Background
Methods
Study design
Study sample
BAIX EMPORDÀ COUNTRY | BARCELONA (CIUTAT VELLA) | CITY OF GIRONA | |
---|---|---|---|
Population1
| 91,678 | 99.093 | 83,312 |
Location | Rural and semi-urban | Urban | Urban |
Primary care providers | SSIBE 4 basic health zones | ICS 4 basic health zones PAMEM 1 basic health zone | ICS 4 basic health zones |
Secondary care providers | SSIBE 1 hospital | PSMAR 1 hospital | ICS 1 hospital |
BAIX EMPORDÀ | BARCELONA (CIUTAT VELLA) | CITY OF GIRONA | ||||
---|---|---|---|---|---|---|
PC doctors | SC doctors | PC doctors | SC doctors | PC doctors | SC doctors | |
Female; male | 2; 4 | 7; 2 | ICS: 4; 3 PAMEM: 2; 2 | 1; 6 | 6; 3 | 3; 5 |
Mean age (range) | 51 (44–61) | 43 (35–51) | ICS: 49 (34–58) PAMEM: 54 (48–57) | 53 (39–60) | 50 (39–60) | 47 (38–59) |
Mean years of experience in centre (range) | 16.8 (13–20) | 12.5 (1.5–20) | ICS: 14.7 (2.5–21) PAMEM: 14.0 (10–18) | 14.2 (1.5–35) | 8.6 (1.5–19) | 16.7 (7–28) |
Medical specialities | Family medicine | Cardiology, emergency care, internal medicine, pulmonology, rehabilitation | Family medicine | Cardiology, gastroenterology, endocrinology, emergency care, internal medicine, nephrology, pulmonology | Family medicine | Cardiology, dermatology, endocrinology, emergencycare, internal medicine |
Data collection
Data analysis and quality of information
Results
Mechanisms contributing to clinical coordination between primary and outpatient secondary care
Opinions on the mechanisms based on feedback
Shared electronic medical record
Mechanism | Contribution to clinical care coordination | Illustrative verbatim quotes |
---|---|---|
Feedback mechanisms | ||
Shared medical record
| A1) Exchange of clinical information across care levels | “We all have access to the same system and you can access the medical record and look up everything on a patient. Their treatments, the pathologies they have, the last appointments they’ve had, and the medical history are there so you can see more or less what their family doctor envisaged or intended and we can more or less all tow the same line, you know? So you don’t tell them, like, exactly the opposite” (secondary care doctor, Baix Empordà) |
Clinical case conferences between PC and SC doctors
| B1) Rapid resolution of queries | “We go there and we discuss our queries, yeah? Some patients, often we don’t even have to book them in (refer them) any more, we do the things they instruct or advise us to do, and then, later we explain to them how it develops and so there’s no longer any need for an appointment” (primary care doctor, Girona) |
B2) Increases the response capacity of PC doctors | “You also empower the doctor with certain knowledge which gives them confidence with their patients. I think it’s a very important method, I think that purely virtual (…) is great to resolve some cases but, in some cases physically having the doctor in front of you to discuss it is an added element that brings with it all this stuff I’m saying about, let’s say, the empowerment of the doctor” (secondary care doctor, Barcelona) | |
Virtual consultations between PC and SC doctors
| C1) Rapid resolution of queries | “It’s fantastic, because if I have a query about a patient, what I used to do was ask about it on the phone and then I’d ask about it by email and now I don’t have to. It’s a job that’s been recorded, the specialist has their own space and I say to them “look, I’m not sure about this patient, he doesn’t seem to be a case for referral. I just wanted you to have a quick look at this and tell me what you think and what we can do”, and this way we save a lot of money, a lot of time and trips” (primary care doctor, Baix Empordà). |
C2) Speed up the diagnostic process | “I’ve used them a couple of times and it went well in the sense that I like to have my patients’ cases all tied up, and when I consulted them, because they solved it for me (…) and he said to me, well, order a Holter for him and if it goes well, discharge, and if not, send him to me for the cardiologist, and he let me order the Holter, because normally they order the Holter, and so they gave me that option” (primary care doctor, Baix Empordà). | |
Institutional telephone
| D1) Speeds up access to secondary care | “We answer straight away, we’re delighted to. Look, the other day a doctor who works around here called me, I think he’s one of the switched on ones, with a suspected serious illness, but he called me, eh? And I told him: “Good grief, tell them to come on Thursday”, in two days they had an appointment” (secondary care doctor, Girona). |
D2) Rapid resolution of queries | “They call you (primary care doctors) and say “hi, what’s up, I’ve got this problem”. Well, sometimes they ask: “what should I do? Shall I send him to you or not?” And sometimes, yes, they call you to say “look, I’ve got this patient who’s got this, this and this, and I’m sending him to you”. OK. They even ask me: “what shall I give him in the meantime?”” (Secondary care doctor, Barcelona). | |
Mechanisms based on programming | ||
Rapid diagnostic pathway for cancer
| E1) Speeds up diagnosis and treatment | “If I suspect possible colon cancer, what I do is make an urgent referral to the rapid diagnostic unit (….) And in less than a week they’ve examined that patient, eh? What I mean is yes, our rapid pathway works perfectly” (primary care doctor, Baix Empordà) |
Shared protocols
| F1) Speed up diagnosis and treatment | “(Digestive medicine) has been a service that, well, has taken a long time to get going and, now with these procedures it’s improved, the waiting lists have been managed better. And so we now have the chance to request the diagnostic test directly, if it fulfils the criteria we’ve already agreed on in this protocol” (primary care doctor, Girona) |
Training sessions
| G1) Improve the clinical appropriateness of referrals | “Sometimes in the sessions, for example, urologists have come in and they say “so, patients with prostate problems (…) request analysis, rectal exam, do this, this and that. And then if everything’s fine you don’t have to refer them and the treatment will be this”. Therefore, what they’re giving you is a series of instructions so you can treat the patient but you’re also saving the patient a lot of visits” (primary care doctor, Baix Empordà). |
Mechanism | Problems in use | Illustrative verbatim quotes |
---|---|---|
Shared medical record
| A1) Difficulties in finding the information | “If you see a medical history from a hospital, normally it lists the problems point by point, and normally you’d dedicate a paragraph of, I don’t know, fifteen lines to it. And in the histories from primary sometimes it’s hard to fathom exactly what the problem is with that patient (…) And, I’m telling you, they don’t write much, and it’s not well registered what problems the patients have, you know?” (secondary care doctor, Barcelona). |
Clinical case conferences between PC and SC doctors
| B1) May hinder access to secondary care | “Sometimes they (joint conferences) also complicate access a bit for some patients that you are sure should go to the specialist and until they pass through the filter of the doctor you’re dealing with, well you can’t refer them. And that, in some cases, can take some time” (primary care doctor, Girona). |
Virtual consultations between PC and SC doctors
| C1) Limited description of reason for referral | “You need to spend more time digging around in the ECAP system (EMR in primary care) or unifying it with the IMASIS system (EMR in secondary care), and try to get an overview of the situation. And if in doubt…if we detect that there really is a problem what we ask them to do is refer the patient to us and we end up examining them ourselves properly from top to bottom, and we can clear up all our doubts” (secondary care doctor, Barcelona). |
C2) Don’t check their work email | “I use it sometimes (email), because when, for example, they send you patients to the outpatient department (...) And when for example I reject a..., I reject a request, then I write to the doctor by email (…) and I say “look, I saw your request…” and I explain the reasons for rejecting it, you know…The surprising thing is that no, they don’t open their work email. When I send emails I ask for that thing to confirm if they’ve read it, yeah? And the surprising thing is that they don’t open their email” (secondary care doctor, Girona). | |
Institutional telephone
| D1) Difficulties in attending to phone calls | “Maybe an internist calls me. So the admin staff let me know “hey, doctor so and so from Hospital del Mar is on the line”. And I’m in the middle of an appointment and I say, oh dear, if she’s calling something must have happened. And so I have to stop my appointment to talk to her, because if they take a message, maybe when I call her back she’s not there any more, or she’s on duty or whatever. It’s really difficult, isn’t it?” (primary care doctor, Barcelona). |
Joint clinical case conferences between primary and secondary care doctors
Off-line virtual consultation between primary and secondary care doctors
Institutional telephone
Opinions on the mechanisms based on programming
Factors influencing the use of clinical coordination mechanisms
Organizational factors
Type of factor | Illustrative verbatim quotes |
---|---|
Organizational factors
| |
A1) Insufficient time to use mechanisms | “Lack of time is what mainly…Of course, you’ve got your job, and this should also form part of the job, shouldn’t it? Being able to do things to help so there’s more communication and more coordination, which we already try to do, you know? But basically I think that (the problem) is lack of time or that this time isn’t included in our working hours, our contracted hours, you know?” (secondary care doctor, Baix Empordà) |
A2) Incompatibility of timetables to participate in joint clinical sessions | “Sometimes it’s due to problems that primary care doctors have, because they don’t finish at two, they finish later and don’t have time to get there, and those that start later, at three, well sometimes they can’t get there beforehand to give us time (…) if they can’t find the time to go sometimes it’d be more practical to just refer the patient (…). And then of course the specialists already knew that they tended not to turn up, so normally they would also leave at, when they finished at two, so in the end, between one thing and another the face-to-face consults weren’t very practical” (secondary care doctor, Barcelona) |
A3) Design of mechanisms: EMR | “There are a lot of duplicated diagnoses. You’ve got a patient, you send them to emergencies and you send them with a generic diagnosis, maybe “stomach pains”, and maybe it’s appendicitis, for example. The one who sees them in emergencies, and the one who operates on them, doesn’t change the diagnosis and adds a new one instead. And so, when you want to put the medical record in order and you want to drag across the processes to put them all into one and link them with an X-ray, well (the EMR) won’t let you do it because (the episode) is closed. (…) I think that a lot has been implemented but the same old problems haven’t been solved.” (primary care doctor, Baix Empordà) |
A4) Design of mechanisms: clinical case conferences | “Well, I suppose that as there’s no real contact (by videoconference), they don’t resolve as many issues. (…) the truth is that I don’t comment on any of them (via videoconferencing). I’d rather they saw the patient, instead of commenting on the plates (image testing results) by videoconference.” (primary care doctor, Girona) |
Professional factors
| |
B1) Attitude and interest in collaborating with the other level | “Right, so, I need to request another analysis to check a, a renal function, yeah? [they can consult and modify test requests through the medical record] And these specialists don’t look at it, they don’t look at it because there are filters. Because in the medical record I can, firstly I can filter it and I can remove all the information that isn’t mine. And that’s what the specialists do. I mean, we’ve got a computerised medical record but they tick the filter and they only look at their own medical history and they don’t look, they don’t look at anything else. They’re not interested, right?” (primary care doctor, Baix Empordà) |
B2) Knowing each other | “In any case, the good thing I was telling you about is that as they’re normally very accessible, and we have a good relationship with everyone, well sometimes we can ask, or have an informal consultation with this person, with this specialist in particular, to talk about the patient and sort some things out, for example” (primary care doctor, Barcelona) |
B3) Lack of awareness of how the mechanisms work | “We designed a rapid pathway for cancer (…). A way, a pathway to say when (they should use it), (…) I also did a session for them, I explained the criteria to them (…), and they carry on sending people via the rapid diagnostic circuit without them fulfilling any of these criteria. I mean, there may be an urgent test required, yeah? I’m not saying there isn’t, but it doesn’t fulfil the criteria to use this pathway” (secondary care doctor, Barcelona) |
B4) Concerns over making diagnosis without physical presence of patient | “And the fear is this (on participating in clinical case conferences), that some day there may be something that has to wait and then is made to wait too long, or that the details are lost (…) or (there’s some problem with) transmitting the information” (primary care doctor, Girona). |