Accountable and Collaborative Care: Lessons Learned from Across the Globe. Alan spoke about how important it is to have Collaborative Care; especially in chronic conditions, such as diabetes and COPD. Collaborative Care is facilitated by multi-specialty facilities which makes it more convenient for the patients to get tests results; for example, to make less visits to the doctors office. This can give patient care continuity, since everyone is working for the same cause: You, the patient. Also bundled payments give physicians the incentive to be more efficient with how they treat their patients.

2.  Introduction to AxSys Health
 Introduction to Accountable and Collaborative Care Solutions Across
the Globe
 Ontario, Canada – Diabetes Chronic Disease Management
 East Elmbridge & Mid Surrey Primary Care Trust -England
COPD Remote Monitoring Services
 National Clinical Network for Cleft Services - Scotland
 Managed Clinical Network for Cancer- Scotland
 National Sexual Health System (NaSH) - Scotland
 Total Knee Replacement Golden Jubilee Hospital - Scotland

3.  AxSys Health is the North
American division of AxSys
Technology Ltd
 Founded by physicians in the
UK. Started operations in
2000
 Approximately 250 employees
across offices in UK, India and
the US.
 AxSys has produced a unique
Collaborative and Coordinated
Care platform called
Excelicare
 The Excelicare solution has
delivered more than 30
discrete specialized clinical
applications across more than
120 clients across the United
States, Canada, Scotland,
England, Ireland, and India

4.  Most of the rest of the world has a single payer model – typically the
government – with a single payer model the focus has been on the clinical side
of care as opposed to the clinical and the payment of care
 Managed Clinical Networks (MCN), a pre-cursor to ACOs are an important
component in the support of better patient access and treatment through a
coordinated care approach. The MCN concept was created in Scotland in 1999
by the Scottish Department of Health
◦ Their definition of MCNs is defined as “linked groups of health professionals and organizations from
primary, secondary and tertiary care, working in a coordinated manner, unconstrained by existing
professional and Health Board boundaries, to ensure equitable provision of high quality clinically
effective services throughout Scotland.”
◦ Like a fine wine, this definition has aged well and seems to translate into the current goals of ACOs.
Some features of a MCN include:
◦ The application integrates primary, secondary and tertiary care services
◦ A care plan is established which will serve all network stakeholders
◦ The care plan has the capability to incorporate evidence-based medical practices
◦ All participating members of the multi-disciplinary care team will have equality of access to the care
plan (access rights can be granted, partly or whole)
◦ Multi-disciplinary team meetings are facilitated through the telemedicine and teleconferencing.
Experts at remote sites are able to discuss the patient review patient notes simultaneously
◦ Automated generation of referral letters, summary documents and discharge letters
◦ Educational and patient advice leaflets can be accessed and distributed

5. Description:
 Chronic Disease Management System (CDMS) started in 2010
for Diabetes and other chronic conditions – Connecting
100,000 providers, 15 Million patients and 1 Million patients
with Diabetes
Objectives:
 The creation of the CDMS-Diabetes reflects the number of
Ontarians with diabetes; there are now more than one million -
a total which has doubled over the last 10 years. The aim is to
manage diabetes treatment and care effectively and
economically, and to prevent the heart attacks, blindness and
amputations.

6. Project Success Metrics – Benefits Realization
 The CDMS-Diabetes is an interactive, real-time information tool to develop
care plans and monitor clinical results to improve treatment. The system is
building on eHealth Ontario's provincial identification and access systems
infrastructure to ensure the secure identification of patients, providers and
relevant diabetes healthcare services, based on common informatics
standards and access technology.
 Providers will be able to manage the care of patients with diabetes according
to recommended guidelines, securely receive, produce reminders, alerts and
reports to help improve the quality and safety of patient care.
 The development of Ontario's CDMS will enable significant improvements to
be achieved in the quality of services and real benefits to be delivered to
patients.
 As the first system of its kind in Canada, the CDMS solution will result in
faster diagnoses, more effective treatment and improved management for
Ontarians living with diabetes. Providing alerts to physicians will help them
better care for their patients.

7. Patient
Claims
Radiology
Laboratory
Access
Consent
Security and Access Control
Enterprise Master Patient Index
Patient and Provider Demographics
Providers
Connecting 100,000 providers, 15 Million patients and 1 Million patients
with Diabetes

12. Description:
 A COPD Community Service was initiated by East Elmbridge
and Mid Surrey Primary Care Trust in 2004 in England to
provide high quality personalized care to patients in the home
setting to reduce inpatient care and focus on preventative
rather than reactive acute care
Objectives:
 Monitor severe COPD patients at home, patients and their
caregivers were to be fully informed about their disease and
options, and patients and caregivers were to be taught to
recognize changes in condition

13. Project Success Metrics – Benefits Realization
 Improved Patient Involvement- The platform empowered patients to become more
actively involved in their own care
 Reduction in patient cost and time – lower costs and time incurred for patients
travel to clinics for assessment and treatment
 Move from Crisis management to Preventative collaboration - published results
demonstrated the change on emphasis from ‘crisis management’ to a proactive
‘preventative partnership’
 Reduced severity of exacerbations - 44% reduction with improved maintenance of
lung function and quality of life
 Reduced hospitalization – 40% reduction in admission for patients seen at home
 Reduced LOS– reduced to 5.9 days a 26% reduction in bed days
 Increased service deliver -80% of services delivered via phone or email, more
patient involvement with same staff levels
 Reduced duplication of effort - Care can be delivered anywhere and referrals made
by email

15. Description:
 Project established in 2000 to deliver interdisciplinary care
between health professionals providing care for cleft lip and
palate patients between the ages 0 and 20 years
Objectives:
 Provide a single record for a patient, accommodate clinical
imaging, generate email and letter alerts to remind clinicians
of their particular responsibility at specific times, and support
and facilitate audit and outcome assessment

16. Project Success Metrics – Benefits Realization
 Improved communication – sharing of information across care providers
 Improved standards of care- a single source of patient information to monitor and
analyze outcomes
 Improved coordinated care - Interdisciplinary treatment planning and care has
improved due to use of the platform
 Improved efficiencies - more effective use of clinicians’ time as well as the
patients, their parents and caregivers
 Improved data access – minimized risk of data fragmentation over multiple sites,
reduced cost, time and effort incurred by offline data entry and replication
 Better patient satisfaction – through improvement in the organization of clinics
and coordination among specialties
 Improved reporting – Reports and analysis on a national basis

17. Care Plan from Birth to 20 Year Old

19. Description:
 Managed Clinical Network (MCN) project established in 1999 to
integrate all cancer settings across the West of Scotland, to have the
patient at the core of the system, to implement care pathway
protocols in conjunction with National datasets, and to incorporate
multidisciplinary team (MDT) meetings within the care pathway.
Covers 50% of the population of Scotland – 2.5 Million people.
Connecting 5 regions and 10 hospitals
Objectives:
 Establish clinical meetings using video conferencing, provide a secure
clinical information system to record the patient history and store
clinical information and medical images. Provide means of informing
primary, secondary and tertiary care teams of ongoing cancer care

20. Project Success Metrics – Benefits Realization
 Reduced travel and delays – The MDT discuss individual cases without extensive
travel patients are referred and seen without delay
 Equitable access to care- Patients are guaranteed that they will receive specialist
review regardless of geography and that all clinicians involved in their care
participate in establishing and reviewing their care plans
 Improved care delivery- the speed of delivery of the treatment plan has improved
as all relevant information such as laboratory reports and pathology is recorded
and collated through one central system
 Improved education – Clinicians have benefited from the sharing of knowledge
through the cross specialty discussions and the meetings also provide an excellent
training ground for junior doctors and other clinical staff who attend
 Improved data quality – through a central repository with better audit trail and
introduction of standardization and accountability

21. Forth Valley HB
SCI-Store
PMI / LABS / RIS Falkirk
iSoft EXPRESS
PAS (x3) iSoft TELEPATH Clinisys Hospital
LABS CHEMOCARE
WS (SOAP) Stirling
Varian
VARIS RT
Royal
EP
Infirmary
Slave
Server
FTP ODBC
ODBC
MSMQ
ODBC Argylle & Clyde HB
SCI-Store
Inverclyde
PMI / LABS
Exceliport Integration Hospital
Slave Server
WS (SOAP)
MSMQ
EP
Lanarkshire HB MSMQ Slave
Server
EP
Slave SIEMENS
DICOM3 Server PACS
DICOM3
Hairmyres
Hospital
Wishaw
Hospital
Ayrshire & Arran HB
EP TELNET
Slave COMPAS
MSMQ, Server ODBC PAS
DICOM
REVIVE
DICOM 3 LABS/RIS
GE CT
GE MRI Crosshouse
Glasgow Southern Beatson Hospital
Stobhill
Royal General Oncology
Hospital
Infirmary Hospital Centre

25. Description:
 Managed Clinical Network (MCN) and integrated Sexual Health
Enterprise Patient Record System (EPR) for Sexual Health project
established in 2007 to integrate all Sexual Health clinics settings
across all of Scotland.
Objectives:
 The NaSH system is a key component of the National Sexual Health
Strategy - ‘Respect and Responsibility: A Strategy and Action Plan for
Improving Sexual Health’, launched in 2005.
 This strategy set out a framework for improving sexual health in
Scotland by enhancing access to information and services whilst
enabling flexibility for local services to respond to local requirements.
 It also highlighted the need to be able to review existing data and
develop a data collection framework to provide a more accurate
picture of sexual health and wellbeing in Scotland, in terms of both
sexual ill health and behaviours and attitudes.

26. Project Success Metrics – Benefits Realization
 Improved Clinical Care with patient focused processes and modern communication tools.
 Streamlining of services enabling improved throughput and availability.
 More effective use of staff resources and more efficient clinical staff training
 Increased ability to share patient data across services.
 Removal of multiple manual record keeping systems.
 Ability to address some clinical governance issues more effectively.
 Improved service security.
 Reduction in resource required to complete coding.
 Improved ability to access and share patient clinical information.
 Reduced requirement for duplicate entry of patient data and better quality of data.
 Increased use of national data standards.
 Reduction in number of potential diverse clinical systems.
 More efficient and increased integration of systems.
 Improved resilience and support for clinical systems.
 Get more value from strategic infrastructure products.
 Increased clinical buy-in and usage of IM&T.
 Better public health information.

35.  ACOs, Patient Centered Medical Homes, and
Bundled Payment methodologies are
Collaborative Care Solutions that have their
precursors both in the US and abroad
 Need to analyze what worked in a single
payer model there and what will work in a
multi-payer model here
 Focus on cooperation while being cognizant
of the competitive realities in the U.S.