FabCarinci.net

Objectives

Methods

Results

Sample Output

Presentations

Reports

Software

SPHIS
Southern Population Health Information System

Carinci F and Talman P, 2002
Monash Institute of Health Services Research

Objectives

The Southern Health Care Network is the largest health care organization in Metropolitan Melbourne, Australia, including community and acute care centres serving a population of over 700,000.
Southern Health's (SH's) vision is to deliver integrated, high quality health services that improve health status using all available resources.
The organization is committed to collaborating with other agencies to optimise the health outcomes of people who live in the cities of Greater Dandenong, Casey, Cardinia, Monash and Kingston.

Implicit in this vision is a commitment to a population health-based approach to the planning, development and evaluation of SH's health services.
To realise this vision and SH's commitment to population health, various elements need to be developed to better understand the community's health needs and to improve the alignment between health services (own and those of other agencies) and these needs.

In early 2001 a new project was called to develop a population-health data model that could facilitate the description of community health needs and the alignment of appropriate health services with these.
The model was required to access relevant information across the continuum of care and assess the incidence of various conditions and service performance.
The initiative followed the establishment of a local Primary Care & Population Health Advisory Committee (PC&PHAC). The PC&PHAC was providing advice to SH's Board on primary care and population health issues and set to be the reference committee for this project. This committee was keen to investigate community's health needs, assess the primary care's contribution to various service systems and identify gaps in service to which primary care could respond.

Recognising the limited resources available the committee agreed that the development of a population-health approach needed to focus on the following consumer groups:

Stroke victim needs
Mental health issues
Frail elderly needs

These areas were chosen to reflect predicted areas of growth in population health needs, existing sub-optimal health service systems or the availability of continuum of care information that was not readily available in other areas.
As frequently happens in health services organization, at this stage the Committee did not have direct access to funding for research that was therefore dependent on dovetailing with other funded projects and studies.
As part of the "hospital demand management projects" SH was given funding to explore and develop strategies to improve the management of chronic conditions and to prevent episodes of acute hospitalisation - admission and readmission.
If this product was proven as a result of the work undertaken from this proposal, SH would have been keen to apply the methodology to systematically understand overall population health needs in many other disease areas.
The management of the organization ultimately was seeking to use this understanding to improve the planning and development of health services.

A proposal made by Fabrizio Carinci on behalf of the Monash Institute of Health Services Research (MIHSR) was then approved: the Southern Population Health Information System (SPHIS).
This project was meeting some of the needs expressed by SH and it was regarded as a useful first step in understanding our community's health needs and information availability.

Agreed deliverables for the project were:

Data collection:

Explore and document all possible sources of relevant data needed to populate the model
Identify constraints or issues in accessing and using this information.
Access the information needed to populate the model including demographic characteristics (age, gender, socio-economic status & other relevant data), burden of disease data, health service utilisation, HIC data etc.
Document gaps in desirable information and explain assumptions made to cover areas where information is not available.
Identify mechanisms and responsibilities for practically and economically providing appropriate access to relevant information and maintaining data bases on an ongoing basis.

Prevention strategies:

Identify best practice clinical models for the management and primary, secondary and tertiary prevention of the disease groups being studied
Identify specific strategies to prevent hospital admissions and readmissions
Develop services that could be provided by primary care agencies that are consistent with these strategies
Propose mechanisms for funding these strategies
Suggest performance measures to evaluate the success these strategies

SH was noting that as funding was coming from the prevention strategies allocation it was critical that the project delivered researched suggestions for improving the management of chronic illness and the prevention of hospital admissions and readmissions for stroke.
In addition the PC&PHAC was very keen that relevant information sourced for the project was made available as soon as possible to both internal and external stakeholders to assist in their ongoing service planning activities.
Making a consistent set of relevant data available to all service providers would have been a useful outcome of this project.
The following deliverables were therefore suggested short term:

Model development:

Develop a population-health model for stroke victims to a level of detail required to design credible long term prevention and management strategies and ultimately to design improved health service delivery systems for the management of stroke.
Document the methodology by which population-health approaches can be systematically developed for other disease groupings.

Organisation and ongoing maintenance:

Document the organisational and skill requirements to maintain the model (recognising that a previous step has identified the data maintenance requirements)
Develop fully costed options and prepare a business case in conjunction with SH's IT department to manage and maintain the ongoing use of the model.

It was anticipated that development of the population-health data model would have been expanded to include other priority areas after this initial development. In addition further work could have been undertaken on meeting gaps in data and linking data bases and information sources.