Self, at Home, and Digital if Possible, Drivers to Population Health Management.

The Dutch healthcare system is known for its strong emphasis on primary care and a decentralized approach to healthcare delivery. This system will have to adapt in view of the ever-increasing demand and overburdened caregivers, because otherwise it will eventually be insufficient to offer patients adequate care at sustainable costs. The focus must shift from the volume and profitability of all parties involved to a collaborative model for achieving the best outcomes for patients. Rivierenland Hospital in Tiel is preparing for a shift from treating sick patients to promoting the general health and well-being of the population in the region. This "population health" approach aims to maintain the health of all citizens. This transformation to a value-based healthcare system, centered on the needs of patients, requires a complete overhaul of the current systems and its entrenched interests and practices. The regional healthcare transformation requires a digital transformation characterized by several IT implications, such as facilitating patient's access EHR data and sharing information at patient journey level to support the partners involved in the regional care and cure for patients. The hospital is planning to categorize its patients in order to establish an information database. This will help the hospital and its regional partners to identify opportunities for regional comprehensive care solutions as part of their transition plan.

The Tiel Shift Towards Person Centered Care.

The health system in the Netherlands is one of the best in the world and it is a challenge to keep this affordable and accessible for everyone. A shift from care to lifelong maintenance of health is highly needed, but the drivers of change are missing. Obviously, the involvement of citizens is essential, but to introduce the change the indispensable incentives must be identified. The believe in integrated network care is growing, but it requires a fresh view on the integration of prevention and care, the involvement of the "old players" to create a new governance model, the supporting IT and adequate funding arrangements. In the Tiel region the implementation of the INCA model for integrated care in the primary care setting might make the difference for this journey.

Person-Centered Care Coordination Next Steps in a Long Journey.

Citizens of the Netherlands receive excellent care, when they need it, insurance based funded according to the solidarity principle. Maintaining this system is a huge challenge, as we live longer and the demand for care is growing. With an increasing percentage of multi-morbidity in all age groups the need for integrated network organized care is growing at equal pace. Gradually the need to shift focus to prevention is increasingly understood, but a challenging business model is still lacking. The involvement of citizens in maintaining their health requires a focus on managing the social determinants of health. The concept of the holistic problem list and the overarching care plan provides a unique way to combine both health and disease management. Our vision is to bring control to the patient and promote coordination of all active problems across the health and social care network.

Factors affecting the manual linking of clinical progress notes to problems in daily clinical practice: A retrospective quantitative analysis and cross sectional survey.

This cross sectional study examines how patient characteristics, doctor characteristics, and doctors' education and attitudes affect the extent to which doctors link progress notes to clinical problems. The independent effects of patient characteristics on the linking of notes was examined with a mixed model logistic regression. The effects of doctor characteristics and doctors' education and attitudes on the link ratio was analyzed with univariate analysis of variance. A survey was used to obtain arguments and attitudes on linking notes. For "patient characteristics", the odds of linking increased with an increase in the number of problems or hospital days, decreased, with an increase in the number of involved doctors, medical specialties or the number of notes. For "doctor characteristics", the link ratio increased with more work experience. For "doctors' education and attitudes", the link ratio increased with more familiarity in linking notes and belief in the added value of problem oriented charting. "Overview" was the most cited reason for linking; "I don't know how" the most cited reason for not linking. There is a huge variation within and between all disciplines. Important arguments, for and against, are found. Recommendations for policymakers and medical leadership are given to maximize the benefits.

Continuity of Health, Citizen Empowerment as Key Driver.

Self-management for prevention and care will play a significant role in the transition to apply person-centered care. Interoperability requirements, an overarching care plan, integration of social determinants, and the focus on prevention are important ingredients in the vision on its implementation.

Transition Requirements from Problem List to an Overarching Care Plan for the Support of Person-Centered Care.

To keep healthcare effective, accessible and affordable to all we need a fundamental paradigm shift. Self-management for prevention and care with the help of healthcare professionals, having a shared view of the state of well-being, will play a significant role in this transition. The problem list is widely adopted as centerpiece of electronic health records and is although often patient oriented, but mostly limited to the institutional level. The requirements for this paradigm shift has been discussed in a series of workshops. Truly person-centered care requires to move towards a holistic problem list with an assessment and planning process resulting in an overarching care plan. The change process towards a real person-centered problem list, integrated in an overarching care plan, should be focused on the transition of health services delivery and requires a transition based on the "Quadruple Aim" principles.

A hospital-wide transition from paper to digital problem-oriented clinical notes. A descriptive history and cross-sectional survey of use, usability, and satisfaction.

OBJECTIVES: To evaluate the use, usability, and physician satisfaction of a locally developed problem-oriented clinical notes application that replaced paper-based records in a large Dutch university medical center. METHODS: Using a clinical notes database and an application event log file and a cross-sectional survey of usability, authors retrospectively analyzed system usage for medical specialties, users, and patients over 4 years. A standardized questionnaire measured usability. Authors analyzed the effects of sex, age, professional experience, training hours, and medical specialty on user satisfaction via univariate analysis of variance. Authors also examined the correlation between user satisfaction in relation to users' intensity of use of the application. RESULTS: In total 1,793 physicians used the application to record progress notes for 219,755 patients. The overall satisfaction score was 3.2 on a scale from 1 (highly dissatisfied) to 5 (highly satisfied). A statistically significant difference occurred in satisfaction by medical specialty, but no statistically significant differences in satisfaction took place by sex, age, professional experience, or training hours. Intensity of system use did not correlate with physician satisfaction. CONCLUSIONS: By two years after the start of the implementation, all medical specialties utilized the clinical notes application. User satisfaction was neutral (3.2 on a 1-5 scale). Authors believe that the significant factors facilitating this transition mirrored success factors reported by other groups: a generic, consistent, and transparent design of the application; intensive collaboration; continuous monitoring; and an incremental rollout.

Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature.

BACKGROUND: A problem-oriented approach is one of the possibilities to organize a medical record. The problem-oriented medical record (POMR) - a structured organization of patient information per presented medical problem- was introduced at the end of the sixties by Dr. Lawrence Weed to aid dealing with the multiplicity of patient problems. The problem list as a precondition is the centerpiece of the problem-oriented medical record (POMR) also called problem-oriented record (POR). Prior to the digital era, paper records presented a flat list of medical problems to the healthcare professional without the features that are possible with current technology. In modern EHRs a POMR based on a structured problem list can be used for clinical decision support, registries, order management, population health, and potentially other innovative functionality in the future, thereby providing a new incentive to the implementation and use of the POMR. METHODS: On both 12 May 2014 and 1 June 2015 a systematic literature search was conducted. From the retrieved articles statements regarding the POMR and related to successful or non-successful implementation, were categorized. Generic determinants were extracted from these statements. RESULTS: In this research 38 articles were included. The literature analysis led to 12 generic determinants: clinical practice/reasoning, complete and accurate problem list, data structure/content, efficiency, functionality, interoperability, multi-disciplinary, overview of patient information, quality of care, system support, training of staff, and usability. CONCLUSIONS: Two main subjects can be distinguished in the determinants: the system that the problem list and POMR is integrated in and the organization using that system. The combination of the two requires a sociotechnical approach and both are equally important for successful implementation of a POMR. All the determinants have to be taken into account, but the weight given to each of the determinants depends on the organizationusing the problem list or POMR.