{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,16]],"date-time":"2026-05-16T04:40:51Z","timestamp":1778906451273,"version":"3.51.4"},"reference-count":33,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2024,3,8]],"date-time":"2024-03-08T00:00:00Z","timestamp":1709856000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2024,3,8]],"date-time":"2024-03-08T00:00:00Z","timestamp":1709856000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100000925","name":"National Health and Medical Research Council","doi-asserted-by":"crossref","award":["1194698"],"award-info":[{"award-number":["1194698"]}],"id":[{"id":"10.13039\/501100000925","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/501100000925","name":"National Health and Medical Research Council","doi-asserted-by":"crossref","award":["1194677"],"award-info":[{"award-number":["1194677"]}],"id":[{"id":"10.13039\/501100000925","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Med Inform Decis Mak"],"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>The burden of chronic conditions is growing in Australia with people in remote areas experiencing high rates of disease, especially kidney disease. Health care in remote areas of the Northern Territory (NT) is complicated by a mobile population, high staff turnover, poor communication between health services and complex comorbid health conditions requiring multidisciplinary care.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Aim<\/jats:title>\n                <jats:p>This paper aims to describe the collaborative process between research, government and non-government health services to develop an integrated clinical decision support system to improve patient care.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>Building on established partnerships in the government and Aboriginal Community-Controlled Health Service (ACCHS) sectors, we developed a novel digital clinical decision support system for people at risk of developing kidney disease (due to hypertension, diabetes, cardiovascular disease) or with kidney disease. A cross-organisational and multidisciplinary Steering Committee has overseen the design, development and implementation stages. Further, the system\u2019s design and functionality were strongly informed by experts (Clinical Reference Group and Technical Working Group), health service providers, and end-user feedback through a formative evaluation.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>We established data sharing agreements with 11 ACCHS to link patient level data with 56 government primary health services and six hospitals. Electronic Health Record (EHR) data, based on agreed criteria, is automatically and securely transferred from 15 existing EHR platforms. Through clinician-determined algorithms, the system assists clinicians to diagnose, monitor and provide guideline-based care for individuals, as well as service-level risk stratification and alerts for clinically significant events.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusion<\/jats:title>\n                <jats:p>Disconnected health services and separate EHRs result in information gaps and a health and safety risk, particularly for patients who access multiple health services. However, barriers to clinical data sharing between health services still exist. In this first phase, we report how robust partnerships and effective governance processes can overcome these barriers to support clinical decision making and contribute to holistic care.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12911-024-02471-w","type":"journal-article","created":{"date-parts":[[2024,3,8]],"date-time":"2024-03-08T18:02:18Z","timestamp":1709920938000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["Developing an integrated clinical decision support system for the early identification and management of kidney disease\u2014building cross-sectoral partnerships"],"prefix":"10.1186","volume":"24","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9814-2204","authenticated-orcid":false,"given":"Gillian","family":"Gorham","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Asanga","family":"Abeyaratne","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sam","family":"Heard","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Liz","family":"Moore","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pratish","family":"George","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Paul","family":"Kamler","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sandawana William","family":"Majoni","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Winnie","family":"Chen","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bhavya","family":"Balasubramanya","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohammad Radwanur","family":"Talukder","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sophie","family":"Pascoe","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Adam","family":"Whitehead","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Cherian","family":"Sajiv","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Louise","family":"Maple-Brown","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nadarajah","family":"Kangaharan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alan","family":"Cass","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2024,3,8]]},"reference":[{"key":"2471_CR1","volume-title":"Cardiovascular, diabetes and chronic kidney disease series no 3","author":"Australian Institute of Health and Welfare","year":"2014","unstructured":"Australian Institute of Health and Welfare. Cardiovascular disease, diabetes and chronic kidney disease - Australian facts: morbidity-hospital care. In: AIHW, editor. Cardiovascular, diabetes and chronic kidney disease series no 3. Canberra: Australian Government; 2014."},{"key":"2471_CR2","unstructured":"Swerissen H, Duckett S, Wright J. Chronic failure in primary medical care. ISBN: 978-1-925015-80-5. Grattan Institute; 2016."},{"key":"2471_CR3","unstructured":"Queensland Health. Integrated Care model changing lives and reducing preventable admissions. Brisbane: Queensland Government 2020 [Available from: https:\/\/www.health.qld.gov.au\/widebay\/publications\/media-releases\/april-june-2020\/integrated-care-model-changing-lives-and-reducing-preventable-hospital-admissions."},{"key":"2471_CR4","unstructured":"AIHW. Disparities in potentially preventable hospitalisations across Australia: exploring the data. Canberra: Australian Institute Health and Welfare; 2020 [Available from: https:\/\/www.aihw.gov.au\/reports\/primary-health-care\/disparities-in-potentially-preventable-hospitalisations-australia\/summary Accessed 5\/1\/2023."},{"key":"2471_CR5","unstructured":"NT Department of Health. Inquiry into Chronic Disease Management and Health Care. Darwin; 2015."},{"key":"2471_CR6","volume-title":"Renal replacement therapy demand study, Northern Territory, 2001 to 2022","author":"JQ You","year":"2015","unstructured":"You JQ, Lawton P, Zhao Y, Poppe S, Cameron N, Guthridge S. Renal replacement therapy demand study, Northern Territory, 2001 to 2022. Darwin: Department of Health; 2015."},{"issue":"1","key":"2471_CR7","doi-asserted-by":"publisher","first-page":"231","DOI":"10.1186\/s12882-019-1421-z","volume":"20","author":"G Gorham","year":"2019","unstructured":"Gorham G, Howard K, Zhao Y, Ahmed AMS, Lawton PD, Sajiv C, Majoni SW, Wood P, Conlon T, Signal S, Robinson SL, Brown S, Cass A. Cost of dialysis therapies in rural and remote Australia - a micro-costing analysis. BMC Nephrol. 2019;20(1):231.","journal-title":"BMC Nephrol"},{"key":"2471_CR8","unstructured":"Gorham G, Cass A, Howard K, Evans K. Central Australia Renal Study: Technical Report Update. Report prepared by Menzies School of Health Research. Darwin; 2016."},{"issue":"11","key":"2471_CR9","doi-asserted-by":"publisher","first-page":"663","DOI":"10.5694\/mja13.11183","volume":"200","author":"AP Gador-Whyte","year":"2014","unstructured":"Gador-Whyte AP, Wakerman J, Campbell D, Lenthall S, Struber J, Hope A, Watson C. Cost of best-practice primary care management of chronic disease in a remote Aboriginal community. Med J Aust. 2014;200(11):663\u20136.","journal-title":"Med J Aust"},{"key":"2471_CR10","unstructured":"Gorham G. Analysis of longitudinal clinical data to evaluate the impact and effectiveness of a CKD program. Renal Society of Australasia Journal. Renal Society of Australasia; 2016. p. 39."},{"issue":"119","key":"2471_CR11","doi-asserted-by":"publisher","first-page":"119","DOI":"10.1186\/s12913-016-1363-0","volume":"16","author":"R Reilly","year":"2016","unstructured":"Reilly R, Evans K, Gomersall J, Gorham G, Peters MD, Warren S, O\u2019Shea R, Cass A, Brown A. Effectiveness, cost effectiveness, acceptability and implementation barriers\/enablers of chronic kidney disease management programs for indigenous people in Australia, New Zealand and Canada: a systematic review of mixed evidence. BMC Health Serv Res. 2016;16(119):119.","journal-title":"BMC Health Serv Res"},{"issue":"1","key":"2471_CR12","doi-asserted-by":"publisher","first-page":"52","DOI":"10.1186\/s12960-017-0229-9","volume":"15","author":"DJ Russell","year":"2017","unstructured":"Russell DJ, Zhao Y, Guthridge S, Ramjan M, Jones MP, Humphreys JS, Wakerman J. Patterns of resident health workforce turnover and retention in remote communities of the Northern Territory of Australia, 2013\u20132015. Hum Resour Health. 2017;15(1):52.","journal-title":"Hum Resour Health"},{"key":"2471_CR13","doi-asserted-by":"crossref","unstructured":"Dixit SK, Sambasivan M. A review of the Australian healthcare system: a policy perspective. SAGE Open Med. 2018;6.","DOI":"10.1177\/2050312118769211"},{"key":"2471_CR14","doi-asserted-by":"crossref","unstructured":"Matthews V, Burgess C, Connors C, Moore E, Peiris D, Scrimgeour D, Thompson S, Larkins S, Bailie R. Integrated clinical decision support Systems promote Absolute Cardiovascular Risk Assessment: an important primary Prevention measure in Aboriginal and Torres Strait Islander Primary Health Care. Front Public Health. 2017;5.","DOI":"10.3389\/fpubh.2017.00233"},{"issue":"6","key":"2471_CR15","doi-asserted-by":"publisher","first-page":"A394","DOI":"10.5334\/ijic.2942","volume":"16","author":"E Savage","year":"2016","unstructured":"Savage E, Hegarty J, Weathers E, Mulligan L, Bradley C, Condon C, et al. Transforming chronic illness management through Integrated Care: a systematic review of what works best and why. Int J Integr Care. 2016;16(6):A394.","journal-title":"Int J Integr Care"},{"key":"2471_CR16","doi-asserted-by":"crossref","unstructured":"Nolan-Isles D, Macniven R, Hunter K, Gwynn J, Lincoln M, Moir R, Dimitropoulos Y, Taylor D, Agius T, Finlayson H, Martin R, Ward K, Tobin S, Gwynne K. Enablers and barriers to Accessing Healthcare Services for Aboriginal People in New South Wales, Australia. Int J Environ Res Public Health. 2021;18(6).","DOI":"10.3390\/ijerph18063014"},{"key":"2471_CR17","volume-title":"Cardiovascular, diabetes and chronic kidney disease series no3","author":"Australian Institute of Health Welfare","year":"2014","unstructured":"Australian Institute of Health Welfare. Cardiovascular disease, diabetes and chronic kidney disease: Australian facts: morbidity - hospital care. In: AIHW, editor. Cardiovascular, diabetes and chronic kidney disease series no3. Canberra: AIHW; 2014."},{"key":"2471_CR18","doi-asserted-by":"crossref","unstructured":"Chen W, Howard K, Gorham G, O\u2019Bryan CM, Coffey P, Balasubramanya B, Abeyaratne A, Cass A. Design, effectiveness, and economic outcomes of contemporary chronic disease clinical decision support systems: a systematic review and meta-analysis. J Am Med Inform Assoc. 2022:ocac110.","DOI":"10.1093\/jamia\/ocac110"},{"issue":"1","key":"2471_CR19","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s43058-021-00234-6","volume":"3","author":"W Chen","year":"2022","unstructured":"Chen W, O\u2019Bryan CM, Gorham G, Howard K, Balasubramanya B, Coffey P, Abeyaratne A, Cass A. Barriers and enablers to implementing and using clinical decision support systems for chronic diseases: a qualitative systematic review and meta-aggregation. J Implement Sci Commun. 2022;3(1):1\u201320.","journal-title":"J Implement Sci Commun"},{"issue":"1","key":"2471_CR20","doi-asserted-by":"publisher","first-page":"66","DOI":"10.1186\/s12916-018-1050-6","volume":"16","author":"T Greenhalgh","year":"2018","unstructured":"Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A\u2019Court C, Hinder S, Procter R, Shaw S. Analysing the role of complexity in explaining the fortunes of technology programmes: empirical application of the NASSS framework. BMC Med. 2018;16(1):66.","journal-title":"BMC Med"},{"issue":"11","key":"2471_CR21","doi-asserted-by":"publisher","first-page":"e367","DOI":"10.2196\/jmir.8775","volume":"19","author":"T Greenhalgh","year":"2017","unstructured":"Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A\u2019Court C, Hinder S, Fahy N, Procter R, Shaw S. Beyond adoption: a New Framework for Theorizing and evaluating nonadoption, abandonment, and challenges to the Scale-Up, Spread, and sustainability of Health and Care technologies. J Med Internet Res. 2017;19(11):e367.","journal-title":"J Med Internet Res"},{"key":"2471_CR22","unstructured":"Harry E, Pierce RG, Kneeland P, Huang G, Stein J, Sweller J. Cognitive load and its implications for health care. NEJM Catalyst. 2018;4(2)."},{"key":"2471_CR23","doi-asserted-by":"crossref","unstructured":"Snipp CM. What does data sovereignty imply: what does it look like? In: Tahu Kukutai and John Taylor, editor. Indigenous data sovereignty: Toward an agenda. Canberra: The Australian National University ANU Press, Australia; 2016. p. 39\u201356.","DOI":"10.22459\/CAEPR38.11.2016.03"},{"key":"2471_CR24","unstructured":"NHS Digital. Clinical Risk Management: Its Application in the Deployment and Use of Health IT Systems - Implementation Guide. In: Standardisation Committee for Care Information, editor. Surrey UK.2016."},{"key":"2471_CR25","unstructured":"NHS Digital. Clinical Risk Management: Its Application in the Manufacture of Health IT Systems - Implementation Guide. In: Standardisation Committee for Care Information, editor. Surrey UK.2016."},{"issue":"1","key":"2471_CR26","doi-asserted-by":"publisher","first-page":"320","DOI":"10.1186\/s12882-022-02947-9","volume":"23","author":"W Chen","year":"2022","unstructured":"Chen W, Abeyaratne A, Gorham G, George P, Karepalli V, Tran D, Brock C, Cass A. Development and validation of algorithms to identify patients with chronic kidney disease and related chronic diseases across the Northern Territory, Australia. BMC Nephrol. 2022;23(1):320.","journal-title":"BMC Nephrol"},{"key":"2471_CR27","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/1479-5876-12-S2-S9","volume":"12","author":"F Velickovski","year":"2014","unstructured":"Velickovski F, Ceccaroni L, Roca J, Burgos F, Galdiz JB, Marina N, Lluch-Ariet M. Clinical decision support systems (CDSS) for preventive management of COPD patients. J Translational Med. 2014;12:1\u201310.","journal-title":"J Translational Med"},{"key":"2471_CR28","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1038\/kisup.2012.73","volume":"3","author":"KDIGO","year":"2013","unstructured":"KDIGO. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3:1\u2013150.","journal-title":"Kidney Int Suppl"},{"issue":"2","key":"2471_CR29","doi-asserted-by":"publisher","first-page":"85","DOI":"10.5694\/mja16.00526","volume":"205","author":"GM Gabb","year":"2016","unstructured":"Gabb GM, Mangoni AA, Anderson CS, Cowley D, Dowden JS, Golledge J, Hankey GJ, Howes FS, Leckie L, Perkovic V. Guideline for the diagnosis and management of hypertension in adults\u20142016. Med J Aust. 2016;205(2):85\u20139.","journal-title":"Med J Aust"},{"key":"2471_CR30","unstructured":"Gliklich RE. Managing Patient Identity Across Data Sources. In: Dreyer NA, Leavy MB, editors. Registries for Evaluating Patient Outcomes: A User\u2019s Guide [Internet]. 3rd edition. Rockville (MD): Agency for Healthcare Research and Quality (US); 2014."},{"issue":"6","key":"2471_CR31","doi-asserted-by":"publisher","first-page":"e207385","DOI":"10.1001\/jamanetworkopen.2020.7385","volume":"3","author":"S Khairat","year":"2020","unstructured":"Khairat S, Coleman C, Ottmar P, Jayachander DI, Bice T, Carson SS. Association of Electronic Health Record Use with physician fatigue and efficiency. JAMA Netw Open. 2020;3(6):e207385\u2013e.","journal-title":"JAMA Netw Open"},{"key":"2471_CR32","doi-asserted-by":"crossref","unstructured":"Gulla J, Neri PM, Bates DW, Samal L. User requirements for a chronic kidney disease clinical decision Support Tool to Promote Timely Referral. Int J Med Informatics. 2017;101:50\u20137.","DOI":"10.1016\/j.ijmedinf.2017.01.018"},{"key":"2471_CR33","doi-asserted-by":"crossref","unstructured":"Margheri A, Masi M, Miladi A, Sassone V, Rosenzweig J. Decentralised provenance for healthcare data. Int J Med Informatics. 2020;141:104197.","DOI":"10.1016\/j.ijmedinf.2020.104197"}],"updated-by":[{"DOI":"10.1186\/s12911-024-02492-5","type":"correction","label":"Correction","source":"publisher","updated":{"date-parts":[[2024,3,28]],"date-time":"2024-03-28T00:00:00Z","timestamp":1711584000000}}],"container-title":["BMC Medical Informatics and Decision Making"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12911-024-02471-w.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12911-024-02471-w\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12911-024-02471-w.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,3,28]],"date-time":"2024-03-28T11:02:33Z","timestamp":1711623753000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcmedinformdecismak.biomedcentral.com\/articles\/10.1186\/s12911-024-02471-w"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,3,8]]},"references-count":33,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["2471"],"URL":"https:\/\/doi.org\/10.1186\/s12911-024-02471-w","relation":{"correction":[{"id-type":"doi","id":"10.1186\/s12911-024-02492-5","asserted-by":"object"}]},"ISSN":["1472-6947"],"issn-type":[{"value":"1472-6947","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,3,8]]},"assertion":[{"value":"31 August 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"26 February 2024","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"8 March 2024","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"28 March 2024","order":4,"name":"change_date","label":"Change Date","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"Correction","order":5,"name":"change_type","label":"Change Type","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"A Correction to this paper has been published:","order":6,"name":"change_details","label":"Change Details","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"https:\/\/doi.org\/10.1186\/s12911-024-02492-5","URL":"https:\/\/doi.org\/10.1186\/s12911-024-02492-5","order":7,"name":"change_details","label":"Change Details","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Ethics approval for the study was granted by the Northern Territory Human Research Ethics Committee (NTHREC) NTHREC 2021\u20134102. All research was performed in accordance with the Declaration of Helsinki and participants involved in the formative and process evaluation provided informed consent to participate.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors report no conflicts of interest.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflicts of interest\/competing interests"}}],"article-number":"69"}}