A smart system capable of recognising patients at risk of hospitalisation has been released this week

The Risk Stratification Tool is part of a primary health care initiative in Australia to tackle the growing epidemic of chronic illness.

The system was developed by Precedence Health Care for the Commonwealth’s Health Care Home initiative.

Health Care Homes are key to the government’s strategy for tackling the enormous challenge of chronic illnesses, such as diabetes.

Close to 200 Health Care Homes around Australia are now able to enrol patients. These general practices and Aboriginal Community Controlled Health Services are hoped to provide better coordinated care for up to 65,000 Australians who are living with chronic and complex conditions.

The program relies on digital health technologies to identify patients most in need of care and to plan and coordinate their care.

The Risk Stratification Tool uses smart predictive technology to determine which patients in a practice are most likely to have a potentially preventable hospitalisation in the coming year. The Tool then automatically pre-fills a questionnaire with available clinical data.

Additional clinical and non-clinical information, such as data on psychological factors, is added to the questionnaire during conversations with patients, family members, carers and providers. This confirms eligibility and determines what level of care the patient needs.

Precedence Health Care developed the smart digital technology for delivering the solution to practices using their digital cloud platform, cdmNet. The algorithm for predicting the level of risk was developed by CSIRO using data from general practices and public hospitals in Victoria.

Professor Michael Georgeff, CEO of Precedence Health Care, says the technology helps transform the care of patients, making sure that those in need are identified early and get the right level of care at the right time.

“Digital health technologies are the beginning of a new approach to health care,” he says. “They can be of enormous help to practices that already struggle with the complexity of managing their growing population of chronically ill people.

“The Risk Stratification Tool scans the complete history of any patient who visits the practice, including checking all their medications and previous pathology tests. It then uses intelligent techniques to determine if they are likely to be hospitalised. If the likelihood is high, it will alert the GP and recommend the patient for enrolment in the Health Care Homes initiative.

“This means that whenever a patient visits their GP, the Risk Stratification Tool will be helping to ensure that they get the care they need. Even if their visit is simply to collect a new prescription, or get a flu shot, the system will be looking for other conditions that could signify a more serious problem.”

However, the system’s advice can always be over-ridden by the patient’s GP, if there is a demonstrated clinical need.

“While the computer may be smart, it is only an assistant to the GP, who is much better at really understanding their patients’ needs,” says Professor Georgeff.

The technology developed for the Health Care Homes initiative is configurable for practices who may not be part of the initiative and wish to implement a patient selection tool.

“The system will help identify people who are in need of more personalised care, no matter whether or not they have access to Health Care Homes. It will help GP practices begin the transition to the future of health care”, Professor Georgeff says.