Care & Compliance Management System
Cross-sector patient care and care management
In 2011, the HerzNetzCenter Köln (HNC) was looking for a Care & Compliance Management Software (CCMS) to further implement its successful philosophy of providing a coordination and support platform to complement its conventional structures. The cornerstones of this strategy and implementation are patient proximity, individualisation, regionality, transparency, sustainability and quality. The software must be able to guide patients with different clinical pictures in different models. It will also be used to centrally manage the data of patients, clinics, specialists, general practitioners, nurses and the Medical Service Center, and to centrally monitor and control patient care.
Das HerzNetzKöln2
Das HerzNetzKöln2 is a cross-sectoral supply model operated by the HNC since 2007. The central approach of Herz-NetzKöln² is to improve the care situation of patients with heart failure through a structured treatment concept that includes all levels of care. Within this framework the HerzNetzKöln2 pursues the following goals:
- Improvement of morbidity, quality of life and prognosis
- Guidelines Adequate care
- Favouring the outpatient care level
- Interface optimization and exploitation of synergy options through standardized supply paths
- Involving the patient as co-therapist
- Special consideration of psychosocial and socio-medical aspects
- Increase in patient satisfaction
- Efficient use of resources
The HerzNetzCenter (HNC) functions in the HerzNetzKöln² as a coordination, information and service center, which in addition to the conventional care levels, structures the care of patients and serves as a quality assurance center.
1,750 patients are currently managed in the model
At present, well over 1,500 patients with heart failure are cared for and managed in the model, which was initially deliberately limited to Cologne. At the same time, almost all of Cologne’s general practitioners and cardiologists, with over 400 practices, are involved in the model. The aim is to ensure efficiently organized and needs-based care and treatment tailored to the individual patient. For this purpose, all services, diagnoses, self-diagnoses and visit reports must be collected and evaluated centrally. In addition, it is essential to provide transparent information to all institutions involved in the model, to coordinate their activities and to record and ensure the quality of care.
“Only by creating a central and at the same time lean case management system were we able to solve this enormously complex and demanding task,” said Prof. Dr. Höpp, Deputy Director of Clinic III of the Heart Centre of the University Hospital of Cologne. The following central requirements had to be solved in strict compliance with data protection regulations:
- Central master data administration of clinic, specialist and family doctor.
- Central management of diagnostic and therapeutic process data.
- Seamless integration of the various HIS and EPA systems.
- Automated communication with the doctors.
- ” Flexible mobile communication and data acquisition at the patient’s site as well as at the staff of the patient service and the model service.
Six months of intensive planning
“In order to implement this CCMS with the underlying ideas and demanding challenges in a software, we have found a powerful, flexible and innovative partner in the company Ontaris GmbH & Co KG from Wuppertal, who has been active in the field of patient monitoring for several years,” says Prof. Dr. Höpp. “It was important for us to find a software development partner who understands our goals and actively implements the solution in close cooperation with us”.
Six months of intensive joint planning were necessary before even one line of code was written. Due to the large number of interest groups involved (hospitals, specialists, general practitioners, nurses, patients), it first had to be determined which patient or diagnostic data would be collected at which point in the process, by which party, how and at what time. From this, a common extract had to be formed, which is provided by the CCMS.
“The trickiest task in this project was to determine exactly the data that was required at the minimum and therefore at the maximum at the same time,” explains Martin Schüßler, Managing Director of Ontaris. “The homogeneous connection of the most diverse HIS and practice management (PV) systems as data suppliers also represented a not inconsiderable requirement”.
The CCMS™
In the CCMS, all information necessary for the cross-sectoral management of the patient in the model is centrally stored and automatically evaluated. In addition to the patient data and the family doctor and specialist in charge, these are above all the results of the examinations regularly initiated by the model. Tasks are then derived from this, if necessary, which are automatically forwarded to the responsible institution (family doctor, specialist or HNK² nurse) and whose successful completion is tracked and documented in the CCMS.
“A very important component of the CCMS and our daily tool is the documentation of the telephone calls we make with the patients,” says Elisabeth Kohnen, head of the Heart Network Nurse of the Patient Service of the HNK². “In addition to the subjective self-assessments of the patients, important diagnostic parameters are also recorded there, which for us are an indispensable basis for the successful management of the patients”.
Connection to the clinic
“HL7 is the basis for all data communication in the health care sector. Therefore we have implemented this interface for communication with all external systems”, says Martin Schüßler. “Via this we can now connect the different HIS and PV systems to the CCMS.”
Connection of the medical practices
“A special challenge was the connection of the medical practices to the CCMS.” Marcus Wähner from the model service of the HNK² supervises the practices participating in the model and knows the problems very well. “In medical practices, we are confronted with a wide variety of electronic patient files, which often do not allow the connection of third-party software. In addition, an Internet connection is often not used for security reasons.” To solve this complex problem, a very pragmatic approach was chosen. The practices receive a small application on an encrypted USB stick, which they can use to fill out the necessary examination reports and then print them out. These printouts are then faxed to the CCMS, where they are automatically processed, imported and assigned to the patient.
Case and task management with tablets
The CCMS automatically assigns tasks to the service personnel and in particular to the individual cardiac nurses in accordance with the model specifications, but also individually triggered. For example, they are reminded which of their assigned patients are currently to be visited or which other care-relevant actions are to be carried out promptly. The HerzNetzSchwestern are provided with this information on their tablets on a mobile basis and can also access all important patient data online or enter the visit documentation on site. All information automatically flows back into the CCMS and is stored exclusively there.
Self-monitoring of patients with digital pen
The patient plays an important role in the care concept of the HerzNetzKöln². His active and daily participation is an important component of the care. “The average age of the patients in the model is about 70 years. It is very difficult to find a suitable technique that can be accepted and operated by the patients and that reliably provides the necessary information”, says Martin Schüßler. The decision was made to use a technology that Ontaris has been successfully using for many years in the field of self-monitoring of patients suffering from diabetes mellitus.
“The patient writes in his paper diary as usual with a pen containing a camera, with the small difference that the data is then sent directly to the CCMS via a mobile phone,” Schüßler explains the system.
Conclusion
The conclusion of both project partners is accordingly positive:
“With the CCMS, we have created a tool with which any processes and models can be mapped. It allows all access variants and is the linchpin in every model-related, individual patient care. That is patient management and quality assurance in a nutshell”.
