Data bridge 'built out of binder-twine and hope' integrates primary care and public health

In Alberta, Canada, stakeholders built a data bridge between independent primary care providers and public health officials to share information on SARS-CoV-2 test results and ultimately improve community-based responses to the pandemic.

Researchers said these efforts, published in Annals of Family Medicine, offer insights for other jurisdictions considering strategies to integrate primary care and public health.

Myles Leslie, PhD, MJ, MA, an assistant professor and associate director of research at the School of Public Policy in the University of Calgary, and colleagues wrote that primary care has been central in supporting public health initiatives, delivering in-community care — including vaccinations — and mitigating the overburdening of emergency and acute care facilities to maintain health system resilience, but “their experiences of integration into the pandemic response are not well understood.”

“With an eye on achieving universal health care and sustainable development, the World Health Organization has emphasized the importance of integrating primary care into broader health systems,” the researchers wrote. “Integration in primary care aims to bring together a diverse group of individuals and professionals to provide care to those with complex health needs while eliminating duplication or gaps in service.”

Leslie said that, in any situation in which the responsibilities for testing and care delivery are split up, “it is key that test results flow seamlessly into primary care.”

To learn more about how the data bridge was constructed, Leslie and colleagues conducted 57 semi-structured qualitative interviews with public health and primary care stakeholders within the Calgary Health Zone.

The researchers found that the local public laboratory’s SARS-CoV-2 test results were initially available to central public health clinicians but not to independent primary care providers.

“This enabled centrally managed contact tracing but meant primary care physicians were unaware of their patients’ COVID-19 status and unable to offer in-community follow-up care,” they wrote.

However, stakeholders leveraged “a policy commitment to the Patient Medical Home (PMH) care model, and a range of existing organizational structures, and governance arrangements to create a data bridge that would span the gap.”

According to Leslie, the PMH (which in the United States is referred to as the PCMH), “seeks to attach a patient to a consistent team of primary health care professionals who then work together to ensure care is not just available but accessible on the patient’s terms.”

“The primary health care team is focused on treating the whole person (not just their diseases) over the long haul and seeks to help patients manage their well-being through prevention and a range of nonmedical interventions that might include physiotherapy, mental health counseling, nutritional counseling, etc.,” he said.

Leslie further explained that the PMH paved the way for the data bridge because it was “an embedded value and ‘normal’ way of thinking amongst the people on the primary care side of [what would become] the bridge.”

“The PMH’s core tenets — its focus on patients and ensuring access and using technology to manage population health — were the lens through which the primary care folks saw the problem and so could imagine a solution,” he said.

This care model and other integration-focused policy mandates are part of the foundation that the data bridge was built on, the researchers wrote. The others were organizational structures that brought stakeholders together to work on integration projects and “governance arrangements that created the relationships and spaces where improvisation could happen.”

Leslie said that the data bridge transformed from being a spreadsheet with SARS-CoV-2 test results from the central lab that public health officials “combed through by hand” to an automated, coded data path from the central lab directly to the primary care provider.

“The data bridge in the article was built out of binder-twine and hope at the beginning, and then over time, the various stakeholders were able to give it some real resources and information technology muscle,” Leslie said. “Test results — whether a patient was COVID-19 positive or negative — that had simply been sitting in the central lab’s data base or were flooding into the public health unit with nowhere to go, finally had somewhere to go. They were being routed towards the doctors whose patients were sick so that care and management advice could be delivered in the community.”

The researchers wrote that without a well-established, functional interface between the central health system and primary care, both everyday primary care integration efforts and pandemic responses are likely to suffer. But there is a silver lining.

“Working to build data bridges and so gain access for primary health care teams to testing data is not only possible, but accomplishable,” Leslie said.

For any primary care systems seeking to learn from the data bridge’s construction, Leslie and colleagues wrote that they might consider ways to work on organization and governance structures that bring primary care and non–primary care stakeholders together to work on common projects and “leverage care model commitments to integration.”

“Such policies and structures develop trusting relationships, open the possibility for champions to emerge, and create the spaces in which integrative improvisation can take place,” they concluded.

In an accompanying editorial, Trisha Greenhalgh, OBE, FRCP, FRCGP, FMedSci, a professor of primary health care at Oxford University, wrote that the study “illustrates how, in the heat of the emergency response, the key role of primary care appears to have been overlooked.”

“As many of us [family doctors] discovered in the early months of 2020, it’s hard to provide holistic care for individuals or proactive advice to families and communities in a fast-moving pandemic when we have no access to testing or to the results of tests that have been ordered by others.”

References:

• Leslie M, et al. Ann Fam Med. 2023;doi:10.1370/afm.2900.
• Greenhalgh T, et al. Ann Fam Med. 2023;doi:10.1370/afm.2935.