E-Health and regional integration of primary & referral based care for patients with chronic disease


Principal investigator


The huge burden to health system worldwide has changed from communicable diseases to non-communicable diseases. Indeed, the world population is living longer and dying at lower rates with the leading causes of death shifting to non-communicable diseases including multi-morbidity. People with multiple chronic illness are major consumers of health care services, accounting for 70% of general practice consultations. They are twice as likely to be admitted to hospital, and stay in hospital disproportionately longer [5]. More importantly, people with multi-morbid chronic conditions require more presentations across different care services and more likely to need a coordinated care to meet their complex needs to live healthy, fulfilling and independent. Therefore, to reduce the fragmentations between different health care, improve the coordination and collaboration of multi-disciplinary professionals in health services, the integrated care has gained increasing attention from managers, health care workers, policymakers and researchers in many countries as a strategy to improve health care delivery, especially with e-Health as a tool for integration.

However, understanding how to implement integrated care in practice is a complex question. Because the meaning and logic of integrated care is the polymorphous nature of a term and lack of a common language and framework make evidence comparison difficult. Moreover, given the e-Health, It is becoming more difficult to obtain the robust evidence from practice, since lack of a sound methodology and results for assessing the effectiveness and contribution of e-Health.

This study is based on the hypothesis that the current problems facing health and social care cannot be addressed by making additional adjustments on the existing health services and ways of working. Developing integrated care means overcoming barriers between primary and secondary care, physical and mental health, and health and social care to provide the right care at the right time in the right place. E-Health has the potential to achieve integration. Lastly, development of common definition is necessary, but integrated care should be treated differently depending on where it thrives.

The aim of this study is to explore how e-Health development supports and accelerates the design and development of a regional model for integrated care between hospital-based referral services and primary care for patients with chronic conditions. In this study, the integration process will be described, insights in how e-Health applications change the established model of practice will be gained. Hopefully, a regional model will be established as a high quality research evidence to make contributions to international experiences. Following research questions will be explored in this study:

  1. What are the main modalities of e-Health in ACT chronic care delivery system? What kind of role e-Health has played in the integration between the hospital-based referral services and primary care?
  2. What is the current research model to evaluate e-Health innovations?
  3. How does the patient flow through the current care system, especially between two different levels of care?
  4. What are the key elements of care at each step in the process? Where are the major decision points relating to the goal of integration?
  5. From the care providers’ point of view, what are the main issues regarding to integration and what are the main problems when apply and adopt e-Health technologies in practice. 


This project will be carried out by the teams from ACT Centre for Health Stewardship, and ACT Health (Chronic Disease Management Unit), with input from NICTA E-Health Team.

Updated:  26 June 2017/Responsible Officer:  Director/Page Contact:  Coordinator