Gorham, Gillian

Abeyaratne, Asanga

Heard, Sam

Moore, Liz

George, Pratish

Kamler, Paul

Majoni, Sandawana William

Chen, Winnie

Balasubramanya, Bhavya

Talukder, Mohammad Radwanur

Pascoe, Sophie

Whitehead, Adam

Sajiv, Cherian

Maple-Brown, Louise

Kangaharan, Nadarajah

Cass, Alan

2024-03-07

The burden of chronic conditions is growing in Australia with people in remote areas experiencing high rates of disease, especially kidney disease. Health care in remote areas of the Northern Territory (NT) is complicated by a mobile population, high staff turnover, poor communication between health services and complex comorbid health conditions requiring multidisciplinary care.This paper aims to describe the collaborative process between research, government and non-government health services to develop an integrated clinical decision support system to improve patient care.Building on established partnerships in the government and Aboriginal Community-Controlled Health Service (ACCHS) sectors, we developed a novel digital clinical decision support system for people at risk of developing kidney disease (due to hypertension, diabetes, cardiovascular disease) or with kidney disease. A cross-organisational and multidisciplinary Steering Committee has overseen the design, development and implementation stages. Further, the system's design and functionality were strongly informed by experts (Clinical Reference Group and Technical Working Group), health service providers, and end-user feedback through a formative evaluation.We established data sharing agreements with 11 ACCHS to link patient level data with 56 government primary health services and six hospitals. Electronic Health Record (EHR) data, based on agreed criteria, is automatically and securely transferred from 15 existing EHR platforms. Through clinician-determined algorithms, the system assists clinicians to diagnose, monitor and provide guideline-based care for individuals, as well as service-level risk stratification and alerts for clinically significant events.Disconnected health services and separate EHRs result in information gaps and a health and safety risk, particularly for patients who access multiple health services. However, barriers to clinical data sharing between health services still exist. In this first phase, we report how robust partnerships and effective governance processes can overcome these barriers to support clinical decision making and contribute to holistic care.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Darwin, NT, 0810, Australia. gillian.gorham@menzies.edu.au.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Darwin, NT, 0810, Australia.

Department of Nephrology, Royal Darwin Hospital, Northern Territory Health, Darwin, NT, Australia.

Central Australian Aboriginal Congress, Aboriginal Corporation, Alice Springs, NT, Australia.

Aboriginal Medical Services Alliance Northern Territory, Darwin, NT, Australia.

Department of Nephrology, Alice Springs Hospital, Northern Territory Health, Alice Springs, NT, Australia.

Department of Nephrology, Royal Darwin Hospital, Northern Territory Health, Darwin, NT, Australia.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Darwin, NT, 0810, Australia.

Department of Nephrology, Royal Darwin Hospital, Northern Territory Health, Darwin, NT, Australia.

Northern Territory Medical Program, Flinders University, Royal Darwin Hospital Campus, Darwin, NT, Australia.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Darwin, NT, 0810, Australia.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Darwin, NT, 0810, Australia.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Darwin, NT, 0810, Australia.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Darwin, NT, 0810, Australia.

Radical Systems, Darwin, NT, Australia.

Department of Nephrology, Alice Springs Hospital, Northern Territory Health, Alice Springs, NT, Australia.

Northern Territory Medical Program, Flinders University, Royal Darwin Hospital Campus, Darwin, NT, Australia.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Darwin, NT, 0810, Australia.

Department of Endocrinology, Royal Darwin Hospital Northern Territory Health, Darwin, NT, Australia.

Division of Medicine, Royal Darwin Hospital Northern Territory Health, Darwin, NT, Australia.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Darwin, NT, 0810, Australia.

BMC Med Inform Decis Mak . 2024 Mar 8;24(1):69. doi: 10.1186/s12911-024-02471-w.

1472-6947

0000-0002-9814-2204

https://pubmed.ncbi.nlm.nih.gov/38459531/?otool=iaurydwlib

https://hdl.handle.net/10137/13271

Chronic disease

Clinical algorithms

Clinical decision support

Clinical information systems

Clinical safety

Integrated patient care

Remote health

Humans

Decision Support Systems, Clinical

Delivery of Health Care

Northern Territory

Hospitals

Risk Assessment

Developing an integrated clinical decision support system for the early identification and management of kidney disease-building cross-sectoral partnerships.

Journal Article

Publication