AU2006200412B2 - Individualized patient care management system - Google Patents

Abstract

INDIVIDUALIZED PATIENT CARE MANAGEMENT SYSTEM The invention provides individualized health assessment reports, care plans and follow-up review templates for patients at risk of or who are known to have one or more 5 chronic health disorders, such as cardiovascular disease, osteoporosis and diabetes. The reports, care plans and templates are generated based on comprehensive patient data collected on a plurality of chronic diseases. Individualized reports (221) include treatment individualized recommendations for the patient. A summary report (228) can be generated that can provide information to the physician comparing the results achieved 10 with the physician's patient to results received by a group of the physician's peers with similar patients. The invention facilitates the creation of health care planning and implementation using best practices techniques for preemptive care of patients with chronic diseases. Follow-through by respective physicians and resources planning (e.g., appointment scheduling) is facilitated using a database for the patient data where the 15 database is accessible by each health care provider for the patient being treated. CENTRALIZED SERVER 102 SERVER PATIENT CARE SERVER MANAGEMENT SYSTEM C+- APDATABASE COMMUNICATIONS CLIENTS 112 CLIENT APPLICATION PACKAGE - -- -- -' CLIENT CARE CLIENT MANAGEMENT DATABASE L -----------

Description

S&F Ref: 750342 AUSTRALIA PATENTS ACT 1990 COMPLETE SPECIFICATION FOR A STANDARD PATENT Name and Address Merck Sharp & Dohme (Australia) Pty Ltd, of 54-68 of Applicant: Femdell Street, South Granville, New South Wales, 2142, Australia Actual Inventor(s): Geoffrey James Pollard Gregory Lyubomirsky Address for Service: Spruson & Ferguson St Martins Tower Level 35 31 Market Street Sydney NSW 2000 (CCN 3710000177) Invention Title: Individualized patient care management system Associated Provisional Application Details: [33] Country: [31] Appl'n No(s): [32] Application Date: AU 2005902304 06 May 2005 The following statement is a full description of this invention, including the best method of performing it known to me/us: 5845c INDIVIDUALIZED PATIENT CARE MANAGEMENT SYSTEM FIELD OF THE INVENTION [00011 The invention relates to patient care management systems and, in particular, to a 5 computerized patient care management system that produces individualized, multidisciplinary patient reports and care plans for patients with one or more chronic diseases. BACKGROUND OF THE INVENTION [0002] Health care is typically provided by health care enterprises such as hospitals, 10 clinics, physician groups, or solo practitioners. Recently, these enterprises have come under increased pressure to treat patients according to current accepted best practices set forth by local and international guidelines. [00031 Following current accepted best practices in the healthcare industry is difficult for many reasons. For example, typically a patient decides to visit a physician for 15 treatment of a specific problem, selects a physician and requests an appointment. The attending physician typically treats the presenting problem and sends the patient on his way. Although the patient can well have other potentially interacting conditions, the amount of time allotted for the standard appointment usually does not permit a holistic evaluation of the patient. Therefore, the physician is unlikely to make recommendations 20 to treat more than the presenting problem and may not consider the interaction of his treatment of the presenting problem with other conditions. [00041 Follow-up visits are sometimes required. While a physician may well schedule one or more follow-up visits, the process for continued monitoring of a particular condition is typically patient-driven and informal, or non-existent. Similarly, while the 25 physician may well recommend lifestyle changes, he or she is unlikely to make recommendations that address more than a single problem and is unlikely to track patient progress in any but the most informal way. Also, it is often difficult for a physician to know how his method of treating a condition compares with the methods used by his peers.

-2 [0005] The attending physician may recommend that the patient see a specialist or other allied health professional or the patient can elect on her own to visit one or more specialists or other allied health professional. As a result, a number of health professionals may participate in the treatment of a particular patient. But because there is 5 often little or no co-ordination of treatment between physicians, one physician may not be aware that other physicians are also treating the patient. [0006] Governmental entities in some areas are providing financial incentives for more proactive patient care management. It would be helpful if there were a way to address some of the problems described above and thereby make it easier for health care providers 10 to provide the best possible proactive care for patients in a cost-effective way. SUMMARY OF THE INVENTION [0007] The present invention provides a holistic health assessment for an individual patient. Typically, the health assessment comprises a "baseline assessment report," which addresses chronic health conditions in the patient, including but not limited to 15 cardiovascular disease, diabetes and osteoporosis. The invention calculates risks associated with these chronic health conditions and produces individualized recommendations based on the risk calculation, personal and family history, laboratory results, physical examination results, personal habits (such as smoking), and the like.. The invention can also produce an individualized care plan and/or follow-up review care 20 plan for the patient, which are based in part on these individualized recommendations. [0008] Computer systems configured to operate in accordance with the invention receive baseline assessment information concerning patients at risk of suffering chronic conditions, such as cardiovascular disease, musculoskeletal disease, diabetes and other chronic disorders, and generates a baseline assessment report of the patients' health, 25 which can be displayed on the user's screen or printed out on a printer connected to the computer system. The baseline assessment information typically includes the patient's personal and family history, lifestyle characteristics, physical examination results, laboratory test results, etc. The baseline assessment report of a patient's health typically includes the results of a risk calculation and individualized recommendations for 30 managing any chronic conditions identified in the baseline assessment information.

-3 100091 The invention can also use the information displayed or printed on the baseline assessment report to generate a care plan for treating the patient's chronic healthcare condition. Care plans can include information concerning the patient's health issues, goals, planned actions to achieve the goals, medications, recommendations for care by 5 other health professionals, care requests, and the like. There are several types of care plans in the healthcare industry. Under certain government-sponsored healthcare cost reimbursement systems, a "team care arrangement" is a care plan that must incorporate arrangements a physician has made for involving other healthcare professionals in the treatment of a patient. A "management plan" is a care plan that may incorporate 10 treatment by and/or consultation with other healthcare professionals, but is not required to do so. The invention may be utilized to generate both of these types of care plans. Moreover, the invention may be configured to generate a "preliminary" version of these care plans (i.e., a "preliminary team care arrangement" or "preliminary management plan," which can be reviewed and revised by the appropriate physician or other health 15 care official, possibly in concert with the patient, before it is converted to a "completed care plan." 100101 The invention may also be configured to generate a follow-up review template based on the information contained in the baseline assessment report and the preliminary or completed care plan, which may used to monitor a patient over time and to chart 20 progress of the treatment and changes in patient behavior. Embodiments of the invention can also generate a summary report on outcomes relative to a cohort of a physician's peers, which allows the physician to measure his treatment and results for patients with chronic conditions against the treatments used and results achieved by his peers. 10011] Accordingly, the present invention provides a computer implemented patient 25 care management and communication system comprising a data collector configured to receive data from a patient including data concerning a plurality of multi-disciplinary chronic conditions of the patient and to store said data in a database, a risk calculator that calculates a risk assessment comprising a risk of a health event based on the collected patient data, a cohort analyzer configured to receive comparative information of treatment 30 results achieved when treating other patients similar to the patient and generate a summary report to communicate said results, an individualized recommendations generator that generates at least one individualized patient statement addressing at least -4 one of the plurality of multi-disciplinary chronic conditions identified in the collected patient data for the patient, the individualized patient statement being based on the collected patient data and the risk assessment calculated by the risk calculator, a report/plan generator that generates an individualized health assessment report comprising 5 the patient data received by the data collector, the risk assessment calculated by the risk calculator and the individualized patient statement generated by the individualized recommendations generator; and a plan development module configured to produce an individualized care plan, wherein, if the risk assessment indicates that the patient has a particular chronic disease condition the individualized care plan may comprise a list of 10 medications associated with the particular chronic disease condition, said list of medications having been drawn from a predefined list of drug groups stored on the server database and presented for selection for incorporation in the individualized care plan. The computerized patient care management system also includes a patient care database for storing the collected patient data, plan data and enrollment data for physicians, patients 15 and allied healthcare professionals. 100121 If the risk calculator determines that the patient has coronary heart disease, diabetes or a bone condition, or a significant risk of one of these conditions, then appropriate individualized treatment recommendations are generated based on factors such as patient body mass index, patient hypertension, patient smoking habits, patient 20 lipid abnormalities, patient overweight, and need for lifestyle modification. In response to a risk assessment by the risk calculator that a patient has a particular condition, the invention prompts the user to enter or select a goal, an action intended to achieve the goal, and/or a suggested medication or treatment for the condition. Then the invention will generate preliminary or completed care plan incorporating the selected goals, actions, 25 medications and treatments. Preferred embodiments of the invention are configured to transmit the collected patient care data to a remote database, as well as receive patient care data from such remote databases. 100131 The invention, which tracks information pertaining to the treating physicians and other allied health care professionals, as well as the patients, also facilitates patients' 30 access to the appropriate allied health care professionals, thereby supporting intervention for chronic health conditions including cardiovascular disease, osteoporosis and the like. The invention is intended to encourage physicians to follow best practice recommendations when treating patients, including those with multiple health conditions.

-4a The invention improves compliance with local and international guidelines by providing structure, analysis, feedback and support via the generation of multi-disciplinary templates that help formulate health management plans for patients with multiple diseases. 5 BRIEF DESCRIPTION OF THE DRAWINGS [00141 The foregoing summary, as well as the following detailed description of illustrative embodiments, are better understood when read in conjunction with the appended drawings. For the purpose of illustrating the invention, there is shown in the -5 drawings exemplary constructions of the invention; however, the invention is not limited to the specific methods and instrumentalities disclosed. In the drawings: 100151 FIG. 1 is a block diagram showing an exemplary networked computing environment in which aspects of the invention can be implemented; 5 [0016] FIG. 2 depicts a high-level block diagram of a patient care management system configured to operate on a centralized server in accordance with one embodiment of the invention; [0017] FIG. 3 depicts a high-level block diagram of another embodiment of the invention; 10 [0018] FIG. 4 is a flow diagram of a method for managing patient care in accordance with one embodiment of the invention; [0019] FIGs. 5a-5b illustrate an exemplary baseline assessment report in accordance with one embodiment of the invention; 10020] FIGs. 6a-6b illustrate an exemplary preliminary management plan in accordance 15 with one embodiment of the invention; 10021] FIGs. 6c-6e illustrate an exemplary completed management plan in accordance with one embodiment of the invention; [0022] FIG. 7 is a flow diagram of a method for generating an individualized multi disciplinary patient care plan in accordance with one embodiment of the invention; 20 [00231 FIGs. 8a-8c illustrate an exemplary three month follow-up review template in accordance with one embodiment of the invention; and [0024] FIGs. 9a-9d illustrate an exemplary summary review report in accordance with one embodiment of the invention. DETAILED DESCRIPTION OF ILLUSTRATIVE EMBODIMENTS 25 Overview [0025] The present invention may be implemented via a computer software application, described herein, which assists in data collection and analysis, and which enables -6 physicians to treat and track treatment results for patients with chronic diseases. The application facilitates enrolling physicians, patients and allied healthcare professionals into the program and capturing patient baseline assessment data. It also aids in creating preliminary care plans and completed care plans to implement treatments, as well as 5 follow-up review templates to track treatment results. The invention also enables periodic synchronization of data between remote devices and a centralized database, enabling efficient administration and generation of transactional and analytical reports. [0026] Preferably, although not necessarily, computer software implementations of embodiments of the invention are operated by physicians, specialized nurses and/or 10 patient care managment program "coordinators," who interact with the physicians. Typically, coordinators identify physicians eligible to participate in the program and collect and enter physician enrollment data into the system. Coordinators may also work with physicians to identify and invite eligible patients to the baseline assessment program based on particular clinical risk factors. Coordinators may engage nurses to interview 15 patients in order to collect and enter patient baseline assessment data into the system, and subsequently may upload collected patient baseline assessment information to a centralized database. Coordinators may also operate the invention to perform subsequent data entry functions or prepare care plans at periodic intervals. Typically, the software is configured so that a coordinator only has access to data from patients in the coordinator's 20 territory. Coordinators can use the software to prepare and print preliminary care plans, completed care plans and follow-up review templates, as well as to generate and print summary reports. [00271 In a typical scenario, patients at risk of cardiovascular and musculoskeletal disorders, or who are known to have one or more chronic diseases or conditions, are 25 identified and invited to come into the physician's office for a consultation with a nurse with the goal of improving health outcomes. The nurse will interview the patient (and possibly the physician) to collect a patient's personaland family history, lifestyle characteristics, physical examination results, laboratory test results, etc.. All of this information, called "baseline assessment information," is entered into the software 30 implemented embodiment of the invention. The invention is configured to capture and use this information to generate a baseline assessment report, which typically includes the results of a risk calculation and individualized recommendations for managing any -7 identified conditions. Based on the baseline assessment report, a coordinator operates the invention to produce a preliminary or completed care plan. [00281 The invention may also be operated to produce a follow-up review template based on the preliminary or completed care plan, which can be used for monitoring a 5 patient over time and to chart progress of the treatment and changes in patient behavior. A coordinator may also use the invention to produce a summary report that provides information used for comparing the results achieved by one physician to results achieved by a group of the physician's peers with similar patients. 10 Exemplary Networked Computing Environment [00291 The invention can be utilized in a networked computing environment having one or more server computers, one or more client computing devices and one or more patient care databases, all interacting with each other via a data communications network, such as the Internet. However, the systems and methods in accordance with the disclosed 15 invention can be implemented within a variety of network-based architectures, and thus should not be limited to the examples shown in the figures and discussed in detail below. [00301 FIG. 1 illustrates a block diagram of an exemplary networked computing environment for managing patient care in accordance with one embodiment of the invention. In FIG. 1, computing environment 100 comprises a server patient care 20 management system 104 residing on a centralized server 102, a server database 106, a communications network 108, and one or more (preferably mobile) client computing devices, such as clients 110 and clients 112. [0031] Centralized server 102, server database 106, clients 110 and clients 112 may each comprise or reside on a personal computer (PC), mini- or mainframe computer 25 system. Some or all of clients 110 and clients 112 may also comprise notebook or laptop computers, as well as a variety of different types of handheld wireless computing devices, such as personal digital assistants (PDAs), digital tablets or WEB-enabled cellular telephones. [00321 In accordance with the invention, server patient care management system 104 30 performs or supports one or more of the following tasks: enrolling patients, physicians and allied healthcare professionals into the patient care program described herein, capturing patient baseline assessment data and other patient data, creating care plans and follow-up review templates, periodically synchronizing data between client devices and server database 106, administration of the patient care program, and generating transactional and analytical summary reports. Server patient care management system 5 104 may be implemented as a JAVA web application, as an application under MICROSOFT's .NET platform, or in any other suitable WEB-server technology. Server database 106 can refer to a standalone database, such as but not limited to a standalone ORACLE database, to which remote databases are synchronize, as described below. Server database 106 may be implemented, for example, with ORACLE, ORACLE LITE, 10 WEB-TO-GO, MICROSOFT WINDOWS SERVER, MICROSOFT SQL SERVER, or with any other applicable database management systems. [0033] In some embodiments of the invention, clients 110 comprise one or more (online) user devices which have continuous access to the centralized server 102 and server database 106 via communications network 108. Clients 110 can connect directly 15 to centralized server 102 to execute the software programs comprising server patient care management system 104 and access the associated data in server database 106 directly. Transactions and data entered via clients 110 can be directly applied to server database 106. [0034] Clients 112 comprise one or more (offline) mobile devices that have installed on 20 each of them a client application package 114 comprising a local patient care management system (shown in FIG. 1 as client patient care management system 116) that is substantially identical to server patient care management system 104 residing on centralized server 102. Preferably, and as described below, client patient care management system 116 is configured to operate in substantially the same manner with or 25 without having an active connection to centralized server 102. Preferably, client application package 114 also comprises a local database (depicted in FIG. 1 as client database 118), which contains a subset of the patient and physician data stored in server database 106. When clients 112 are in the offline state (i.e., not communicatively coupled to centralized server 102 and server database 106), they are configured to store new and 30 changed physician and patient data in client database 118. Later, when an online connection to centralized server 102 is established, clients 112 are configured to allow users to log into the server patient care management system 104, for example, to synchronize new and changed data collected offline with the data currently stored in -9 server database 106 (that is, to upload any physician or patient data added or updated since the previous synchronization to the server database 106 and to download any new or changed physician or patient data entered by other users via other devices or servers, which may be applicable to clients 112. 5 100351 Thus, users can operate clients 112 to collect data, such as patient data, physician data, etc., while disconnected from centralized server 102, and then periodically connect to centralized server 102 to synchronize the collected data with server database 106 via the connection. In preferred embodiments of the invention, the connection to the centralized server 104 occurs via a secure high-speed connection, a secure wireless 10 connection, or a secure dial-up network connection, which are well known in the computer networking industry. 100361 Communications network 108 can be a local area network (LAN),wide area network (WAN), an intranet or the Internet. In a networked computing environment in which the communications network 108 is the Internet, for example, the central server 15 102 may comprise one or more WEB servers, with which the client computing devices communicate via any of a number of known protocols, such as, hypertext transfer protocol (HTTP) or wireless application protocol (WAP), as well as other known communication protocols. The client computing devices may be equipped with one or more network-enabled computing applications to gain access to the WEB servers and to 20 receive and display various types of patient care and physician data. [0037] FIG. 2 shows a more detailed block diagram of a patient care management system, such as server patient care management system 104 depicted in FIG. 1, which is configured to execute on a centralized server in accordance with one embodiment of the invention. As shown in FIG. 2, server patient care management system 104 includes a 25 data collector 202 and a report/plan generator 204. The report/plan generator 204 may include a risk calculator 206, individualized recommendations generator 208, and cohort analyzer 210. Patient care management system 104 may also include other components, not here illustrated, such as a data synchronizer, one or more databases, and an administration component. The report/plan generator 204 may be configured to generate 30 a variety of different types of reports, including, for example, a baseline assessment report 220 (with individualized recommendations 221), a preliminary care plan 222, a completed care plan 224, a follow-up review template 226, a summary report 228, as well as other -10 reports and plans (not shown in FIG. 2) for print or display purposes. These reports, recommendations and plans are discussed in more detail below with reference to FIGS. 5a, 5b, 6a-6e, 8a-8c and 9a-9d. [0038] Data collector 202 captures and stores baseline health data for patients. The 5 captured data may include baseline data, pathology and/or radiology data, laboratory data, care plan information and so on. Preferably, the captured data also includes information concerning a number of chronic conditions including cardiovascular, bone and joint (osteoporotic) conditions, diabetes and others. In accordance with privacy concerns and requirements, however, embodiments of invention may be configured to exclude from the 10 data capturing process all information, such as names and addresses, from which the identity of a patient could be ascertained, although the patient may be identified anonymously by reference to an anonymous patient identifier. The anonymous patient identifier may include, for example, some combination of a physician identifier, coordinator identifier and nurse identifier, as well as other information, such as visit date, 15 required to track patient data. [00391 Cohort analyzer 210 permits users, such as program coordinators for the patient care management program, to compare the data, recommendations and the treatment results for multiple physicians, and to produce summary reports to aid such comparisons. [00401 Except for the cohort analyzer 210, which typically exists only on server patient 20 care management systems, the client patient care management systems, such as clients 110 and client 112 in FIG. 1, comprise substantially the same functional components as those that reside on the server patient care management system 104 and operate in substantially the same manner. Accordingly, more details about the other physical components of server patient care management system 104, such as risk calculator 206 25 and individualized recommendations generator 208, are provided below with reference to FIG. 3, which depicts a more detailed illustration of a patient care management system configured to operate, in accordance with embodiments of the invention, on either a client computing device or a centralized server. [0041] As shown in FIG. 3, patient care management system 300 comprises data 30 collector 302, report/plan generator 304, risk calculator 306, individualized recommendation generator 308 and patient care database 318. Preferably, patient care - 11 management system 300 is coupled to an optional monitor 362 (for displaying reports, plans and data entry screens, for instance) and an optional printer 364 (for printing plans and reports). [0042] Data collector 302 is configured to capture data entered by a user, including 5 baseline patient data for one or more patients. It can be configured to operate as a standalone application that resides on the remote device (e.g., client 112 in FIG. 1). Alternatively, data collector 302 can be configured to operate as a WEB server application resident on centralized server 102 and to be accessible via the Internet or other suitable communications network 108. In some embodiments of the invention, data 10 collector 302 is capable of running in a WEB browser. The data captured by data collector 302 may be stored in a database associated with a central server (e.g., server database 106) or a local database associated with the remote device (e.g., patient care database 318 in FIG. 3). [0043] In preferred embodiments, data collector 302 comprises a collection of 15 subroutines configured to display to the user on monitor 362 data entry screens (i.e., online forms) configured to capture data entered by the user via a connected keyboard or other input device (not shown). Thus, data collector 302 comprises enrollment data entry screens 314, baseline assessment data entry screens 316 and plan development data entry screens 328, which are all configured to receive data from a user and store this data in 20 patient care database 318, where it will be accessible to other components of the system. More specifically, users may employ enrollment data entry screens 314 to enter into patient care management system 300 basic information (e.g., names, addresses, telephone numbers, etc.) for physicians, patients and other allied healthcare professionals (i.e., specialists such as neurologists, oncologists, podiatrists, etc.), thereby enrolling them into 25 a patient care management program. As discussed above, however, enrollment data entry screens 314 may also be configured to preserve the privacy of patients by capturing only enough information necessary for tracking chronic health conditions or risks and excluding from capture any information that would allow the patient to be personally identified. 30 [0044] After the physicians, patients and allied healthcare professionals have been enrolled (and their data is stored-sometimes anonymously-in patient care database 318), nurses may use the baseline assessment data entry screens 316 to enter baseline -12 health data (i.e., current and historical health condition data) for specific enrolled patients. Typically, but not necessarily, this step is carried out by having a nurse interview patients and enter patients' responses to a specific set of questions presented on the user interface screen. However, the system also may be configured to permit patients to enter their own 5 responses to health questions. Report/generator 304, risk calculator 306 and individualized recommendation generator 308 will use the baseline data entered via baseline assessment data entry screens 316 to produce the baseline assessment reports and treatment recommendations for patients (shown in FIG. 2 as baseline assessment report 220 and individualized recommendations 221), which are discussed in more detail below 10 with reference to FIGS. 5a and 5b. Physicians, nurses and program coordinators may also invoke the user interface for displaying and printing reports 350 in order to display or print the baseline reports on monitor 362 or printer 364. [0045] Risk calculator 306 typically comprises a software program or subroutine that executes logic defined by a set of risk assessment algorithms designed to evaluate 15 baseline data for a patient to produce an estimation of the risk that a patient will experience an event, such as a heart attack or a bone fracture, associated with a defined set of chronic conditions, such as cardiovascular disease or osteoporosis. Medical research institutions and other groups or individuals concerned with chronic health care issues have developed a number of these risk assessment algorithms, as well as 20 recommendation statements concerning heart disease, osteoporosis and diabetes, based on analyses of patient baseline assessment data. Individualized recommendations generator 308 comprises data and logic for generating recommendation statements for cardiovascular disease (cardio 330), osteoporosis (osteo 332) and diabetes (diabetes 334). [00461 The risk algorithms performed by risk calculator 306 and the cardiovascular 25 disease recommendation statements provided by cardio 330 in individualized recommendations generator 308 in the present invention were derived from research and development conducted at the Department of Epidemiology & Preventive Medicine at Monash University, Australia, and the Framingham Study data, the results of which have been altered to account for local conditions and local populations of Australia. The 30 recommendations for bone and joint related health issues (osteo 332) were developed at the Institute for Bone and Joint Research, University of Sidney, Australia. Risk calculator 306 and individualized recommendations generator 308 may also be configured to use other known risk assessment algorithms and/or other recommendation statements, as - 13 would be apparent to those skilled in the art, to assess baseline data for the purpose of generating treatment recommendations for patients. [0047] Physicians and program coordinators use plan development data entry screens 328, in conjunction with plan development module 320, to develop healthcare plans for 5 specific patients based on the recommendations and reports generated by report/plan generator 304 and individual recommendations generator 308. Thus, as shown in FIG. 3, plan development data entry screens 328 are communicatively linked to plan development module 320, which typically includes software modules, functions or routines for guiding physicians and program coordinators through the process of creating preliminary care 10 plans, completed care plans and follow-up review templates, examples of which are shown in FIGS. 6a-6e and 8a-8c, and discussed in more detail below. The software modules used to create the plans and templates are indicated in FIG. 3 as preliminary care plans 322, completed care plans 324 and follow-up review templates 326. [0048] In preferred embodiments, the user interface for displaying and printing reports 15 and plans 350 is configured to permit a user to select an option to print out the reports and plans associated with a single patient or a single physician, or, alternatively, to select a "bulk printing" option, which will cause the system to print out all at once the reports and plans associated with a multiplicity of patients and/or a multiplicity of physicians. Typically, baseline assessment reports are not stored in patient care database 318. 20 Instead, each time a report is requested, whether it is a report for a single patient or for many patients, the report/plan generator 304 will retrieve baseline data and plan data for the patient from patient care database 318, and invoke risk calculator 306 and individualized recommendation generator 308 to perform a new risk assessment and generate a new list of recommendations, respectively. Consequently, each time a report is 25 requested for a particular patient, the system uses the very latest baseline assessment and plan data available in patient care database 318 for that particular patient. [0049] The data entry and plan development screens may be programmed in hyper-text markup language ("HTML"), for example, and rely on a JAVA interface to the patient care management database 318. Such programming techniques are well known in the 30 computer arts. The embodiment of the invention shown in FIG. 3 may be configured to operate in standalone mode, where there are no connections to other computers or other patient care management databases. Alternatively, the invention may be configured to - 14 operate in server mode (requiring periodic synchronization with remote client patient care management systems and client databases) or client mode (requiring periodic synchronization with remote server patient care management systems and server databases). In cases where patient care management system 300 connects to remote 5 patient care systems and databases, there is also included an optional synchronization module 312, as shown in FIG. 3, which performs the tasks of establishing a connection with the remote patient care management system (via a network interface to remote patient care mgmt systems and databases 370) and synchronizing patient care database 318 with any such remote databases. Thus, any changes made to a patient's data stored in 10 patient care database 318 will be automatically uploaded to the remote database, and any changes made to the patient's data on the remote database will be automatically downloaded to patient care database 318. One example of an optional synchronization module that may be utilized to perform or facilitate the synchronization function on mobile computing devices is Oracle Database Lite, available from Oracle Corporation of 15 Redwood Shores, California, USA. [00501 FIG. 4 illustrates an exemplary method for managing patient care using the system described above. As shown in FIG. 4, the first step is to collect baseline assessment information (step 402 in FIG. 4). This step is typically carried out by using data collector 302. Then a risk calculation is performed (at step 404) by risk calculator 20 306. Next, individualized recommendations for the patient are generated (step 406) by, for example, the individualized recommendation generator 308 in FIG. 3. At step 408, the system generates a baseline assessment report, which typically includes the results of the risk calculation performed at step 404 and the recommendations generated at step 406. Next, at step 410, the system generates a preliminary care plan, comprising, for example, 25 a team care arrangement, a management plan, or both, which contains various goals, treatments and actions recommended for a particular patient based on the baseline assessment report. The preliminary care plan and the baseline assessment report are typically generated by program coordinators and delivered to and discussed with the patient and the patient's doctor. Based on these discussions the preliminary care plan 30 may be modified as appropriate. When the doctor and patient agree (sign off) on the treatment and actions contained in the original or modified preliminary care plan, it is converted to a completed care plan for the patient (step 412). Thus, a preliminary team care arrangement will be converted to a completed team care arrangement, and a - 15 preliminary management plan will be converted to a completed management plan. The system is also configured to permit generating and printing a follow-up review template (step 414) for the completed care plan, which may be used at a later point in time (e.g., 3 months after the completed care plan treatment starts) during any periodic follow up visits 5 between the doctor and the patient (step 416). [0051] An example of the patient data that may be incorporated in a baseline assessment report is illustrated in FIGs. 5a-5b. As shown in FIGs. 5a and 5b, the data captured can include one or more of the following: current and previous conditions that the patient has suffered (e.g., coronary heart disease (CHD) such as heart attack/bypass graft/angina), 10 stroke, diabetes, high blood pressure (hypertension), high cholesterol (hyperlipidaemia) 502 and information concerning whether or not the patient is currently on medication, the name of the medication, whether or not the patient was previously on medication and the name of the previous medication 504. Additional information collected and subsequently displayed or printed can include information concerning patient pain and location, and 15 characterization of the pain. If the patient has osteoarthritis, and if he takes medications therefore, then the baseline assessment report may also include information concerning fractures and locations of fractures, corticosteroid medication, thyroid medication and gastro-protective medication (See section 506 of FIG. 5a). Additional information collected can include whether the patient is a present or past smoker and details 20 concerning his smoking habits and intentions to continue or change his current practices. Similar information for alcohol usage, eating habits (such as adherence to a low fat and/or low salt diet) and exercise habits can also be collected 508. Family history information 512 and results of a physical examination 510 can also be collected. Laboratory test information can be collected, including but not limited to total cholesterol, triglycerides, 25 high and low density cholesterol, blood glucose, microalbumin, creatinine, glomerular filtration rate and average blood glucose level (HbAlC), x-ray results, and so on 514. If the collected data is sufficiently complete, a risk assessment 516 and one or more individualized recommendations 518 based on the collected data and the results of the risk assessment calculation can be produced. Individualized recommendations can 30 include possible treatments, general information, and lifestyle change information and can include personalized interpretations of baseline data for a patient. Individualized recommendations can include recommendations for bone and joint conditions such as osteoporosis 520.

- 16 [0052] In some embodiments of the invention, the algorithm used to generate the appropriate treatment recommendations for a patient can be broken down into three distinct sub-algorithms. These three sub-algorithms are known as the sequence A algorithm, the sequence B algorithm and the sequence C algorithm. 5 [0053] The sequence C algorithm is executed for patients who are known to have coronary heart disease and can perform the following: determination of presence or absence of coronary heart disease, calculation of a body mass index (BMI), determination of hypertensiveness, and determination if patient is on a salt 10 restricted diet, identification of smokers, identification of qualifiers for lipid therapy, identification of overweight, identification of those requiring lifestyle modifications not addressed above, 15 determination of risk of CHD event within next four years, and display/print recommendations based on the above. [00541 The sequence B algorithm is executed for patients who are known to be diabetics and can perform the following: determination of diabetic status, 20 calculation of a body mass index (BMI), determination of hypertensiveness, identification of smokers, identification of qualifiers for lipid therapy, identification of overweight, 25 identification of those requiring lifestyle modifications not addressed above, determination of risk of CHD event within next four years, and display/print recommendations based on the above. [0055] The sequence A algorithm is executed for patients who are not known to have CHD, peripheral vascular disease (PVD) or diabetes and can perform the following: 30 calculation of a body mass index (BMI), determination of hypertensiveness, - 17 identification of smokers, identification of lipid abnormalities, identification of overweight, identification of potential (undetected) diabetes, 5 determination of risk of CHD event within next four years, and display/print recommendations based on the above. [0056] In preferred embodiments of the invention, algorithms A, B and C are executed in the following order: sequence C, sequence B, sequence A. If the patient meets the criteria for sequence C (determined from the baseline assessment data for the patient), 10 sequence C is executed and sequence B and A are not executed. If the patient does not meet the criteria for sequence C, but does meet the criteria for sequence B, then sequence B is executed and sequence C and A are not executed. If a patient does not meet sequence C or B criteria, but meets the criteria set out in sequence A, then the algorithm for sequence A is executed. 15 [00571 Bone and joint related recommendations can also be generated by a fourth sub algorithm and can include the following acts: determination of fracture, determination of x-ray results, determination of bone mass density (BMD), 20 determination of taking medication and if so, which medication, and display/print recommendations based on the above. [0058] Sequence C can be applied to patients who are known to have coronary heart disease (CHD). The processing that is performed is based on baseline assessment information collected for the patient during the data collection phase. Based on the 25 baseline assessment information and calculations and algorithms executed, individualized multidisciplinary information can be provided and appropriate statements can be printed or displayed in the sections corresponding to section 518 on the preliminary care plans, completed care plans or follow-up review plans or on the baseline assessment report (see FIG. 5b). For example, if "CHD" is indicated in personal history section 502 of the 30 baseline assessment report, a body mass index (BMI) is calculated and displayed in section 510. The following is an appropriate way to calculate BMI: BMI (in kg/m2) = weight in kg / (height in meters) 2 - 18 [00591 Hypertensiveness can be determined by ascertaining if the patient has Systolic BP 140 and/or Diastolic BP 90). If the patient is determined to be hypertensive and the patient is currently on medication for hypertension, an appropriate statement such as 5 the following can be printed or displayed in section 518 of FIG. 5b: "Although antihypertensive treatment has been prescribed, <identifier's> blood pressure is above recommended levels. In view of his/her established coronary disease it is important that his/her blood pressure be well controlled. Consideration should be given to investigating underlying causes (e.g., renal 10 artery stenosis or certain drugs) or increasing medication. It is now recognised that many patients with significant degrees of hypertension require two or three drugs to control hypertension. A beta-blocker and ACE-inhibitor should be included in such combinations as both of these drugs have been shown to reduce mortality in secondary prevention settings." 15 [0060] If section 508 indicates that the patient is on a low salt diet, an appropriate statement, such as: "[identifier] is taking a low salt diet. By avoiding added salt on meals and by using minimal salt in cooking it is possible to produce a small, but worthwhile 20 reduction in blood pressure. Salt restriction also enhances the effectiveness of some antihypertensive, particularly ace-inhibitors. He/she should therefore be encouraged to maintain this habit." can be printed or displayed in section 518 of FIG. 5b. 25 [00611 If section 508 indicates that the patient is not on a low salt diet 508, an appropriate statement, such as: "[identifier] is apparently not restricting his/her salt intake despite being hypertensive. By avoiding added salt on meals and by using minimal salt in 30 cooking it is possible to produce a small, but worthwhile reduction in blood pressure. Salt restriction also enhances the effectiveness of some antihypertensive, particularly ace-inhibitors.". can be displayed in section 518 of FIG. 5b. 35 [0062] If section 504 indicates that the patient is not on medication for hypertension, (no antihypertensive drugs are listed on baseline assessment) an appropriate statement, such as: "<identifier> has a significantly elevated blood pressure. If this elevation is 40 confirmed treatment for hypertension should be instigated as a high priority. A - 19 beta-blocker and/or ACE-inhibitor is an appropriate initial drug in most cases. However, most patients with significant levels of hypertension require two or three drugs to achieve adequate blood pressure control. A target of less than 140 mmHg systolic and 80 mmHg diastolic is desirable." 5 can be displayed in section 518 of FIG. 5b, followed by the on low salt diet statement or not on low salt diet statement, as appropriate. [00631 Smokers/nonsmokers can be identified. If section 508 indicates that the patient 10 is a smoker, an appropriate smoker statement, such as: "[identifier's] smoking habit is the greatest threat to his/her future health and well-being. By itself it causes premature heart disease and cancer. It also magnifies the effects of other risk factors such as high cholesterol and high blood pressure. 15 If he/she stops smoking now his/her excess cardiovascular risk will drop by half within a year but it will take about 15 years for most of the risk it confers to disappear. 20 For help to give up smoking he/she could be referred to a local agency such as 'Quitline'." can be displayed in section 518 of FIG. 5b. If the patient is not a smoker, but has a smoking history within the past 5 years, an appropriate statement, such as: 25 "[identifier] reports that he/she quit smoking within the last five years. This is the most important step possible to improving his/her further health and well-being. His/her excess cardiovascular risk is halved within one year of complete cessation and will progressively return to "non-smoker' levels over about 15 years." 30 can be displayed in section 518 of FIG. 5b. [0064] Qualifiers for lipid therapy are considered. If the total cholesterol > 4 and the patient is currently taking drugs that belong to the Statin class, then an appropriate 35 statement, such as: "[identifier] has a total cholesterol which is higher than advisable for an individual with previous coronary heart disease. However the questionnaire indicates that he/she is currently receiving medication to lower cholesterol levels. The next steps are: 40 1. Review compliance with dietary advice. All lipid-lowering drugs lower cholesterol more effectively if a low fat diet is prescribed concomitantly. 2. Review compliance with medication. Many patients take cholesterol lowering medication irregularly after the first few weeks of therapy.

- 20 3. Consider changing drug therapy to a more potent drug or combination of drugs." can be displayed in section 518 of FIG. 5b. 5 [0065] If the patient's total cholesterol > 4.0mmol/l and the patient is not taking drugs that belong to the Statin class then an appropriate statement, such as: "[identifier] has lipid levels which are elevated for an individual with established coronary heart disease and qualifies him/her for lipid lowering therapy 10 under the current PBS (Pharmaceutical Benefits Scheme i.e. Australia's national pharmaceutical reimbursement system) guidelines. Statin therapy should be introduced with the aim of reducing the total cholesterol level to 4.0 mmol/L or less. Along with medication, his/her dietary practices should be reviewed with 15 an emphasis on maintaining a low intake of saturated animal fats. An appropriate low-fat diet should include a minimal intake of meat, full-cream milk, pastries, cakes, biscuits and butter containing foods. [identifier] should be warmed that this is lifelong therapy and compliance must be maintained." 20 can be displayed in section 518 of FIG. 5b. [0066] If the patient's total cholesterol 54.0 mmol/l and the patient is currently taking drugs that belong to Statin class) then a statement, such as: 25 "His/her cholesterol level has been reduced below the PBS treatment qualifying level. It is important to ensure that compliance with treatment is maintained and to ensure that his/her cholesterol level is reduced as much as practical." 30 can be displayed in section 518 of FIG. 5b. [0067] If the patient's total cholesterol < 4.0 mmol/L and the patient is not taking drugs that belong to the Statin class, then a statement, such as: "[identifier] does not qualify for lipid lowering therapy under current PBS 35 guidelies. However, most Australians will benefit from optimal blood lipid levels which is best achieved by a diet low in saturated fats." can be displayed in section 518 of FIG. 5b.

- 21 [0068] A determination can be made as to whether the patient is overweight based on the BMI calculation displayed in section 510. If the patient's BMI > 30, an appropriate statement, such as: "[identifier] is seriously overweight - to a degree that places him/her at 5 serious risk of diabetes, arthritis and heart disease. A serious attempt of weight loss is imperative for the maintenance of good health. A low calorie diet should be presented and consideration given to referral to a dietician if the response is insufficient or not-sustained." 10 Individuals whose BMI is in excess of 35 and have not responded to diet, or whose weight is progressively increasing, can benefit from specialist referral." can be displayed in section 518 of FIG. 5b. 15 [0069] If the patient's BMI > 25 and BMI <= 30, an appropriate statement, such as: "[identifier] is mild to moderately overweight and this should be addressed now. Even this level of excess weight can place him/her at risk of diabetes, arthritis and heart disease. Instruction should be given about the value of a low calorie diet to bring his/her BMI to a more satisfactory level (i.e. BMI less 20 than or equal to 25)." can be displayed in section 518 of FIG. 5b. [0070] On the other hand, if the patient's BMI > 18 and BMI <= 25, an appropriate 25 statement, such as: "[identifier] is within the ideal weight range. He/she may however still benefit from a low fat diet because of its beneficial influence on the development of atherosclerosis." 30 can be displayed in section 518 of FIG. 5b. [0071] If the patient's BMI <= 18, an appropriate statement, such as: "[identifier] is below the health weight range and it is not advisable to alter his/her diet without consideration of its likely effect on his/her calorie 35 intake." can be displayed in section 518 of FIG. 5b.

- 22 [0072] Identification of those requiring lifestyle modifications not addressed above can be performed next. If section 508 of the baseline assessment report indicates that the patient "never or hardly ever" exercises, an appropriate statement, such as: "He/she reports none or little physical exercise. If no contra-indications 5 (e.g., arthritis ) he/she should be encouraged to undertake about 30 minutes per day of brisk walking (or equivalent). Benefits include reduced weight, lower blood pressure and an improved lipid profile." can be displayed in section 518 of FIG. 5b. 10 [0073] If section 504 of the baseline assessment report indicates that the patient's medications for CHD does not include "Aspirin" or that the patient's medication for NSAIDs does not include "aspirin", an appropriate statement, such as: "Because of its ability to reduce cardiovascular risk, low dose 15 aspirin is recommended for all patients over the age of 30 years. In cases of aspirin intolerance Clopidogret may be considered as a suitable alternative." can be displayed in section 518 of FIG. 5b. 20 [0074] It will be appreciated that the recommendations displayed or printed for other sequences, such as for example, for Sequence B patients (diabetics), although addressing the same health condition (e.g., overweight, hyperlipidemia, etc). can be customized for the health condition the patient has. [0075] In some embodiments of the invention, data for the preliminary care plan is 25 entered by a patient care coordinator and is discussed with a general practitioner physician prior to the physician/patient consultation. [0076] When the data collection phase is complete, the report/plan generator 304 can generate a preliminary care plan 222. A preliminary care plan 222 refers to a template that is generated based on a patient's baseline data and the results of a risk calculation run 30 on the patient's data (i.e., a patient's risk profile). The preliminary care plan 222 can also include a plan of actions intended to improve patient health outcomes, a medication plan, and referrals to other physicians or health care professionals and care requests. In some cases, the preliminary care plan will comprise a preliminary team care arrangement or a preliminary management plan, as defined by certain governmental healthcare cost -23 reimbursement programs. The preliminary care plan 222 can be prepared by a coordinator for the review and modification (if desired) by a physician for use by the physician when consulting with the patient. The preliminary care plan 222 can be modified by a physician (potentially in concert with the patient) to develop the completed 5 care plan 224. The information collected on the completed care plan 224 can be used to generate the three month review plan using the process described with respect to FIG. 7, described below. [0077] An exemplary preliminary care plan, as discussed above, is illustrated in FIGs. 6a-6b. In this case, and as shown by its title 652, the preliminary care plan comprises a 10 preliminary management plan, even though it incorporates information about an allied healthcare professional. Production of a preliminary care plan can include one or more of the following acts as represented in FIG. 7: selection of a health issue 702, selection of a goal for the health issue 704, selection of a planned action for the health issue 706, selection of one or more medications to treat the health issue 708, selection of a health 15 care professional to whom the patient can be referred 710 and selection of a care request for the selected referral 712. This process can be repeated for each health issue. It will be appreciated that although the process is depicted as occurring in a particular sequence, no particular sequence of acts is contemplated, with the exception that a health issue must be selected before acts 704 through 712 can be completed. 20 [0078] Health issues can include but are not limited to one or more of: PVD (peripheral vascular disease), coronary heart disease (CHD), diabetes, hyperlipidemia, hypertension, impaired glucose tolerance, osteoarthritis, osteoporosis, overweight, smoker and so on. Health issues can be selected from a pre-defined list and subsequently modified to customize the health issue to the patient. A number of health issues can be selected for 25 each patient. A health issue not listed in the predefined list can be entered as an "other" option. In the exemplary preliminary care plan of FIGs. 6a-6b, health issues are represented by coronary heart disease (CHD) 602, hypertension 603 and osteoporosis 604. 100791 Upon selection of a health issue, one or more goals (as represented by goal 606 30 for health issue 602 and goal 608 for health issue 604) can be selected from a pre-defined list. The selected goal(s) for each health issue can be subsequently modified to customize the goal(s) to the patient.

- 24 [0080] After selection of a health issue, a planned action addressing the health issue (as represented by action 610 for health issue 602 and by action 612 for health issue 604) can be selected from a pre-defined list. The selected action(s) can subsequently be modified to customize the action(s) to the patient's needs. 5 [00811 After selection of a health issue, a list of predefined medications or a list of drug groups and a list of medications in the drug group can be displayed for selection. A medication approach (e.g., start medication, titrate medication dosage, maintain medication dosage at current level, change medication to [...], add new medication) can be associated with each selected medication. Medications so selected are represented by 10 medication 614 for health issue 602 and by medication 616 for health issue 604. [0082] After selection of a health issue, a health care professional can be selected to help manage the patient's health. The health care professional can be selected from a predefined list, or a new professional can be added. Associated information such as professional type, (cardiologist, diabetic educator, etc.), name of professional, contact 15 details and care request can also be selected. Professionals and associated information so selected are represented by professional 618 for health issue 602 and by professional 620 for health issue 604. Care requests for the selected professional are represented by care request 622 for professional 618 and care request 624 for professional 620. [00831 A summary of the preliminary care plan and a review date can be entered on the 20 preliminary care plan (see section 626 of FIG. 6a and section 628 of FIG. 6b, respectively). Although the review date can be set at any subsequent time period, it is suggested by the inventors that the review date not be less than three months from the initial physician-patient consultation. [0084] In some embodiments of the invention, the completed care plan 654 (FIG. 6b) is 25 substantially identical in format to the preliminary care plan; however, the content comprises the preliminary plan information which has been reviewed and potentially updated by the physician. [0085] FIGs. 8a-8c illustrate an example of a follow-up review template that can be generated in accordance with the invention. In this example, the follow-up review 30 template is based on a management plan. However, it could also be based on a team care arrangement. The follow-up review template can include information from the completed - 25 patient care plan (e.g., goals 802, actions 804, and medications 806 for each health issue as well as check boxes (e.g., check boxes 808, 810 and 812) to indicate that the item was not achieved 808, is in progress 810, or has been achieved 812. The follow-up review template also contains sections to indicate the next steps to be taken 814 and any changes 5 to medications 816. In some embodiments of the invention, personal history information is reviewed for changes from the baseline assessment (as illustrated in FIG. 8c). The risk assessment calculation can be rerun so that initial risk and current risk can be compared (not shown). [0086] FIGs. 9a-9d illustrate a Summary Report. The summary report for a physician 10 can include one or more of the following: the number of patients assessed by the physician and by a cohort of physicians 902, the number of patients with plans prepared by the physician and by a cohort of physicians 904, the number of patients with completed plans by the physician and by a cohort of physicians 906, the number of patients reviewed at follow up by the physician and by a cohort of physicians 908. The 15 Summary Report may also include a comparison of treatment results that a cohort of the physician's peers achieved when treating patients similar to the physician's patients. [0087] The various techniques described herein may be implemented in connection with hardware or software or, where appropriate, with a combination of both. Thus, the methods and apparatus of the present invention, or certain aspects or portions thereof, 20 may take the form of program code (i.e., instructions) embodied in tangible media, such as floppy diskettes, CD-ROMs, hard drives, or any other machine-readable storage medium, wherein, when the program code is loaded into and executed by a machine, such as a computer, the machine becomes an apparatus for practicing the invention. In the case of program code execution on programmable computers, the computing device will 25 generally include a processor, a storage medium readable by the processor (including volatile and non-volatile memory and/or storage elements), at least one input device, and at least one output device. One or more computer programs may be utilized to create and/or implement the domain-specific programming models. Aspects of the present invention, e.g., through the use of a data processing API or the like, are preferably 30 implemented in a high level procedural or object oriented programming language to communicate with a computer system. However, the program(s) can be implemented in assembly or machine language, if desired. In any case, the language may be a compiled or interpreted language, and combined with hardware implementations.

- 26 [0088] While the present invention has been described in connection with the preferred embodiments of the various figures, it is to be understood that other similar embodiments may be used or modifications and additions may be made to the described embodiments for performing the same function of the present invention without deviating therefrom. 5 Therefore, the present invention should not be limited to any single embodiment, but rather should be construed in breadth and scope in accordance with the appended claims.

Claims (23)

1. A computer implemented patient care management and communication system comprising: a data collector configured to receive data from a patient including data 5 concerning a plurality of multi-disciplinary chronic conditions of the patient and to store said data in a database; a risk calculator that calculates a risk assessment comprising a risk of a health event based on the collected patient data; a cohort analyzer configured to receive comparative information of 10 treatment results achieved when treating other patients similar to said patient and generate a summary report to communicate said results; an individualized recommendations generator that generates at least one individualized patient statement addressing at least one of the plurality of multi disciplinary chronic conditions identified in the collected patient data for the patient, the 15 at least one individualized patient statement being based on the collected patient data and the risk assessment calculated by the risk calculator; a report/plan generator that generates an individualized health assessment report comprising the patient data received by the data collector, the risk assessment calculated by the risk calculator and the at least one individualized patient statement 20 generated by the individualized recommendations generator; and a plan development module configured to produce an individualized care plan wherein, if the risk assessment indicates that the patient has a particular chronic disease condition, the individualized care plan may comprise a list of medications associated with the particular chronic disease condition, said list of medications having 25 been drawn from a predefined list of drug groups stored on the server database and presented for selection for incorporation in the individualized care plan.

2. The patient care management system of claim 1, further comprising a patient care management database for storing the patient data received by the data collector. -28

3. The patient care management system of claim 1, wherein the data collector comprises at least one baseline assessment data entry screen configured to receive patient enrollment data for enrolling the patient.

4. The patient care management system of claim 1, wherein the data collector 5 comprises at least one enrollment data entry screen configured to receive physician enrollment data for enrolling at least one physician.

5. The patient care management system of claim 4, wherein the at least one enrollment data entry screen is further configured to receive allied healthcare professional data for enrolling at least one allied healthcare professional. 10

6. The patient care management system of claim 1, wherein the data collector comprises at least one plan development data entry screen configured to receive treatment plan data.

7. The patient care management system of claim 1, wherein the health event comprises at least one of the following: 15 coronary heart disease; diabetes; and a bone or joint condition.

8. The patient care management system of claim 1, wherein in response to the risk assessment, the individualized health assessment report includes at least one 20 individualized treatment recommendation based on one or more of a patient body mass index, a patient hypertension, a patient smoking habit, a patient lipid abnormality, a patient weight, or a patient lifestyle.

9. The patient care management system of claim 1, wherein if the risk assessment calculated by the risk calculator indicates that a patient had or has a significant risk of a 25 bone and joint condition, the individualized health assessment report includes at least one recommendation based on patient data collected by the data collector including at least one of patient fracture data, patient x-ray results, patient bone mass density, or prescribed patient osteoporosis medication. - 29

10. The patient care management system of claim 1, wherein if the risk assessment calculated by the risk calculator indicates that a patient has a particular chronic disease condition, the individualized health assessment report includes a goal, an action intended to achieve the goal, and a suggested medication to treat the particular chronic disease 5 condition.

11. The patient management system of claim 1, further comprising: a synchronization module; and a network interface; wherein the patient data received by the data collector is transmitted to a remote 10 database via the synchronization module and the network interface.

12. The patient care management system of claim 1, further comprising: a plan development module configured to produce an individualized care plan; wherein, if the risk assessment indicates that the patient has a particular chronic disease condition, the individualized care plan includes a list of goals associated with the 15 particular chronic disease condition.

13. The patient care management system of claim 12, wherein the individualized care plan further includes a list of actions associated with the particular chronic disease condition.

14. The patient care management system of claim 13, wherein if an action in the list of 20 actions is a referral to an allied health professional, the individualized care plan includes information concerning the allied health care professional.

15. The patient care management system of claim 12, wherein the plan development module is configured to generate a periodic review plan template for facilitating monitoring of the patient against the individualized care plan over time. 25

16. A computer readable non-transitory storage medium storing a computer executable program for directing a processor to execute a method for patient care -30 management and communication, the program comprising: computer executable code for collecting patient care data relating to the health of a patient to establish a baseline assessment of the patient's health condition; computer executable code for calculating the patient's risk for particular chronic 5 disease states based on the baseline assessment; computer executable code for receiving comparative information of treatment results achieved when treating other patients similar to the patient and generating a summary report to communicate said results; computer executable code for generating an individualized treatment report for the 10 patient based on the patient's baseline assessment and a result of the risk calculation, the individualized report evaluating any chronic disease conditions of the patient and generating there from a set of individualized statements suggesting treatment for any chronic disease conditions of the patient; and computer executable code for producing an individualized care plan, wherein, if 15 the risk assessment indicates that the patient has a particular chronic disease condition the individualized care plan may comprise a list of medications associated with the particular chronic disease condition, said list of medications drawn from a predefined list of drug groups stored on the server database.

17. The computer readable non-transitory storage medium of claim 16, wherein the 20 individualized statements comprise recommendations for managing a chronic disease condition of the patient.

18. The computer readable non-transitory storage medium of claim 16, wherein the individualized statements comprise at least one goal in the treatment of a chronic disease condition of the patient. 25

19. The computer readable non-transitory storage medium of claim 18, wherein the individualized statements comprise at least one action to achieve the at least one goal.

20. The computer readable non-transitory storage medium of claim 18, wherein the individualized statements comprise at least one recommended medication treatment to achieve the at least one goal. -31

21. The computer readable non-transitory storage medium of claim 18, further comprising monitoring the patient over a period of time and determining if the at least one goal was achieved, in progress or not achieved.

22. A computerized patient care management system substantially as described herein 5 with reference to the accompanying Figures.

23. A method for patient care management substantially as described herein with reference to the accompanying Figures. DATED this 14 th day of March, 2012 10 Merck Sharp & Dohme (Australia) Pty Limited Patent Attorneys for the Applicant SPRUSON & FERGUSON