A comprehensive electronic patient record for global risk assessment in a rural community

Interprofessional health care is becoming more prevalent with an increase in chronic diseases such as diabetes and cardiovascular disease. In addition preventative models often require large numbers of risk factors for identification of preclinical cases. CSU has established a diabetes screening clinic augmented by an ACCESS database. The novelty of our work is that the ACCESS database integrates into the public health sector and provides a more comprehensive review of health/disease indicators. Information on traditional health indicators in addition to autonomic nervous system function tests, fundus examination and foot assessment results as well as pro-inflammatory, pro-coagulation and antioxidant biochemistry can be added by the university-based screening clinic as well as by diverse primary health care practitioners and specialists that would otherwise not have access to this detailed information for patient assessment and treatment. Our results are in favour of this interdisciplinary database indicating that over one year we have identified 16.2% of people with no previous medical condition to have pre-diabetes, 2% had retinal disease and 21.5% had foot problems. Moderate to severe ECG anomalies were identified in 19.3% of the participants. Of these, 68.8% were either commenced on treatment, had their treatment changed or received surgery. Our results indicate that a comprehensive EPR manager as part of an interdisciplinary health screening initiative is able to track people that require intervention but were missed in the current public health system as implemented in our community.