Primary care and regional information systems: integration or inclusion?

The extension of primary care tasks and the development of integrated care models require greater sharing of information between doctors and family paediatricians and the territorial and hospital health network. How can this be achieved?

Four options are possible, some of which may be complementary. The first and simplest one is to create dedicated software platforms where to concentrate and manage the information to be shared, such as taking charge of patients, clinical workflows, and activities carried out. Family doctors, local specialists and hospitals use the platform together, each according to its own role.

The main problem with this solution is that doctors need to use another software to enter and view information. Family doctors are usually reluctant to leave their EMR for another application, not to disperses patient data in two different environments. Specialists, especially those from certain branches, such as diabetology, are also against using two software.

The second option, possibly in addition to the first, is to integrate the EMR of family doctors and any specialist applications to the shared platform, so as to avoid software duplication. Easy to say, difficult to implement for several reasons: the number and heterogeneity of software to be integrated; the lack of concepts and information in some software that are needed to fully manage a clinical workflow or medical activity; the problem of information coding and consistency.

A third option is to use the regional EHR as information sharing platform. The limitation of this solution is the lack of specific functions for care and assistance processes. Not everything can be managed through documents, even if structured. The workflow of an integrated management of a disease can be complex and requires some interactivities between the different actors. Even in this case the integration of medical records can be difficult and complex for the same reasons seen above.

The fourth, more radical option involves the use by family doctors and paediatricians of a free-choice regional electronic medical record, natively integrated with the territorial and hospital systems, such as the booking system, the vaccine registry, the screening system, the chronicity management system. This is the road that Emilia Romagna is following in Italy, not without difficulty and resistance, whose file is now used by about a third of family doctors in the region. This road will be followed by the province of Trento and is under observation by other regions.

As it is easy to imagine, the main question concerns the autonomy of family doctors who want to be free to choose and use the software they prefer, without being imposed by the regions. The discussion is not about the technical characteristics or functions of the software, but about the principle of autonomy and, in a more or less hidden way, about the fear of being controlled by the region.

Looking at the experience of other health systems, for example Israel or in some cases USA, we can verify that where a single information system is used, both by primary care and by the clinics and hospitals belonging to the network, the real integration of care is achieved thanks to the integrated medical record.

In order to reason correctly, therefore, on which architecture to create to allow the integration of care, one should start from the needs, opportunities and constraints that each choice entails. The discussion should not be approached by putting ideological aspects or the maintenance of the status quo before technical considerations.

If the objective is to find the most effective solution, we must be willing to consider choices that require change, so that primary care is no longer an island with respect to the health system, but on the contrary is an integral and substantial part of it.

Think outside the box!

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