This project aims to overcome barriers to care providers sharing information by designing, developing, implementing and evaluating a novel information and communication system that supports the delivery of population-based health care. Conducted in Durham County, North Carolina, by Duke University Medical Center and its project partners, the project will primarily benefit Medicaid beneficiaries. The proposed information system will enhance the efficiency of the care delivery process, lower the inappropriate utilization of healthcare resources and improve the quality of the care delivered. The proposed system will be created in three phases over three years. Phase I will provide a centralized, web-based database of patient information (care management plans, initial enrollment health data) by tracking and monitoring where enrollees receive care, and by providing online interactive care management protocols. In Phase II, the project will enhance the core information on each patient by importing electronically stored data from two practice-specific databases to create a shared data repository. The goal for this phase is to define and demonstrate the principles for making data exchange possible. In Phase III, tools will be developed to proactively assist with population-based disease management and preventive health services. Specifically, the project will develop an intelligent agent programmed with specific monitoring rules that can detect lapses in care.
This project is a pioneering effort to create the information management resources that will be needed to coordinate the health care of populations on a community-wide basis. It will be a model for the type of information system that will be required to support health care delivery by multi-disciplinary teams across traditional institutional boundaries. The project will have significant ramifications for similar efforts across the country as health care shifts from disease-focused care of individuals in a hospital or clinic to the management of population health throughout a region. The project will develop new, replicable technology that facilitates population-based care management.
The partners involved with this initiative include: Duke Family Medicine, a large family-practice clinic staffed by Duke faculty and residents, providing care to a large Medicaid and indigent population as well as to insured patients; Duke Children's Primary Care, a large pediatric practice staffed by Duke faculty and residents, also serving a large Medicaid and indigent population; Lincoln Community Health Center, a federally-financed community health center that serves a large low-income population (61 percent are uninsured; the balance are Medicare/Medicaid); Durham County Department of Social Services, an agency that administers "welfare" programs and Medicaid, provides protective services for abused/neglected and chronically ill children and adults who are almost all low-income; and Durham County Health Department, an agency that provides communicable disease control and chronic disease detection and management, environmental health services and regulation, and personal health care services to low-income people (primarily young women and children).