Integrated primary care needs
integrated research infrastructure:
The Netherlands Primary Care
Database
Robert Verheij, NIVEL Primary Care Information Network.
R.Verheij@NIVEL.nl
Health care system in NL
• Gatekeeping role for GP for specialist care.
• GP: List system (epidemiological
denominator).
• Health care entrepreneurs
• Managed competition
• Health insurers play a key role
• Doctors are never far away
Routine Electronic health records
• Increasing use (eg. 99% of GPs use EHR
system).
• Represent a continuous source of information
relating to diseases, illnesses and treatment of
patients.
Why EHR data from primary care?
• Primary care first point of contact with health care system for
most problems;
• Dense network of services;
• Covers all morbidity:
– not only serious cases (cf hospital data or causes of death);
– And not only reportable deseases (as in occupational health monitors).
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Routinely available;
Cheaper than health interview surveys;
Much cheaper than health examination surveys;
Professional health assessment;
Epidemiological denominator is not a problem in countries
with list system (UK, Italy, DK, NL). In other countries (B, Fr)
this can be resolved;
• Longitudinal: follow patients through time!
Information about what?
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•
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•
Quality of care
Accessibility
Developments in public health
Manpower planning
Information for whom?
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Managers of practices or groups of practices
Patient organisations
Ministry of health
Health insurers
NIVEL repositories based on EHR data
NIVEL repositories representative samples of:
• General practices (120 practices; 400.000
patients)
• Allied health services (40 physiotherapists, 40
exercise therapists, 30 dieticians).
• Primary care psychologists (650)
Research examples
• Evaluation of health care system reform (Van Dijk
2012)
• Association between different diseases
(Raterman et 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 to allied health services
(Bossen et al. 2011).
Silo’s of data that
can not be linked
National trend towards
integrated care
 Multidisciplinary guidelines
 Multidisciplinary disease 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.
timeline
How to collect data in health care
system of small scale individual
health care professionals?
Out of hours service
region
phyisio
psych
dietician
GP
psych
phyisio
GP
dietician
GP
pharmacy
phyisio
pharmacy
phyisio
pharmacy
psych
GP
psych
GP
dietician
dietician
phyisio
pharmacy
psych
Primary care GP
groups
Primary care group
pharmacy
dietician
dietician
Secondary care
pharmacy
psych
phyisio
Useful
feedback for
practice
management
and
negotiations
with insurers.
www.nivel.nl/mijnpraktijk-demo
But what about privacy?
Fexible zone model
(Kuchinke et al. 2011)
Linking
anonymous
data using
pseudonyms
Via Trusted
Third Party
(TTP)
Additional
information via
informed
consent
Software complexity
• General practitioners: 8 software packages
• Allied health care: appr 10 software packages
• Out of hours services: 3 software packages
But what about the quality of the data?
EMR-scan: data Quality checks
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……
Decide upon data requests and research themes
Examples of research questions
Chronic patients
Relation GP-dietician and
• Nutrition advice: dietician better than GP?
• Fysiotherapists in GP practices: what happens
in elsewhere in the health care system?
• Effects of prevention in primary care on
morbidity and health care utilisation.
• Evaluation of different payment systems and
organisational models.
Acute care
Relation GP versus out of hours service
• Relation between GP care during office hours
• Unnecessary use of out of hours service.
• Did patients consult their regular GP for the
same problem?
Mental health
Relation GP-primary care psychologist
• What happens in the GP practice before
people consult a psychologist?
• And after?
• What is the role of the practice assistant for
mental health problems?
• Co-morbidity.
Netherlands Primary Care Research
Database: A research infrastucture
like a a Swiss army knife