1. Sustainability and scalability Croatian Institute of Public Health
CHRODIS PLUS
Sustainability and scalability
The title and the main topic of this presentation is sustainability and scalability of the pilot.
Marija Švajda
Croatian Institute of Public Health
Zagreb, 26th-27th March 2019

2. Strengths Weaknesses Opportunities Threats
GOVERNANCE
PRACTICE DESIGN
TARGET POPULATION EMPOWERMENT
EDUCATION AND TRAINING
SUSTAINABILITY AND SCALABILITY
Strengths
Weaknesses
You wouldn’t say so when you see this schema, would you? To get to sustainability and scalability we have to go through all quality criteria first, and detect strengths, opportunities, weaknesses and threats for each of them. Because only through knowing our strong sides, and our weaknesses and threats, we can build sustainable project.
Opportunities
Threats

3. Governance
MDS aligned with international standards and mutually between systems
Clearly defined institutional responsibilities and mandates regarding eHealth and health information systems in Croatia
3 years of available routine data collected from EHRs in GPs S W O T
Unclear institutional mandates in health information standards in Croatia
Our goal, when it comes to governance dimension, is to align our minimum data set with international standards, and to clearly define institutional responsibilities regarding eHealth and health information systems in Croatia.
The good thing is we have, for past 3 years, available routine data collected from electronic health records in GPs, and we have decision supporting tools in GPs. However, institutional mandates in health information standards are still unclear, and implementation of new technical solutions in GPs goes relatively slow. To be successful we have to make institutional mandates more clear, and speed up the implementation of technical solutions.
Decision supporting tools in GPs
Relatively slow implementation of new technical solutions in GPs

4. Practice design
Info to general practitioners on the current and expected use of diabetes control check-list as a minimum dataset within diabetes registry
“Diabetes panel” module is a useful decision-making tool which meets the administrative needs of Croatian Health Insurance Fund
All GPs are using “diabetes panel” module within their EHRs S W O T
“Diabetes panel” module doesn’t provide an insight into the health history of the patient
GPs have no control over their work in the “diabetes panel” module
MDS of diabetes panel is not aligned with CroDiab
From practice design point of view, we should inform GPs on the current and expected use of diabetes control check-lists.
On the positive side, diabetes panel module is useful tool which meets the administrative needs of NHI fund, and all GPs are using it. The opportunity for change lays in its modifiable data structure. But we are aware of its weaknesses as well. It doesn’t provide an insight into the health history of the patient, GPs don’t have a control over their work in the panel, and MDS of diabetes panel is not aligned with our diabetic patients registry. Threats are relatively low awareness of the importance of standardised clinical practice and health information system, and some parameters in diabetes panel are not equally available for all GPs.
Easily modifiable data structure of diabetes panel module within EHR in GPs
Relatively low awareness of the importance of standardised clinical practice and health information systems
Some parameters in the “diabetes panel” module are not equally available for all GPs

5. Target population empowerment
Info on available services at primary health care level (GPs) and the expected benefits and empowerment for their regular use
GPs are motivated to participate in development of tool to help them in efficient monitoring of diabetic patients S W O T
Some GPs are not informed on what the panels are and how to use them
GPs are generally overworked
The practice should actively promote the empowerment of the target population. We would do that by informing GPs on available services and expected benefits, and encouragement for their regular use.
GPs are motivated to participate in development of a tool which would help them in efficient monitoring of diabetes patients, and that strength should be used for our goals. The opportunity lays in strong evidence of efficiency of interventions with help of diabetes registers. However, the weakness is that some GPs are not informed on what the panels are and how to use them, and they are generally overworked. The threat is potentially low motivation for basic clinical practice topics.
Strong evidence of efficiency of interventions with help of diabetes registries
Potentially low motivation due to topics that are covering basic clinical practice (such as “proper washing hands”)

6. Education and training
Education and feedback to data sources on their performance and QI
There is system of continuous health professionals education in place that can be used for the pilot purpose
General practitioners are educated through various educational platforms which regularly cover diabetes topics
Diabetes patients are generally highly motivated to attend regular check-ups S W O T
Diabetes is only until recently in the domain
of GPs
Guidelines for the GPs are constantly changing
Diabetes patients are generally poorly aware of their rights and responsibilities as a diabetes patient
The importance of diabetes registry in quality of care not perceived by patients
In an attempt to reshape the practice (increase panel usage) we will give feedback to our GPs on their performance and quality indicators.
There is a system of continuous health professionals education in place that can be used for the pilot purpose, GPs are educated through various educational platforms which regularly cover diabetes topics and diabetes patients are generally highly motivated to attend regular check-ups. These are strong sides which are going to contribute to our education and training efforts. Opportunity lays in potentially high interest in insight of personal health history, status, goals and achievements of diabetic patients. On the other hand, we have a few obstacles here: diabetes is only until recently in the domain of GPs, guidelines for the GPs are constantly changing, diabetes patients are generally poorly aware of their rights and responsibilities, and the importance of diabetes registry in quality of care is not perceived by patients. Relatively low interest of patients in „internal” organisational issues within health care system might be a threat here.
Potentially high interest in insight of personal health history, status, goals and achievements of diabetic patients
Relatively low interest of patients in „internal” organisational issues within health care system

7. Sustainability and scalability
Ensured sustainable check lists usage and diabetes registry holding
CIPH has an important role in strategic planning and implementation of pilot good practices S W O T
Unclear institutional responsibilities and mandates regarding eHealth and health information systems
The continuation of the practice is the key and we are supposed to ensure sustainable check lists usage and diabetes registry holding. The strengths lay in the fact that CIPH has an important role in strategic planning and implementation of pilot, has long experience with other, similar registries, and has a sustainable source of funding.
However, unclear institutional responsibilities and mandates regarding eHealth and health information systems might be an obstacle in maintaining sustainability. We also have to take care of data quality over time, because it may have a tendency to decrease.
CIPH holds diabetes registry and has a sustainable source of funding
Decrease in data quality over time (coverage, timeliness, accuracy etc.) due to lack of feedback from reporting authorities

8. Number of patients in CroDiab and yearly number of applications
Number of patients in CroDiab registry (from 2013 CEZIH, from 2015 Panels)
The pilot has very high sustainability potential, because panels are already contributing to CroDiab registry very much – since their introduction yearly number of applications to CroDiab registry has tripled.
However, panels are not aligned with indicators which need to be tracked in order to improve the quality of care. Some important elements are missing from panels, like hypoglycaemia or feet examination.
One of the goals of the pilot is aligning panels with MDS.
39925
39772
42282
41362
37825
35643
32572
28964
23650
26238
23082
15495
4474
Yearly number of applications to CroDiab registry
Yearly number of applications from Panels

9. THANK YOU!