David Font

Integrated Health Care Barcelona Esquerra (Ais-Be): A Global View of Organisational Development, Re-Engineering of Processes and Improvement of the Information Systems. The Role of the Tertiary University Hospital in the Transformation

The Integrated Health Area “Barcelona Esquerra” (Área Integral de Salud de Barcelona Esquerra – AIS-BE), which covers a population of 524,000 residents in Barcelona city, is running a project to improve healthcare quality and efficiency based on co-ordination between the different suppliers in its area through the participation of their professionals. Endowed with an Organisational Model that seeks decision-taking that starts out from clinical knowledge and from Information Systems tools that facilitate this co-ordination (an interoperability platform and a website) it presents important results in its structured programmes that have been implemented such as the Reorganisation of Emergency Care, Screening for Colorectal Cancer, the Onset of type 2 Diabetes Mellitus, Teledermatology and the Development of Cross-sectional Healthcare Policies for Care in Chronicity.

Chronic renal patient across the continuum of the healthcare from family practitioner to nephrologists

Introduction : The chronic kidney disease (CKD) is defined as a decreasing in renal function shown by a glomerular filtration rate (GFR) The prevalence of CKD in Spain, reaches almost 10% of the grown population (EPIRCE study). The prevalence of CKD in the assisted population older than 18 years old in the Spanish primary care centers is 21,3%, almost 20% are in stage 3 (GFR 30-59 ml/min/1,73m) and 33,7 % are older than 70. More than 40% of the patients with CKD also suffer from high blood pressure (HBP), more than 50% dyslipidemia, 27% are diabetics and until 24% presents cardiovascular comorbidities (EUROCAP study). Description of the implemented practice : An outpatient nephrology program (ONP) has been started in order to give early attention to the chronic renal patient, as an alternative to hospital specialty exercise, to offer support to the physicians of the primary care teams (in Spanish, EAP) from “Consorci d’Atencio Primaria de Salut de l’Eixample” (CAPSE) which is a public entity constituted by “Institut Catala de la Salut” (ICS) and Clinic Hospital (HCP). Furthermore, another aim of this program is to contribute to the formative tasks regarding renal patients in the following Basic Health Areas (ABS): 4C (EAP Les Corts) since 2006, 2C (EAP Comte Borrell) and 2E (EAP Casanova) since 2007. A total population of 81793 adults, 20% of the older than 18 years belonging to AIS-BE (Integral Health Area of Barcelona Esquerra), all of them treated by a 57 primary care physicians team in 2013. This program used to offer a reference nephrologist for each EAP, establishing criteria for referral, consulting clinical cases and formative sessions. The consultancy was organized through the reference nephrologist by e-mail or in person involving a monthly movement of the specialist to the primary care centers. Results : This ONP has included fast consultancy, the use of clinical management applications, creation of databases of first visits and reports of discharge from external consultations. All this meant the healthcare continuation of the chronic renal patient and a better coordination between the primary care service and the nephrologists. Along 2008, the “clinical pathway of nephrology” has been designed. During 2010 the consensus document SEN-SEMFYC has been diffused, which contains the referral criteria from primary care to the specialist and a group of recommendations about renal patient in primary care ambit. In 2012 the consensus document SCN-CAMFiC-SCHTA-ACI-ACD i Departament Salut Generalitat Catalunya was published. Since 2007 a yearly update in nephrology, for primary care professionals, has been organized reaching its ninth edition in 2015. The impact of the ONP in the relationship between both healthcare levels can be seen in the table copied in this link (please copy it in your browser to see it): https://www.dropbox.com/s/k89990q8ano1a0o/16 %C3%A8. ICIC 2016 Abstract 278. Table.docx?dl=0 Discussion : The early detection and the confirmation of the CKD require monitoring by the family doctor, and the nephrologist, when it is needed. The ONP allowed us to spread the knowledge about the chronic kidney patient by the family doctor; it has facilitated the joint decision-making between different levels of care and to adjust the number of derivations. The effectiveness and efficiency of the implemented practice in CAPSE has encouraged the extension of the program to 8 EAP from AIS-BE in 2010. Conclusion : The precocity and the containment of the program bridges the gap between primary care and hospital care to respond to chronicity, aging and dependency.

Meaningful clinical communication and Integrated Care in Barcelona. Eight years of experience

Context: Public healthcare system in Catalonia is based on yearly contracts stablished among the Public Healtcare Administration (Catsalut) and the different Healthcare Organizations (HCO). Each one has its own Electronic Patient Record (EPR) system. In 2006 a task force group was committed for a radical redesign of the healthcare in an area of Barcelona with a population on 600.000 inhabitants with a focus on the improvement in the relationship between Primary care (PC) and Specialized Care (SC) for a better integrated care for the population. Once the new model was accepted by all the HCO, an specific workgroup was created to develop a ICT-supported system to interchange meaningful clinical information and enable the continuity of care. Twenty-three centers were involved. They belong to nine different HCO: three hospitals, one SC outpatient clinic and six PC organizations. Initial analysis of the departure situation resulted in a high heterogeneity in relation to the degree of technological investment, development and maturity in the use of EPRs by the professionals. Several ICTs options were considered. The decision was to implement an interchange platform using structured xml files with clinical content based on standadrd HL7 v2.5 messages. Results: The solution got the integrated connection of all the EPRs of the different HCOs in spite of their big differences. Also the project has speed-up the process of investment and maturity in the use of EPR in those HCOs with a worse departure situation. The overall system supports the full information cycle of several clinical processes like the patient referral from PC to SC with all the possible circumstances at each step in the workflow and the return of clinical documentation, the request for specific procedures from PC to SC with the return of the report and the related images if it’s the case, the communication to PC of the admission of a patient at the Emergency ward and the return of the discharge reports, as well as new collaboration processes like the teleconsultation in Dermatology. All the messages are completely generated and fully integrated in all the different EPRs of the nine HCOs. Since January 2010 until December 2015 statistics showed a total of 323360 requests from PC to the SC centers, 577.575 professional integrated care activities done over the patients, 839.779 relevant clinical documents and 91374 images done at the hospitals delivered on time at the point of care accessible by the PC centers. All of these transactions are the result of standardize and improve existing workflows using ICTs. Outstanding results have been the start up of Teledermatology, a new service made possible through ICTs. Quality of the images provided by the PC physicians were good enough in 94,3% of the cases. Delay in the SC answer has been reduced to 1,84 days and avoiding more than a half of the SC visits at the hospital (58,2%). Conclusions: Several management and clinical scores demonstrates the benefits of such implementation in the quality of care of the population covered by the HCOs. The other big achievement has been the standardization of the clinical processes in this area of the Barcelona city. A good Governance model of the different IT departments involved as well as the ICT providers, based upont profesionalism, leadership and transparency, is a key point for the success At this moment we are in the process to evolve to a bigger platform with the capability to connect all the HCO and centers in Catalonia.