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The Health Navigator project was the recipient of a WA Health Excellence Award from the Director General of the WA Department of Health.

Five years ago, project leaders Carol Cunningham, Jenny Howson, Lesley Pearson and Debbie Schofield wrote about the innovative effort, which used Extensia’s shared health record to enable coordinated care for rural and remote people with chronic health conditions.

At almost every health summit or forum, Australia’s lack of systems interoperability is a big topic. The consensus is that, as a system, the health sector struggles to identify chronically ill patients and deal with their conditions effectively.

A partnership in Western Australia is solving such problems using an interoperable shared record system developed in a collaboration between the Silverchain Group, WA Country Health Service (WACHS) and Queensland company Extensia to link other community records. When required, it can also upload them to the national My Health Record system.

In 2013, staff at the WA Country Health Service in the Wheatbelt region needed a way to coordinate care and empower people with chronic health conditions such as diabetes, chronic respiratory and chronic heart conditions to self-manage. The result was a partnership between WACHS and the Silverchain Group to develop and implement the “Health Navigator” program.

This virtual program uses telehealth to deliver care coordination and support clients’ self-management through the use of the Flinders University chronic conditions self-management tools. One priority of Health Navigator is to share clinical information across environments including public health, private GPs, Silverchain Group and non-government organisations including the Asthma Foundation WA and Diabetes WA.

To allow this, Health Navigator makes use of a shared electronic health record developed by Extensia called the Consumer Information Sharing System, or CISS. Once a consumer gives consent, they are registered on CISS and their health information is shared between nominated providers in real time. The consumer can also access their own electronic record.

Consumers have the option to view their CISS health record on their home computer, tablet or mobile phone or on a shared computer at their local library or community resource centre, for example. The program has been promoted through posters and newsletters and clients can self-refer or be recommended to the service by their GP or other health professional.

After a year of education and familiarisation with the consent process where consumers and providers used an “opt in” model for CISS, the consent process was changed to “opt-out”. The outcome has seen a significant increase in the number of consumer registrations.

Health Navigator took the lead for this from Scotland, where 100 per cent of the population is registered in a shared health record program after a similar user education and familiarisation program. When it comes to sharing health information, providing transparency about programs appears to work.

How it works

CISS stores and shares all health information including images, reports, personal monitoring readings, new medications and follow-up treatments. It stores information in any format that is useful for health providers. CISS gives healthcare providers, both internal and external to WACHS, quick access to the information they need where they need it. This leads providers to a better understanding of the client’s health, which can then be efficiently communicated with other health providers in the region.

It also means that, in telehealth consultations, all parties can view CISS, which can save time and make for a more productive telehealth meeting. While all health projects need to have clear goals and measure their success by reporting outcomes, this level of accountability has been difficult to achieve in digital health projects. With CISS, the ability to receive real-time notifications and reports changes that dynamic.

When new clients participate in CISS, real-time notifications are automatically sent to everyone who needs to be informed to ensure they can trigger the necessary downstream processes. The system also automatically identifies certain types of referral, for example by diagnosis, and generates a number of reports from the information stored in CISS. These reports trigger real-time notifications that are automatically sent to members of the care team, enabling timely responses to improve consumer care.

Daily activity reports are sent to the CISS team so they can monitor usage and a graphical statistics report is sent monthly. The monthly report enables the system leads to monitor when information stored in CISS is viewed by multiple healthcare providers, enabling appropriate clinical communication for the benefit of the client. This measures the real purpose of a shared record.

Diabetes and asthma telehealth services

Diabetes WA is partnering with WACHS to deliver diabetes education and support through telehealth to people in regional and rural WA, where there may be limited or no services. CISS allows more efficient integrated care across the partnership because it prevents unnecessary intervention by enabling all health providers involved in a consumer’s care to share health information.

In the Wheatbelt and Great Southern regions of WA, CISS works in conjunction with the Health Navigator service. A two-way referral process is in place where consumers requiring diabetes education are referred by Health Navigator to the Diabetes Telehealth Service (DTS), and DTS refers consumers who need extra support to manage their health to Health Navigator.

Once the consumer has consented, all client health information is shared in CISS. Diabetes educators upload information directly from their clinical software system, Best Practice. GPs upload from their clinical software system, and the Health Navigator coordinators and WACHS health providers enter data via a web portal.

As one consumer said: “When I go to see my GP she’s got all my information, and I see a lot of people so it’s great not to repeat all my information every time.”

Asthma WA, in partnership with the WA Country Health Service and WA Primary Health Alliance, has a program modelled on the Diabetes Telehealth Service which went live on September 1 2016. The service provides education and support for consumers with asthma and COPD and uses CISS to enable appropriate sharing of information between consumers and their providers.

Independent evaluation under way

Australia does have scaleable, interoperable health programs, and the WA Country Health Service has implemented one of them. Starting small, WACHS first registered 800 consumers in greatest need, enabling processes to be fine-tuned and the community to be educated about the new program.

In addition there are approximately 700 healthcare providers using the system, including half of the GPs in the Wheatbelt and Great Southern regions, who are trained and registered to upload to CISS.

Asthma WA and Diabetes WA are on board, and there is no limit to the number of NGOs that can join. It is the first time these organisations have been able to share health information in a privacy-compliant manner across platforms.

All of which is empowering people to live healthier, happier lives. Another consumer said: “It was like a giant weight lifted … and I feel pretty happy about myself.”

We believe Health Navigator shows how a health partnership can use a community shared record like Extensia’s to fill gaps and build bridges between services and deliver health benefits and efficiencies around the country.

About the authors

  • Carol Cunningham is the project officer for CISS with WACHS’s Health Navigator Service
  • Jenny Howson is general manager – regional and health services at the Asthma Foundation WA
  • Lesley Pearson is director of clinical operations for country WA at the Silverchain Group
  • Debbie Schofield is manager of diabetes management at Diabetes WA.

Originally published here.

About the WA Wheatbelt region

The Wheatbelt covers an area of 154,862 square kilometres, and surrounds the Perth metropolitan area. It is home to three distinct Aboriginal groups – Njaki Njaki Nyoongar, Ballardong Nyoonger and Gubrun. The Wheatbelt population of about 76,000 people has a median age of 44 years, with approximately 4.5 per cent of the population identifying as Aboriginal or Torres Strait Islander descent.


Improved quality of care for patients

Reduced duplication of services by improved monitoring and care coordination

Improved patient and family knowledge enabling self-managed health

Improved knowledge of health services

Reduced risk of hospital admissions and unnecessary readmissions

Increased practice capacity to manage patients with chronic or multiple conditions.


Coordinated care for chronic disease

User security and authentication

Interface to desktop clinical systems

Centralised, hosted, shared EHR

Audit logs

Patient consent management.


Extensia clearly displays information from along a patient’s care continuum by integrating with primary, secondary and tertiary health software and non-clinical software systems.

Its ease of use encourages genuine collaboration between healthcare providers for care planning, which is why it has been deployed in Indigenous health, aged care, clinical trials, disabilities care, and chronic disease management in metropolitan, regional, remote settings. It has also been used to share information and enable coordinated care between state-run hospitals and Commonwealth-funded primary care ​systems.

By aggregating data, Extensia also fuels innovation by improving the functionality of health apps, AI, machine learning, mobile devices and emerging technologies.​

Meanwhile, each Extensia community is able to have its own tailored consent model and data governance oversight.


To discuss the benefits of our RecordPoint platform, book your demo with one of our experienced team.