Integrated Care is a key strategic priority for NSW Health and to achieving the Premier’s Priority of improving care in the community. Substantial investment is made annually to integrate services, systems and improve experience and outcomes for patients their families and carers.

The dynamic nature of Integrated Care means models of care are constantly evolving and continuously improving. Monitoring and evaluating the various methods and approaches to delivering Integrated Care across NSW is key to identifying which activities provide the right care, in the right place, to the right people.

Monitoring and evaluation of Integrated Care is used to:

  • provide insights into the effectiveness of integrated care programs and interventions
  • inform decision-making
  • determine whether a specific program or intervention is meeting its objectives

Integrated care captures a number of data and information points to assist with monitoring improvement and progress over time.

Internal data collection platforms

Integrated Care Outcomes Database (ICOD) 

Patient enrolment data on Integrated Care initiatives are captured in the Patient Flow Portal. Three times a year the data is extracted, and linked to other NSW Health data sources, then de-identified and uploaded onto the Integrated Care Outcomes Database.

The ICOD enables the tracking of activity of patients that have been enrolled in an integrated care initiative such as:

  1. demographics of enrolled patients
  2. trends in enrolments for local initiative
  3. performance against key indicators:
    • emergency department visits
    • hospital admissions
    • average length of stay
    • readmission rates
    • potentially preventable hospitalisations.

Patient Flow Portal (PFP) 

The Patient Flow Portal provides access to a suite of modules that can be used by Integrated Care staff and local health district executives to monitor and manage IC initiatives. The main modules used to monitor Integrated care initiatives are the Integrated Care Module and the Integrated Care Patient List Views.

The Integrated Care module is a state-wide, standardised system for capturing data on enrolment of patients into integrated care initiatives through the phases of identification, selection, enrolment, intervention and review. It allows monitoring and tracking through the integrated care process and provides an enriched data source that can support comprehensive reporting.

Health Information Exchange (HIE) 

HIE is the electronic movement of health-related information amid organisations according to nationally recognised health standards. The goal of facilitating access is to retrieve clinical data provided by physicians, nurses, pharmacists, other health care providers and patients.

The HIE contains the Admitted Patient Data Collection (APDC), Emergency Department Data Collection (EDDC), and the NSW Registry of Births, Deaths, and Marriages (RBDM) data.

Enterprise Data Warehouse for Analysis, Reporting and Decision Support (EDWARD)

EDWARD is a new enterprise data warehouse providing a single source of truth, enabling the provision of high-quality information to the wide range of analytics tools used system wide, and the development of new analytics applications. EDWARD contains all Non-Admitted Patient (NAP) data.

Lumos

Lumos is a state-wide GP data linkage initiative linking data across primary, ambulatory and acute care. Data collected from GPs will be linked to patients enrolled in IC initiatives. Lumos is currently partnered with 10 PHNs across 40 practices with around 400,000 patient journeys currently in the Lumos database. There will be two data extractions per year, which will provide end-to-end patient journeys.  is an ethically approved program that securely links encoded data from general practices to other health data in NSW, including hospital and emergency department, with privacy of patients securely maintained.

External data collection platforms 

Centre for Health Research Linkage (CHeReL)

The Centre for Health Record Linkage (CHeReL) links multiple sources of data and maintains a record linkage system that protects privacy. Record linkage brings together information that relates to the same individual, family, place or event from different sources. This makes it possible to create longitudinal sequences of health events. Combined, these individual ‘stories’ create a larger story about the health of people in NSW. Information from both the HIE and EDWARD are linked to IC patients by CHeReL.

BHI Healthcare Observer

Data that is currently being collected by BHI include Patient Experience Surveys. BHI collects data on patient experience and the performance of various hospitals and clinics. Data from patients who have given consent for their results to be shared will be sent to CHeReL.

The Health Outcomes and Patient Experience (HOPE) System

The new Patient Reported Measures (PRMs) IT system, HOPE supports the routine collection, measurement and timely reporting to clinicians. HOPE systems will be implemented across districts, trialled through the Leading Better Value Care initiatives, followed by Integrated Care initiatives. The data collected through HOPE will complement the range of existing NSW Health PRMs collections, including the Patient Survey run by BHI.

is an ethically approved program that securely links encoded data from general practices to other health data in NSW, including hospital and emergency department, with privacy of patients securely maintained.
Current as at: Wednesday 23 September 2020
Contact page owner: System Performance Support