Integrated management programs for chronic disease; the role of ICT

1. Integrated management programs for chronic disease; the role of ICT M. Hollander, MD, PhD, Julius Health Centers, Utrecht, The Netherlands D. van Dijk, PT. Product Manager CHM, VitalHealth Software, Ede, The Netherlands N.J.de Wit,MD, PhD, Julius Center for Health Sciences and Primary Care, UMC Utrecht, The Netherlands

2. Developments in primary care • Aging population (in 2040 25% > 65 years) • Increasing prevalence of chronic disease (2/3 of elderly has >1 chronic disease) • Disease management programs for chronic conditions

3. Developments in primary care • Substitution in chronic disease management from secondary to primary care • Delegation of care to nurse practitioner

4. Disease management programs (DMP) in Primary care • Diabetes Mellitus • COPD • Cardiovascular Risk Management • Mental health (stepped care) • Elderly care

5. “Traditional” role of ICT in Primary Care • Registration system for GP • Subjective, Objective, Evaluation (ICPC) and Plan • Anamnestic and diagnostic data • ICT based Information resources

6. “Advanced “role of ICT Improvedlogisticsandcommunication High qualitypatientinformationsources Self management programs Service improvement (E consultationand E prescription) ICT baseddisease management programs Future: Advanced medicaldecision support ?

7. Mission: Population oriented multidisciplinary primary health care Academic primary care; research and education integrated in routine care Laboratory environment for health care innovation Julius Health Centers Leidsche Rijn

8. Julius Health Centers Leidsche Rijn • 4 multidisciplinary health centers in Leidsche Rijn, Utrecht, The Netherlands • Academic primary care practice from UMC Utrecht • 90 professionals, 34.000 patients • 6 specially trained GP specialists • Disease-management programs for CVRM, DM, COPD, mental health and prevention

9. Chronicdisease management Julius Health Centers; background • Integrated disease management programs • Collaboration with all professionals involved • Financial support by insurance company

10. Chronicdisease management Julius Health Centers; background • Internal coordination by GP specialist • Information on comordidity, medication and lifestyle factors • ICT support by Health Management system (VitalHealth Software)

11. ICT in LRJG: exchange between systems GP-EMR CHM SSO Paramedics Medical specialists Patients exchange

12. Diabetes

13. Cardiovascular risk management

14. Decision-support

15. DMP integration

16. Referral

17. ICT supported DMP: Advantages • Multidisciplinairy network approach • Process- and decision support and workflow management • Regular reports to ensure transparency of care • Overview of relevant comorbid disease

18. ICT supported DMP: future challenges • General lifestyle management module • Self-management module • Integrated management between different DMP

19. Self-management

20. Chronic disease management Julius Health Centers 2013 Included in Vital Health: • Diabetes: n=760 • COPD: n=158 • CVRM: n=2700 (planned 2013) • Lifestyle program Julius Fit: n=100

21. Chronic disease management Julius Health Centers 2013 82.3% of all DM patients managed in primary care  100% included in VH  94% complete assessment of indicator- parameters 51% of all COPD patients managed in primary care  86% included in VH  90% complete assessment of indicator- parameters

22. Conclusion • ICT plays an important role in adequate management of chronic disease in primary care • Communication between DMP and routine care registration is essential • Integration between different DMPs is the future challenge