Utilizador:Solstag/Artigo para Workshop for Ongoing Projects at CBMS

=Technology enhanced integration of hospital and primary care in the M’boi Mirim neighborhood of São Paulo city=

Alexandre Hannud Abdo∗† , Ana Delgado‡§ , Ana Mafra‡§ , Tatiane Ocon Nascimento‡ and Mario Bracco‡§

∗ Faculdade de Medicina, Universidade de São Paulo, Brazil.

Email: abdo@member.fsf.org

† Garoa Hacker Clube, São Paulo, Brazil

‡ Hospital Municipal Dr. Moyses Deutsch, São Paulo, Brazil

§ Hospital Israelita Albert Einstein, São Paulo, Brazil

Abstract

Lack of coordination between primary and secondary care can have adverse effects for patients.[4] Our research project consists of a multi-strategy intervention to connect the healthcare professionals of one hospital and 18 primary care units (PCUs) in the southern neighborhood of M’boi Mirim, in the city of São Paulo, Brazil. The focus of this paper is a privacy-oriented and feature-rich online collaboration network, set up for professionals to provide more continuous care to patients as they cycle between PCUs and hospital care. Besides the network, a capacity building online course is being offered and a telemedicine service made available. Results will follow from outcomes of patients with conditions sensitive to primary care, from gains in efficiency of procedures, and from exchange patterns between professionals plus their overall condition at work.

Keywords-Healthcare integration; primary care sensitive conditions; collaboration networks

I. INTRODUCTION

We present an overview of an ongoing effort to integrate the healthcare network serving a neighborhood in the city of São Paulo with a population of around 300,000 people, by offering the technological means for professionals to work together across units and explore team collaboration, knowledge exchange, distance education, collaborative cartography and telemedicine. Our hypothesis is that this integration of primary and secondary care will lead to better clinical outcomes of patients, particularly in terms of hospital readmission rates, by providing more continuous and better qualified attention at all levels to conditions sensitive to primary care. Our work is motivated by both the observation of efficiency issues related to low coordination between hospital and primary care units (PCUs) and by studies showing improvement of hospital readmission rates following the implementation of the Family Healthcare Strategy (Estrat´egia de Sa´ude da Fam´ılia), which can be thought of as integrating primary care in PCUs with patient’s home and family care.[1]Our study has multiple outcomes: a cohort of 600 patients with conditions sensitive to primary care is being recruited to have their evolution followed during and after hospital leave; the quality of life, work satisfaction and mental health levels of professionals is being assessed; and the adherence to technologies and the development with them of teamwork, information exchange and learning practices is being monitored, as well as the impacts of these on the efficiency of procedures.

A. Local context

The neighborhood of M’boi Mirim is a complex and mostly poor region undergoing constant transformation and expansion.[2] It is home to large occupations such as the Nova Palestina camp, social movements as the Frum em Defesa da Vida, and was once considered the most violent region in the city. The main reference hospital for the region is the Hospital Municipal Dr. Moyses Deutsch (HMMD), whose department of research leads this project with support from staff of the Hospital Israelita Albert Einstein (HIAE), which jointly manages the HMMD. It is the reference hospital for around 30 PCUs, of which 17 are managed by the non-governmental organization Centro de Estudos Dr. Joo Amorim (CEJAM) and are our partners in this research.

Our professionals face common problems for Brazilian healthcare[3], such as a chronically overloaded system, difficulty in finding qualified candidates to work in an already disfavored region, and a density of professionals below recommendations. More directly related to our work, the people being cared for are an uneducated, aging population, with increasing prevalence of chronic diseases and multimorbidity, who have difficulty caring for themselves and their relatives. The region also faces high environmental risk from lack of proper infrastructure and high rates of violence and drug abuse, particularly alcohol. It is not uncommon for patients to arrive at the hospital incorrectly reporting their reference PCU, incapable of describing previous conditions or prescribed medication, and unaware of environmental aspects of their condition. It is also not uncommon for patients leaving the hospital to fail to properly report to their PCU and seek continuity of care.

It is a challenging environment, but this coexistence of need and opportunity to improve these conditions through a more integrated care between PCUs and hospital service has also been a driving force for our work.[4]

Figure 1.|Professionals at the PCU and the hospital talk about a patient

II. I NTERVENTION

Although we’ll provide a brief description of the distance education and telemedicine strategies, the focus of this paper is the collaboration network application.

1) Online course: A online continuous education course is offered to improve and update professional’s clinical knowledge, through which we also intend to stimulate the habit of learning together. It is focused on case studies of conditions most relevant in the region, and will confer a certificate. Besides support from tutors and colleagues through discussion forums, there are regular video conferences with rotating specialists. 185 professionals enrolled, a quarter of which have been following closely, with 14 drop outs.

2) Telemedicine: A telemedicine service is being organized together with HIAE, who, as a manager of the HMMD and partner in this research project, will provide expert time and the telemedicine infrastructure on its side. The patient cohort has only started to build up this year, so we don’t have any data on this yet.

3) Collaboration network: Our main application is built upon a software platform called the RedMatrix (https:// redmatrix.me/), a Free Software (MIT License) project that pioneered web based, fully decentralized, secure and private information systems. Secure and private need no justification here, but we additionally understand that decentralization is critical to the design of healthcare infrastructure and standard procedures, and health information systems should be designed to minimize the impact of network outages and impairments, while at the same time taking full advantage of networking when available. Thus this technology can be deployed in a well connected city such as So Paulo, but can also be viable in regions with only occasional or unstable connectivity such as across the Amazon, and be more resilient in disaster and recovery situations where disruption of healthcare procedures may have drastic consequences.

The primary use for this application is to allow practitioners to engage in conversation, enabling coordination and exchange of information and opinions about patients that we expect will provide them with more continuous and integrated care. The usual interface is a social channel, much like a timeline of exchanges, see Figure 1. Members can create posts, embed images and videos and attach files to them, or add files to a personal storage. They enjoy finegrained control over who can access any of these items, which is essential when discussing patients to ensure only the professionals caring for that person are involved. There’s also the ability to form group channels, which forward messages to specific members, such as one being used to advance standardization of medical records between the hospital and PCUs.

As use of the network matures, we’ll also enable a cartographic module and enlist community health agents (ACSs) to map environmental and social conditions of the region. This cartography can then be employed to assist diagnosis, treatment and preventive healthcare actions.

III. P RELIMINARY RESULTS

Patient inclusion has been moving slower than we planned, but the collaboration network is increasingly being adopted by the professionals, with 56% of queries from the hospital resulting in feedback from the PCUs, of which 19% exposed misreports of reference PCU, avoiding misdirecting on leave, and 70% provided the hospital with information about the health and living conditions of the patient. We will present further results during the conference.

ACKNOWLEDGMENT

This work is funded by CNPq and FAPESP through PPSUS grant 2012/51228-9, and was funded by FAPESP through postdoctoral researcher grant 2012/05820-3. The authors kindly thank Ariel Kogan for catalyzing the project.

REFERENCES

[1] Macinko J, Oliveira VB, Turci MA, Guanais F, Bonolo PF, Lima-Costa MF. The Inuence of Primary Care and Hospital Supply on Ambulatory CareSensitive Hospitalizations Among Adults in Brazil, 1999–2007. Am J Public Health 2011; 101:1963–1970.

[2] Alves HPF, Alves CD, Pereira MN, Monteiro AMV. Dinmicas de urbanizao na hiperperiferia da metrpole de So Paulo: anlise dos processos de expanso urbana e das situaes de vulnerabilidade socioambiental em escala intraurbana. Rev Bras Est Pop,2010,27:141159.

[3] Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian Health System: history, advances and challenges. The Lancet 2011, 377(9779):1778-97.

[4] Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care. JAMA 2007;297(8):831–841.