Introduction

In primary care health care systems, primary care physicians (PCPs) provide most basic care services, and if necessary, refer to secondary care for specialized work-up and treatment. If hospital care is required, agreement between PCPs and secondary care physicians (SCPs) on the conditions for patient referral and back-referral are considered crucial to providing high quality patient care. The regional healthcare network of Utrecht, a region in the Netherlands, developed a set of collaborative patient care agreements (CPCAs) for specific chronic conditions. Even though these CPCA are endorsed by all relevant regional health care organisations, the adoption of these agreements in practice remains substandard. In this project, through linkage of routine care data, as registered in daily practice by PCPs and SCPs, a regional transmural care database (RTD) was developed for monitoring the use of the CPCAs. Its data was transformed into’ mirror data’ used to support PCPs and SCPs in discussing and improving current practice and to support a learning healthcare system within the region.

Methods

The development of the RTD is part of a larger action research project on joint care, called ZOUT (an acronym which is translated as “The right care at the right place in the Utrecht region”). The RTD includes data from three regional hospitals, and about 70 affiliated primary care practices which are united in the Julius General Practitioners Network (JGPN). These data were extracted, linked and presented in the form of mirror data, following simple methods to allow replication of our approach. CPCAs addressing transmural care for three chronic conditions were selected. Data from the primary care practices and the hospitals were linked by an independent trusted third party. This enabled relevant hospital data to be added to the primary care dataset, thereby providing transmural routine care data for individual patients.

Results

During the development of the RTD, a roadmap was created including a detailed step-by-step checklist of the organizational, administrative, technical and legal arrangements which needed to be made. Legal and administrative challenges proved most challenging. Also, incompleteness of data and the impossibility to translate several agreements into extractable data limited the potential for providing a comprehensive overview of the extent to which agreements in the CPCA were adhered to in daily care.

Discussion

We present a systematic, comprehensive (technical as well as practical) and reproducible roadmap to developing a regional transmural care database suitable for generating mirror data on joint transmural care between PCPs and SCPs. This approach includes all technical steps in data selection and linkage, as well as the substantive steps that need to be taken in the analysis and application of the results. The mirror data, which reflects the follow-up of agreements formulated in the CPCAs, enabled shared reflection and discussion between PCPs and SCPs. This supports the search for bottlenecks and potentialities for improving daily collaborative care, thereby showing great potential to serve a learning regional healthcare system.

中文翻译：

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开发区域性透壁护理数据库：路线图

介绍

在基层医疗保健系统中，基层医疗医生（PCP）提供最基本的护理服务，如有必要，请参考二级医疗以进行专门的检查和治疗。如果需要医院护理，则PCP和二级护理医师（SCP）之间就患者转诊和转诊条件达成的协议被认为对提供高质量的患者护理至关重要。荷兰乌特勒支地区医疗保健网络针对特定的慢性病制定了一套合作的患者护理协议（CPCA）。尽管这些CPCA得到了所有相关地区医疗保健组织的认可，但在实践中采用这些协议仍然不合标准。在这个项目中，通过联系日常护理数据（由PCP和SCP在日常实践中注册），开发了区域透壁护理数据库（RTD）来监控CPCA的使用。其数据被转换为“镜像数据”，用于支持PCP和SCP讨论和改善当前实践并支持该地区的学习型医疗系统。

方法

RTD的开发是一项有关联合医疗的大型行动研究项目的一部分，该项目名为ZOUT（首字母缩写，翻译为“在乌得勒支地区正确的地点提供正确的护理”）。RTD包括来自三家地区医院的数据，以及约有70种附属的初级保健实践，这些实践被统一在Julius全科医生网络（JGPN）中。按照简单的方法来提取，链接和以镜像数据的形式呈现这些数据，以允许复制我们的方法。选择了针对三种慢性病的透壁护理的CPCA。来自初级保健实践和医院的数据由独立的受信任第三方链接。这样就可以将相关的医院数据添加到初级保健数据集中，从而为每个患者提供透壁常规保健数据。

结果

在RTD的开发过程中，创建了一个路线图，其中包括需要进行的组织，行政，技术和法律安排的详细分步清单。法律和行政挑战被证明是最具挑战性的。同样，数据的不完整以及无法将若干协议转换为可提取的数据也限制了全面概述CPCA在日常护理中遵守协议的程度的潜力。

讨论区

我们提出了系统的，全面的（技术的和实践的）和可复制的路线图，以开发区域性透壁护理数据库，适用于生成有关PCP和SCP之间的联合透壁护理的镜像数据。该方法包括数据选择和链接中的所有技术步骤，以及结果的分析和应用中需要采取的实质性步骤。镜像数据反映了CPCA中制定的协议的后续情况，使PCP和SCP之间可以进行共同的反思和讨论。这为寻找瓶颈和改善日常协作护理的潜力提供了支持，从而显示了为学习型地区医疗保健系统提供服务的巨大潜力。