GPs and diabetes specialists in Wolverhampton are sharing information via Graphnet’s CareCentric portal.

The system covers 16,500 diabetes patients and provides health professionals with an up-to-date picture of their treatment, across care settings. It has been trialled with diabetes patients for five months and will next be rolled out for use with COPD patients.

CareCentric is being used to extract data items from 49 GP practices, which feed data into the trust’s Diabeta3 system. This gives hospital clinicians a picture of a patient’s clinical results, including blood pressure history, cholesterol and creatinine levels.

They are also able to monitor whether foot risk assessments and retinopathy screening have been done and recorded in the patient record.

A locally-developed algorithm produces a list of risk-stratified patients. CareCentric applies this algorithm to its data stores and displays the results in a series of web-based dashboards, highlighting to GPs what needs to be done for each patient to improve their care plan.

“It takes information from all areas and brings it into one place,” said Wolverhampton Clinical Commissioning Group head of business and performance management Mike Hastings.

“It builds relevance into that data and presents it back as gap analysis in the care of patients and allows practices and specialists to improve care.”

Hastings told EHI a team has been working with local practices and the Royal Wolverhampton Hospitals NHS Trust for two to three years, setting up the project.

This involved building trust with GPs to get data sharing agreements in place, developing infrastructure and ensuring all the necessary information governance arrangements are in place.

He explained that the majority of GPs in the area use Emis Web. Those using TPP’s SystmOne provide a monthly extract to the portal, which is accompanied by a note saying the information may not be up to date.

The portal is currently a separate system that doctors must log into, but the CCG is looking at embedding it within the Emis record. Work is underway to also give hospital staff access to a summary of the GP record within their clinical portal.

Hastings said the CCG has taken the approach that if the patient has opted out of the Summary Care Record programme or, their information will not be extracted to the CareCentric portal.