Integratedprimary care needsintegrated research infrastructure:The Netherlands Primary Care Database Robert Verheij, NIVEL Primary Care Information Network. R.Verheij@NIVEL.nl
Health care system in NL • Gatekeepingrolefor GP for specialist care. • GP: List system (epidemiologicaldenominator). • Health care entrepreneurs • Managedcompetition • Health insurersplay a keyrole • Doctors are never far away
Routine Electronic health records • Increasinguse(eg. 99% of GPsuse EHR system). • Represent a continuous source of information relatingtodiseases, illnessesand treatment of patients.
Why EHR data fromprimary care? • Primary care first point of contact with health care system for most problems; • Densenetwork of services; • Covers allmorbidity: • notonlyserious cases (cfhospital data or causes of death); • Andnotonlyreportabledeseases (as in occupational health monitors). • Routinelyavailable; • Cheaperthan health interview surveys; • Muchcheaperthan health examination surveys; • Professional health assessment; • Epidemiologicaldenominator is not a problem in countrieswith list system (UK, Italy, DK, NL). In othercountries (B, Fr) thiscanberesolved; • Longitudinal: follow patientsthrough time!
Information about what? • Quality of care • Accessibility • Developments in public health • Manpower planning
Information forwhom? • Managers of practices or groups of practices • Patientorganisations • Ministry of health • Health insurers
NIVEL repositoriesbased on EHR data NIVEL repositoriesrepresentative samples of: • General practices (120 practices; 400.000 patients) • Allied health services (40 physiotherapists, 40 exercisetherapists, 30 dieticians). • Primary care psychologists (650)
Research examples • Evaluation of health care system reform (Van Dijk 2012) • Associationbetween different diseases (Ratermanet al 2012). • Quality of care trends (Van Dijk, 2011). • Multimorbidity (eg Van Oostrom et al. 2008). • Developments in public health (eg Verhaak 2005). • Evaluation direct access toallied health services (Bossen et al. 2011).
National trend towards integrated care • Multidisciplinaryguidelines • Multidisciplinarydisease management programs; • Physiotherapistst and primary mental health care accessible without referral; • Introduction of GP out of hours co-ops; • Primary care entrepreneurs … make it necessary to broaden the information basis and include also other primary care disciplines.
Record linkage • GPs • Pharmacies • allied health services, • out of hours services • primary mental health care + possibility to link to secondary care data • follow patients through the health care system. • possibility to approach patients for additional information.
How to collect data in health care system of small scale individual health care professionals?
Out of hours service region Secondary care Primary care groups Primary care group psych psych psych psych psych psych phyisio phyisio phyisio phyisio phyisio phyisio GP GP GP GP GP GP dietician dietician dietician dietician dietician dietician pharmacy pharmacy pharmacy pharmacy pharmacy pharmacy
Useful feedback for practice management and negotiations with insurers. www.nivel.nl/mijnpraktijk-demo
Fexible zone model (Kuchinke et al. 2011) Linkinganonymous data usingpseudonyms Via TrustedThird Party (TTP)
General practitioners: 8 software packages • Allied health care: appr 10 software packages • Out of hours services: 3 software packages
EMR-scan: data Qualitychecks www.nivel.nl/mijnpraktijk-demo
Governance Strong emphasis on involvement of professional organisations. • National association of GPs • Association of primary care psychologists • Association of dieticians • Etc…… Decideupon data requestsand research themes
Chronicpatients Relation GP-dieticianand • Nutritionadvice: dieticianbetterthan GP? • Fysiotherapists in GP practices: whathappens in elsewhere in the health care system? • Effects of prevention in primary care on morbidityand health care utilisation. • Evaluation of different payment systems andorganisationalmodels.
Acute care Relation GP versus out of hours service • Relationbetween GP care during office hours • Unnecessaryuse of out of hours service. • Didpatients consult theirregular GP for the sameproblem?
Mental health Relation GP-primary care psychologist • Whathappens in the GP practicebeforepeople consult a psychologist? • Andafter? • What is the role of the practiceassistantformental health problems? • Co-morbidity.
Netherlands Primary Care Research Database: A research infrastucturelike a a Swiss armyknife