to the Dashboard Grids and Reports
- Edit and Delete FORMS for observations like BP and Social risk in Background details
.jpeg "Create patient lists specific to each user")
User and staff management
With over 100 hundred users, we are introducing a 2-tier user and persons section to categorize users better. This will also allow notices and links to be done at a primary and secondary level.
- CASELOADS are defined by associated staff/users in groups
- Posting reminders, notes, and tasks in groups/individuals
- Access rights defined in Admin, Edit, and View only users
- Audits/Searches can then be done at primary and secondary levels
- Roles of users and persons can be more descriptive
- Reporting tools and patient lists as a group
.jpeg "Using present forms to enter data additional to the menutree")
Improved Entering of events/links
Other than following a menu tree and entering one clinical event at a time, you can now enter events using FORMS. Data that comes in other formats can now be uploaded using File Attachments. You also got more Quicklinks customized to your renal unit requirements
- Bulk entering/upload of patient associations
- Bulk removal and re-allocation of patients
- Entering the same events against patient lists
- Edit/enter in pop-up boxes
- Click and pop-up Grid Variables
- Update Cause of DM = Diabetes Mellitus as an ongoing algorithm for HbA1c>64 in the CKD group.
- Auto-clustering according to GP/Domicile code using the DM cluster code/Xcel files
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additional tools for users in 2023 - planned release december 2023
SEARCH / Audits
- To enhance the user experience and provide more clinical utility, we have implemented the following improvements:
- Date Range Optimization: We have narrowed the date range and repositioned the SEARCH button in closer proximity to the date range input. This streamlines the process of specifying date parameters and initiating searches, making it more efficient for users to retrieve relevant data.
- Event-Rate Algorithms: Our system now incorporates event-rate algorithms, allowing users to monitor specific clinical events, such as the rate of infections in vascular access across different modalities. This feature provides valuable insights into the occurrence and trends of these critical events, aiding in proactive intervention and management.
- Monthly Reporting: We have integrated monthly reporting capabilities directly into dashboards and patient grids. This ensures that healthcare providers can easily access and track essential data on a regular basis, facilitating informed decision-making and continuous monitoring of patient progress.
- Variable Integration: Important variables from FORMS are seamlessly integrated into patient grids and reports. This integration enhances the clinical utility of our system, enabling users to analyze and correlate variables efficiently for comprehensive patient assessments.
- Quick Links: Quick links to Kaitautoko Mate Huka and Social Services have been added, simplifying access to these critical support services. This streamlines the process of connecting patients with the necessary resources to address their specific needs, whether related to diabetes care or social support.
- Health Indicator Reporting: Our reporting tool now encompasses a wide range of health indicators, including physical and mental health assessments, as well as transplant workup data for both donors and recipients. These comprehensive health indicators provide a holistic view of patient health status and transplant-related assessments, aiding in comprehensive patient care.
- These enhancements collectively contribute to a more clinically robust and user-friendly system, empowering healthcare providers with the tools and insights needed to deliver high-quality care and closely monitor patient health and outcomes.
MoH Diabetes Care KPIs
- We are committed to rigorously monitoring the Quality Standards for Diabetes Care outlined in the 2020 guidelines. This monitoring will take place on an annual or monthly basis and encompasses various critical aspects of diabetes care, including:
- Primary Care, Self-Management, and Education: This involves ensuring that patients in primary care settings receive the appropriate care, guidance for self-management, and access to educational resources to effectively manage their diabetes.
- Management of Diabetes and Cardiovascular Risk: We focus on comprehensive management strategies for diabetes that also address associated cardiovascular risk factors, which are crucial for patient health.
- Management of Diabetes Complications: Our approach involves adhering to extensive guidelines for managing diabetes-related complications. These guidelines provide a structured framework for delivering the best possible care.
- In-Hospital Care for Diabetes Emergencies: In cases where patients require hospitalization due to diabetes emergencies, our healthcare providers are equipped to deliver specialized care tailored to the specific needs of these situations.
- Particular Groups of Diabetes Patients: We recognize that different groups of diabetes patients may have unique requirements. Our care approach is designed to cater to these specific needs.
- Delivery of Systematic, High-Quality Diabetes Care: We are committed to consistently delivering diabetes care of the highest quality, following systematic protocols and best practices.
- To ensure the effective tracking of these Key Performance Indicators (KPIs), we integrate them into the patient dashboard. This approach allows healthcare providers to have a clinical, real-time view of patient progress and adherence to the Quality Standards for Diabetes Care, enabling prompt interventions and the delivery of optimal care.
PowerBI dasboards
We will actively monitor the Quality Standards for Diabetes Care in 2020 on an annual or monthly basis. These standards encompass various aspects of diabetes care, including:
Primary Care, Self-Management, and Education: Ensuring that patients receive appropriate primary care, engage in effective self-management, and have access to educational resources.
Management of Diabetes and Cardiovascular Risk: Managing both diabetes and the associated cardiovascular risk factors comprehensively.
Management of Diabetes Complications: Implementing extensive guidelines for the management of diabetes-related complications.
In-Hospital Care for Diabetes Emergencies: Providing specialized care when patients with diabetes require hospitalization for emergencies.
Special Groups of Diabetes Patients: Addressing the unique needs of special groups within the diabetic patient population.
Delivery of Systematic, High-Quality Diabetes Care: Ensuring the consistent and high-quality delivery of diabetes care.
To facilitate monitoring and assessment, our service offers interactive filters that allow users to observe and track changes and the impact of interventions in real-time. Our dashboards provide access to this information in a dynamic and immediate manner, enabling healthcare professionals to make data-driven decisions and uphold the standards of diabetes care effectively.
Primary Care, Self-Management, and Education: Ensuring that patients receive appropriate primary care, engage in effective self-management, and have access to educational resources.
Management of Diabetes and Cardiovascular Risk: Managing both diabetes and the associated cardiovascular risk factors comprehensively.
Management of Diabetes Complications: Implementing extensive guidelines for the management of diabetes-related complications.
In-Hospital Care for Diabetes Emergencies: Providing specialized care when patients with diabetes require hospitalization for emergencies.
Special Groups of Diabetes Patients: Addressing the unique needs of special groups within the diabetic patient population.
Delivery of Systematic, High-Quality Diabetes Care: Ensuring the consistent and high-quality delivery of diabetes care.
To facilitate monitoring and assessment, our service offers interactive filters that allow users to observe and track changes and the impact of interventions in real-time. Our dashboards provide access to this information in a dynamic and immediate manner, enabling healthcare professionals to make data-driven decisions and uphold the standards of diabetes care effectively.
Patient App: HealthCart
Patient-Centered Medical Applications (Apps) have emerged as invaluable tools in enhancing routine healthcare and fostering ongoing communication between patients and healthcare providers.
Automated Health Data Collection: Patients can conveniently and accurately collect their health data using these apps. This includes vital signs, medication adherence, blood glucose levels, and other relevant health metrics. This automated data collection reduces the risk of manual errors and ensures healthcare providers have access to real-time, reliable patient information.
Telemedicine Integration: The apps seamlessly integrate telemedicine services, enabling patients to connect with healthcare professionals remotely. This facilitates virtual consultations, check-ins, and follow-ups, which is particularly valuable in chronic disease management. Patients can receive timely guidance and adjustments to their care plans without the need for in-person visits.
Improved Health Outcomes: Algorithm-driven care plans, embedded within the apps, empower patients with personalized care strategies. These algorithms analyze patient data and provide tailored recommendations for managing chronic conditions like diabetes and chronic kidney disease. This individualized approach can lead to improved health outcomes by optimizing treatment plans and interventions.
Color-Coded Alerts: The inclusion of color-coded alerts within the apps serves as a visual aid to highlight critical health indicators and potential issues. Patients can quickly identify areas of concern, such as abnormal readings or medication non-compliance, and take appropriate actions. Healthcare providers can also use these alerts to prioritize patient care.
Patient Empowerment: The apps empower patients to take ownership of their chronic disease management. By providing easy access to their health data, care plans, and educational resources, patients are better equipped to make informed decisions about their health. This proactive involvement can lead to enhanced self-management and adherence to treatment regimens.
Patient-Centric Data: These apps pivot the focus of healthcare data towards a patient-centric model. Patient-generated data becomes central to the care process, enabling healthcare providers to tailor interventions, track progress, and make adjustments based on the patient's unique needs and preferences.
In essence, these medical apps usher in a new era of patient-centered care, where individuals actively participate in managing their chronic conditions. They bridge the gap between patients and healthcare providers, fostering continuous communication and collaboration for improved health outcomes.
Automated Health Data Collection: Patients can conveniently and accurately collect their health data using these apps. This includes vital signs, medication adherence, blood glucose levels, and other relevant health metrics. This automated data collection reduces the risk of manual errors and ensures healthcare providers have access to real-time, reliable patient information.
Telemedicine Integration: The apps seamlessly integrate telemedicine services, enabling patients to connect with healthcare professionals remotely. This facilitates virtual consultations, check-ins, and follow-ups, which is particularly valuable in chronic disease management. Patients can receive timely guidance and adjustments to their care plans without the need for in-person visits.
Improved Health Outcomes: Algorithm-driven care plans, embedded within the apps, empower patients with personalized care strategies. These algorithms analyze patient data and provide tailored recommendations for managing chronic conditions like diabetes and chronic kidney disease. This individualized approach can lead to improved health outcomes by optimizing treatment plans and interventions.
Color-Coded Alerts: The inclusion of color-coded alerts within the apps serves as a visual aid to highlight critical health indicators and potential issues. Patients can quickly identify areas of concern, such as abnormal readings or medication non-compliance, and take appropriate actions. Healthcare providers can also use these alerts to prioritize patient care.
Patient Empowerment: The apps empower patients to take ownership of their chronic disease management. By providing easy access to their health data, care plans, and educational resources, patients are better equipped to make informed decisions about their health. This proactive involvement can lead to enhanced self-management and adherence to treatment regimens.
Patient-Centric Data: These apps pivot the focus of healthcare data towards a patient-centric model. Patient-generated data becomes central to the care process, enabling healthcare providers to tailor interventions, track progress, and make adjustments based on the patient's unique needs and preferences.
In essence, these medical apps usher in a new era of patient-centered care, where individuals actively participate in managing their chronic conditions. They bridge the gap between patients and healthcare providers, fostering continuous communication and collaboration for improved health outcomes.
RENAL REALITY UPGRADES IN VERSION 2.7.1 - RELEASED 1 APRIL 2023
eGFR is now auto-calculated using the CKD-EPI formula.
Change in Renal Modality (PD/HD) is only possible with the correct type of Dialysis Access in place.
On HD patient lists, eGFR will be replaced with URR (the last one from the previous six months) - if no URR is done, it will show "No URR."
"Transplant failed" is now a trigger on the Transplant update status bar.
The total number of patients per Renal modality is now showing in the top row - this replaces the RED number, which refers to the number of Red alerts per Renal Modality.
Corrected Calcium is now auto-calculated and displayed on grids of patient dashboards.
HD history and scripts can now be viewed as pop-ups. HD sessions can also now be considered in LIST mode - to allow clinicians to look at a complete list of HD sessions and summary/comment on valuable changes.
Transplant recipient and donor assessment forms are now added to the Forms sections. A progress percentage will be made visible on the patient dashboard as per the Transplant status - with options to pop-up view these forms as an overlay on the patient dashboard.
URR calculations under 10% will now be discarded. This happens when patients in acute settings get multiple Urea values from the lab.
Toxicology results are now visible for non-Transplant patients on immunosuppression for other reasons, such as Lupus nephritis.
Text-based results, like CAPD fluid results and Radiology - will be added to our data import in version 2.7.5
Updated Cause of CKD as per ANZDATA 2023 list.
PD review drop-down menu list updated.
Second-layer definition of Medication list -which will allow users to search medications via their class of drug, but also allow auditing and reports based on the type of drug - ie, ACEi use in Diabetics in version 2.7.5
Replace Weekly Kt/v on the PD patient list (in place of eGFR on the dashboard) in version 2.7.5
Prescribing safety and meeting MoH guidelines for electronic signing of scripts
One-off prescribing in addition to long-term medica
tion scripts
Reality apps upgrades version 2.7.2 - planned release jan 2024
The medication Tab was refined to allow edits/updates by verified users.
The clinical event Search feature can now be done at the Primary Menu-item level, and the default date Search has been reduced to 1 week.
The list of Clinical events was enhanced to show more details, and expanded the Menu-item tree with comments.
All Filters now default to "Contains" as the assisting tool for users looking for clinical events and notes in patient lists.
Heading under REPORTS now includes the Clinical variable and means as part of the top-row titles.
Primary roles of users will remain free-text to allow flexibility to Admin users to allocate any new roles required.
We will add urine PCR/ACR values to the CarePlans report - so that users can see HbA1c, eGFR, demographics, alerts, and urine analysis all on one page/view/list of patients- version 2.7.3
Biometrics like Blood pressure, weight, and BMI are to be shown as pop-ups with the option to edit too for new values.
All QuickLink entries can now be used as a Pop-up feature. This will allow users to interact with the patient dashboard whilst entering new data like clinical notes and medications.
In our Cloud-based version, users will be able to enter events against multiple patient lists/checked-boxed patients - useful in a situation like Covid - where we can update multiple patients at the same time.
Templated Free-text boxes that the user can maintain/edit locally will be available in our Cloud-based version by the end of 2023.
Activates theMAP (tracking acute admissions to hospitals), which will allow us to add Acute Admissions and Alerts as Events in all patients in The Reality apps database. - planned in our Cloud version end of 2023.
Photo IDs of staff and patients will be added to our Cloud app and released end of 2023.
Conversion of Domicile codes into actual patient location, which in turn can then be used to show mon patient dashboard next to their other demographics.
Audit trail of clinical events upgraded to include the action of users when data changed, ie Deleted, created, edited, etc.
View-only mode will be available in our Cloud version - this will allow other clinical staff to at least view renal and diabetes dashboards without the ability to edit/change until they are valid edit/admin users.
Cloud app: Create an AKI modality (Allocation) from the eGFR Red Alert change that is linked to the associated staff member/physician
DIABETES REALITY IN VERSION 2.7.3 - planned RELEASE april 2024
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Primary roles of users will remain free text to allow flexibility to Admin users to allocate any new roles required.
DM and CKD Careplan summary includes a Color-coded alert now visible from the Diabetes Main page. This will allow the addition of Google Calendar and Maps widgets when we Cloud-based.
Text-based results, like Radiology - will be added to our data import.
Add GP details to our data import - this will allow auto-clustering of patients at the point of import and our ability to add GP details to clinic letters.
Conversion of Domicile code into actual patient location, which can then be used to display patients lists on Google Maps on our Cloud version.
We replaced Bicarbonate with random/POC Glucose levels on the DM dashboard and Add Reports (Activities with DM All headings).
Adding the Medical Notes section to the DM view will allow non-prescribing users to edit still/update medication notes.
Add LTC nurses (Ngati Ruanui LTC. Tui Ora LTC, Ngaruahine LTC) under CaseLoads and Persons.
List view on all forms, i.e., KHM goals and Foot protection services.
Created a Quick screening form for Foot protection services - a form that anyone can use before referral to a Podiatrist or for routine screening of patients with DM and CKD.
Admin level change of patient clusters, both at the individual patient level but also as part of multi-patient list entry (Bulk-entries).
Second-layer definition of the Medication list will allow users to search medications via their class of drug but also allow auditing and reports based on the type of drug - i.e., ACEi use in Diabetics.
Cloud app: Create a DM Acute Admission modality (Allocation) from theMAP linked to the associated staff member/physician and their caseload.
the concepts of chronic disease management at simcart
.png "Shared ownership with the patient")
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