Integrated care issues: Transfer of patient care information.

Background: Transfer of patient care information between organizations is usually done by means of a transfer by paper: the patient himself hands the information over from the multidisciplinary team from one organization to another. In 2012, a stroke care pilot project regarding transfer of nursing and paramedical patient information, Cross-enterprise Document Sharing XDS, was started. Organizations from the Rotterdam Stroke Service n=19 in the Netherlands started a collaboration with "Care-portal Rijnmond", a safe gateway where health care organizations can exchange information in an easy, safe and reliable way. The assumption is that health care will be delivered in a more efficient and effective manner when ICT is used, even when organizations have different electronical patient file systems. Methods: A panel of experts in stroke care stroke nurses, neurologists, rehabilitation specialists, elderly care physicians reached consensus about the content of patient information that is necessary for a qualitative good, timely and correct information transfer. They used the Delphi method, a structured communication technique to reach consensus. The national standards ICT institute in Healthcare, Nictiz, were integrated in the project. For the diverse parts of the project, different project leaders were installed. These project leaders developed detailed project-plans. The project leaders were also the ambassadors for the project and were seeking for funding. The involved professionals and project leaders had every week skype meetings or face to face meetings. They kept the project on the agenda in the health care organizations. Results: Already existing agreements concerning the collaboration in the integrated care service were adjusted and new agreements regarding the innovative project were made. The information about the project was shared with multiple stakeholders. The initial developed dataset was translated to the general information "building bricks" from Nictiz. Software was chosen and ICT systems were adjusted to the new working method. A viewer for viewing patient information was installed. Tests showed that information was received earlier and was more complete available for example for the rehabilitation unit after the patients' discharge. The professionals were able to develop a rehabilitation plan for an individual patient, even if the patient was not transferred yet. When the patient was admitted, they could start immediately with rehabilitating that patient. Discussion/conclusion: Information is quickly available and therefore treatment can start earlier. It may benefit for example the rehabilitation process positively. Furthermore, this is an uniform solution based on standards, and therefore useful for multiple patient groups. It is assumable that the patient will profit and have better rehabilitation outcomes. Limitations and lessons learned: There were multiple new parties and it was therefore a challenge to reach consensus. Furthermore, because the delay there was a change of professionals over time, which means that these professionals had to be informed and introduced in the project. And lastly, over time safety and privacy regulations changed and new interventions were needed to cope with the new regulations. This is an ongoing project, with the goal to connect all organizations by means of XDS. [ABSTRACT FROM AUTHOR]