Chapter V
Primary Care Network
In an effort to optimize the delivery of primary care services while ensuring cost-effectiveness and efficiency, there is a need for a more proactive approach to bridging the gap between the medical research community and the primary care physician. Accordingly, evidence-based medicine as developed and promoted by medical researchers purportedly offers scientifically-supported services and practices that can help to ensure "value for money." In addition, the dearth of new technologies, drugs, clinical prevention activities and other services that primary care physicians have been asked to adopt are questioned because information about the true effectiveness of these technologies, and their marginal gains over existing practices, have been difficult to assess by practising physicians. Although in some cases efforts have been made to summarize information, for example, in the area of clinical prevention initiatives, experience has shown that they may not be readily transferrable to the practice setting, despite the desire of the majority of family physicians to deliver the best and latest health-care advances in a cost-efficient manner to their patients. The problem for physicians is therefore how to access the information necessary to provide high-quality care in a timely manner and thus continue to maintain the high levels of satisfaction reported by patients with respect to their personal physicians.The development of guidelines and standards for care has been adopted in response to this perceived need. This process is not unique to Canada but rather is occurring around the world. However, the dissemination and adoption of these guidelines have proved difficult and unsuccessful, often because common issues for the physician in applying such information in the practice setting are frequently not addressed.
To facilitate the dissemination and uptake of such information by a majority of primary care practitioners and thus move beyond the generation of scientific information as an end in itself, Dr. Warren McIsaac assisted the Physician Advisory Group in the development of a General Practice Dissemination Network, a proposal which is outlined below.
Based on the lessons learned in a partnership between a community of practising physicians in Stratford and the academic research organization, the Institute for Clinical Evaluative Sciences in Ontario (ICES), the following outlines a method by which practice guidelines and standards of care can be adopted on a province-wide basis, enlisting the support and endorsement of practitioners internally, through a shared culture and informal norms, rather than through external orders, i.e., command and control regulation in order to benefit the health-care system.
Experience has proven that merely mailing information packages is not sufficient to foster adoption by a substantial proportion of physicians. What is necessary is a mechanism for broadly communicating the proposed technical approaches, addressing barriers to implementation, providing incentives as well as disincentives for adoption by physicians as well as support for physicians wishing to incorporate desired approaches into practice but encountering barriers, identifying problems with proposed approaches in the field, and revising and communicating this to the broader group of physicians in the province. Developing such an infrastructure would also provide an ongoing capability to diffuse other innovations that are developed in the future to address common clinical problems in primary care.
Since the majority of primary care physicians in Ontario are affiliated with a Department of Family Medicine or General Practice that is organized around a community hospital. The proposed General Practice Dissemination Network would be based on this existing structure. The hospital medical staff together with the Departments of Family Medicine and General Practice in these community hospitals have existing organizational structures that effect change from time to time in community care by decisions made and enacted at the community level. These existing organizational structures should be expanded to address important clinical care levels in the ambulatory care office setting that have significant effects on the quality of primary care, utilization and costs. The network established of physician groups across the province would be grounded within local physician communities and thus would be in a position to influence the local dissemination of information.
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(...health-care system) Review Essay: The High Cost of Administration in Health Care: Part of the Problem or Part of the Solution?, Bovbjerg, Randall R, Journal of Law, Medicine and Ethics, 23 (1995): 186-94.
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