Experts from the medical association gradually sank, and experts from Xinhua Hospital came to Chongming Branch for consultation. Information picture
editorial comment/note
Health is an inevitable requirement to promote people’s all-round development and the common pursuit of the broad masses of the people. General Secretary of the Supreme Leader stressed that people’s health should be given priority in the strategic position of development, and the construction of a healthy China should be accelerated. Since the General Office of the State Council issued "Guiding Opinions on Promoting the Construction and Development of Medical Consortium", the construction of medical consortia in China has been fully promoted everywhere, from "managing diseases" to "managing health", and the structural reform path of medical supply side has become increasingly clear. As a pioneer in the construction of medical associations, Shanghai has established 55 medical associations in recent years, mainly in the form of regional medical associations and specialized medical associations, which effectively promoted the downward shift of the focus of health work and the sinking of resources, significantly improved the grassroots service capacity and optimized the overall medical service efficiency. In June 2019, Guangming Daily’s research team went to Yangpu District, Huangpu District, Xuhui District, Minhang District and other places in Shanghai, interviewed a number of tertiary and secondary hospitals and district health and health committees, and conducted in-depth research on the construction of medical associations in Shanghai.
Aunt Zhang, a 60-year-old from Chongming District, Shanghai, was diagnosed with breast cancer in a community hospital and referred by a family doctor to a tertiary hospital in the region — — Chongming Branch of Xinhua Hospital was found to be in a serious condition after diagnosis, and was transferred to the General Hospital of Xinhua Hospital for breast surgery. After surgery, he returned to Chongming Branch for chemotherapy, and finally returned to the community for follow-up and rehabilitation guidance from family doctors. Living in the far suburbs, but not having to run dozens of kilometers to see the top three hospitals in the urban area, Aunt Zhang benefited from the pattern design of gradient medical treatment and linkage referral of the medical association.
In Shanghai, a reasonable medical order of "minor illness at the grassroots level, serious illness at the hospital, and recovery at the grassroots level" has gradually taken shape. In October, 2010, the former Shanghai Municipal Health Bureau, together with the relevant commissions, issued the Guiding Opinions on the Pilot Work of the Regional Medical Consortium in this Municipality, which took the lead in promoting the reform of the medical consortium in China. By the end of 2018, the city had established 55 regional medical associations, all tertiary hospitals and community health service centers participated in the construction of medical associations, and 83 secondary hospitals participated in the construction of medical associations, achieving full coverage of the grid construction of medical associations.
1. The sinking of high-quality resources enhances the ability of primary medical services.
Upgrading from a second-class hospital to a third-class hospital has treated more difficult and critical patients, but fewer patients have been transferred to other hospitals. The complexity of the hospital’s surgery has gradually increased, and the development of new technologies has become active … … In the past 10 years, Chongming Central Hospital, located in the outer suburbs of Shanghai, has changed greatly since it became Chongming Branch of Xinhua Hospital. It has become a reality for residents to "stay in the village for minor illnesses and stay on the island for serious illnesses". All this stems from the connection with Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine.
In January 2009, Xinhua Hospital began to build Chongming Central Hospital. In April 2011, the regional medical association model was pioneered in China. At present, a "Xinhua —" led by Xinhua Hospital, with Chongming Branch of Xinhua Hospital as the core unit, and secondary medical institutions and 18 community health service centers in the joint area has been formed. Chongming Regional Medical Association ".
General surgery carried out the first laparoscopic repair of esophageal hiatal hernia, orthopedics carried out the first arthroscopic knee surgery, urology carried out the first laparoscopic nephrectomy, and successfully carried out the first gas-free endoscopic thyroidectomy via retroauricular approach in China & HELIP; … Since the construction of the medical association, more than 60 new technologies and projects have been introduced into Chongming, filling the gap in medical technology on the island. Three diagnostic centers for examination, imaging and ECG have been built. Residents on the island can enjoy the medical technology diagnosis service of tertiary hospitals when they have an examination in the community health service center, and they no longer have to travel to the urban area for an hour or two to see an "expert clinic". At present, the on-island medical treatment rate of Chongming residents exceeds 95%.
Behind the remarkable improvement of medical level in Chongming Island is the silent dedication and persistence of a large number of experts sent by Xinhua Hospital. Up to now, Xinhua Hospital has sent 45 experts to Chongming Branch of Xinhua Hospital, including 14 academic leaders working part-time and 31 resident experts, covering 22 disciplines. Xinhua Hospital also launched the "Excellent Young Medical Talents Training Program" in Chongming Branch. Gao Ming, a young general surgery doctor, became one of the first batch of "excellent young people" in 2011. In the past few years, Gao Ming obtained a master’s degree and became the deputy director of general surgery. Nowadays, master’s degree or doctor’s degree accounts for nearly 60% of general surgeons in Chongming Branch of Xinhua Hospital, which was zero before Xinhua Hospital aided Chongchong.
The sinking of expert resources in tertiary hospitals has obviously promoted the medical level of secondary hospitals and community health centers in Shanghai. "Xuhui District — After the establishment of the "Zhongshan Hospital" medical association, more than 30 well-known international and domestic experts from Zhongshan Hospital affiliated to Fudan University opened teaching rounds, expert clinics, guided operations and gave lectures and discussions in Shanghai Xuhui District Central Hospital. The workstation of Academician Ge Junbo of Chinese Academy of Sciences was unveiled, and the endoscopy center of Xuhui Hospital affiliated to Fudan University, with Professor Yao Liqing as its director, was officially launched … … The expert "luxury lineup" went into battle, which activated the vitality of secondary hospitals and also reduced the pressure and diverted the tertiary hospitals. The departments of general surgery, orthopedics, oncology and ultrasound in Chongming Branch of Xinhua Hospital have successively become key medical specialties in Shanghai. "In the past, this all belonged to urban hospitals ‘ Exclusive ’ It is not easy to achieve such achievements in the discipline construction of suburban hospitals. " Fei Zhewei, executive director of Chongming Branch of Xinhua Hospital, said.
At the "Two-way Referral" service desk on the first floor of Shanghai Minhang District Central Hospital, the research team learned that the hospital has set up a "two-way referral" green channel, and based on the "Zhongshan Hospital-Minhang" medical association, it has established two-way referral channels with seven community health service centers in the north of Minhang District, providing convenience for contracted residents to transfer to the community for priority appointment, priority payment, priority treatment and priority inspection.
For a long time, the community health service centers in the outer suburbs are short of medical staff and people’s trust in primary medical institutions is not enough, which is the crux of the difficulty in promoting graded diagnosis and treatment. Shanghai gives full play to the leading role of tertiary public hospitals, aiming at the needs of disease spectrum and diagnosis and treatment of key diseases in the region, and strengthens the sinking of high-quality medical resources into the platform of community health service center through the forms of co-construction of departments, joint outpatient service of all specialties and teaching demonstration, so as to promote the improvement of the overall medical service level in the region. At the same time, we will further enhance the support of high-quality resources for family doctors’ contracting services, and continuously improve the service level of family doctors through services such as remote consultation, remote ECG diagnosis and remote image diagnosis. In 2018, a total of 330,000 remote consultation services were provided to the community.
Since the "Healthy China 2030" Planning Outline was issued, the concept of "great health" has become a major innovation in health and health undertakings. Since January 2018, "Xinhua — Chongming regional medical association entered the "2.0 era", and changed from "treatment-centered" to "health-centered", paying attention to the health management of the whole population and the whole life cycle, and developing towards the great health goal of "early detection, early treatment, less illness and no illness". At present, the "Health Wisdom House for Chronic Disease Management" in Luhua Community and the "Information Health Wisdom House" in Chengqiao Community have been built to undertake the functions of health screening, health education, prevention and control of chronic diseases and graded diagnosis and treatment for community residents. At the same time, a health lecture hall will be held to cultivate the healthy lifestyle of residents in the form of centralized teaching and free consultation.
2. Innovating system and mechanism to protect medical association.
In January and April of 2011, Shanghai launched two regional medical complexes, namely Ruijin-Luwan and Xinhua-Chongming. In December 2017, the General Office of the Shanghai Municipal Government issued the "Implementation Opinions on Promoting the Construction and Development of Medical Associations in this Municipality", which put forward specific requirements for promoting the construction and development of medical associations in this Municipality, and basically established the institutional framework of medical associations. The regional medical association represented by "Xinhua-Chongming", the specialist medical association represented by "Pediatric Medical Association" and the radiation medical association represented by "Huashan Dermatology Medical Association" were launched in an all-round way, and all three-level public hospitals participated and played a leading role.
Minhang District has continuously increased investment to provide financial support and organizational guarantee for the capital construction of medical institutions in the region, the purchase of large-scale equipment, the training and introduction of talents, and the construction of key disciplines. Give policy support to the cooperative health service system of medical teaching and research. At the same time, Minhang District provides regional medical services and health management information data, and realizes interconnection and resource sharing with Fudan University.
In terms of innovative talent team construction, Xuhui District explores the new mechanism of talent training and use under the framework of medical association, and relies on medical association to strengthen the cultivation of general practitioners’ clinical ability in otolaryngology, ophthalmology, ultrasound medicine, oral cavity and child health care, so as to alleviate the shortage of talents in weak clinical disciplines in the community. The South Campus of Renji Hospital affiliated to Shanghai Jiaotong University School of Medicine and Pujiang Community Health Service Center have cooperated in various ways in personnel training. Through the diabetes grading diagnosis and treatment studio and cardiovascular expert studio, the experts from the South Campus have taught the general practitioners in the center, and arranged the general practitioners in the service center to make teaching rounds in Jen Jinan Hospital to promote the flow of talents.
Medical insurance reform is an important starting point to incite the coordinated reform of "responsibility, right and benefit" of medical associations. "Xinhua — Chongming regional medical association "pilot medical insurance total package prepayment mechanism, improve the incentive and risk sharing mechanism of" balance retention and reasonable overspending sharing ",and enhance the enthusiasm of medical institutions for self-management; At the same time, the reform of contract service fee and performance pay system for family doctors will be used to promote the effective service of family doctors.
In terms of management and service mode, the internal personnel, resources and equipment of the close medical association shall be managed in a unified way, and the medical institutions affiliated to the medical association shall purchase and distribute drugs and consumables in a centralized way, with division of labor and cooperation for mutual benefit and win-win, so as to gradually realize the homogeneous management of health and medical services in the medical association, promote the sinking of high-quality resources and enhance the ability of primary medical services.
In December 2018, the Shanghai Municipal Health and Health Commission formulated the Planning Plan for the Construction of Medical Associations in Shanghai (Trial) and the Work Plan for Comprehensive Performance Appraisal of Medical Associations (Trial), aiming at promoting the construction of graded diagnosis and treatment system, establishing a performance appraisal system for medical associations, evaluating the operation and effectiveness of medical associations, and effectively guiding the work of medical associations. Coordinate the salary distribution within the medical association and fully mobilize the enthusiasm of medical staff. Encourage medical institutions above the second level in the medical association to send professional and technical and management talents to primary medical and health institutions.
Xuhui District has improved the post assessment and appointment methods of community health service centers, and continued to give policy preference to community health service centers in terms of talent selection, scientific research projects, and evaluation. Minhang District has included the two-way referral of medical associations, technical assistance from higher-level hospitals to primary hospitals, etc. into the comprehensive budget, district comprehensive target management assessment and performance assessment of public hospitals, which has provided a strong guarantee for the healthy development of medical associations.
3. Information technology construction empowers medical associations
"Thanks to the remote ECG consultation, otherwise my illness would be really delayed." Gong Daye, a resident of pujiang town community in Minhang District, realized the benefits of remote ECG consultation. Recently, Gong Daye suddenly suffered from chest tightness after exercising at home, and went to the community hospital to have an ECG. The community doctor immediately transmitted it to Minhang District Central Hospital. The experts in the remote consultation center immediately gave a diagnosis of acute anterior myocardial infarction and suggested that he should go to the superior hospital for treatment immediately. Gong Daye was quickly referred to Zhongshan Hospital affiliated to Fudan University with better conditions, and his condition was quickly controlled.
Sun Keyu, director of the emergency department of Minhang Central Hospital, told the research team that the patient "filmed" in the community service center nearby, and doctors in Minhang District Central Hospital could read the film remotely through the Internet and complete the diagnosis report in time, so residents did not have to run around looking for experts with "films". Such a convenient "diagnosis chain" benefited from information technology as a link. The research team learned that the hospital used MUSE (Electrocardiogram Information Management System) and PACS (Medical Image Information System) to diagnose the cases uploaded by the community health service center, which improved the correct diagnosis rate of community patients. According to reports, in 2018, the hospital had more than 100,000 MUSE consultations and more than 200,000 PACS consultations.
Queue for registration, medical treatment, payment and medicine … … The time spent queuing in the hospital often makes people "tired and unloved". In order to explore a new mode of Internet medical information service for the benefit of the people, the Minhang District Health and Health Commission has gradually changed the passive waiting mode in the traditional medical service process since 2016. Residents only need to download the "Minhang Jieyi" APP and bind the medical card or medical insurance card through mobile phone registration, so that they can make an appointment, register, pay, check the waiting queue and test report at one time, which simplifies the medical treatment process and shortens the queuing time. Up to now, the "Minhang Jieyi" system has been put into use in 20 hospitals in the whole district, which has been widely praised by residents in the area.
Walking into the "Daytime Chemotherapy" Center of Renji Hospital affiliated to Shanghai Jiaotong University School of Medicine, the research team saw that "intravenous drug dispensing robots" were busy working. The medical staff took the patient’s prescription from the Internet, printed and generated the QR code, and then posted it on the infusion bag. Then, the medicine, disposable dispenser and infusion bag were placed on the fixed device inside the robot. After scanning the QR code, the robot began to dispense drugs automatically. In the past, intravenous chemotherapy drugs in hospitals were manually prepared by Yamatonokusushi, a nurse in the intravenous drug allocation center. The toxicity of drugs and the difference in operating environment pose certain risks to medical staff and patients. "This ‘ Robot ’ It not only realizes the traceability of the drug preparation process, the automatic recovery of medical waste, but also connects with the hospital information system, making the drug preparation process digital and intelligent, protecting the staff and reducing the pollution of dispensing. " Zhang Jidong, deputy dean of Renji Hospital affiliated to Shanghai Jiaotong University School of Medicine, introduced.
In addition, through the whole process of information management, Yan Chai Hospital seamlessly connects the outpatient process and hospitalization process of patients undergoing day surgery, and manages all aspects of patients from admission registration to discharge, guiding patients to treat in an orderly manner. Zhang Jidong said that the qualification management of the doctor in charge of daytime surgery was established in the information system, and the admission system standards for daytime surgery were increased in the workstation module of outpatient doctors, such as disease type restrictions and surgical restrictions. At the same time, the system collected and accumulated a large number of clinical diagnosis and treatment data, which also promoted the research on the diagnosis and treatment of daytime surgical diseases.
Jinshan District realizes seamless communication of two-way referral through WeChat group; Minhang district uses the database of blood sugar information management system to give advice on blood sugar control in time; Xuhui District will build a full-scale cloud platform, play the role of a secondary hospital hub, and provide online green channels for contracted residents; Renji Hospital in Pudong District realizes the cross-hospital sharing of patients’ electronic medical records, and residents’ health information and data are recorded in real time, accurately and completely, which greatly improves the medical and health management ability … … With the help of information technology, Shanghai has built a bridge of communication between medical institutions at all levels, and through the sharing of medical information among medical institutions in the medical association, it has realized centralized diagnosis and mutual recognition of graded diagnosis and treatment, two-way referral, examination and inspection.
It is understood that at present, through the information-based priority referral channel in Shanghai, the city’s community health service centers have referred more than 800,000 people to higher-level hospitals during the year, and higher-level hospitals have referred 69,000 people to the community. The timely and smooth medical experience has enhanced the "viscosity" within the medical association, laying the foundation for deeper graded diagnosis and treatment. The "information-based medical association" constructed in Shanghai weaves a large network of residents’ health protection and constructs a whole-process health management model.
4. Regional resource sharing makes experts close to home.
"I have been going to Shanghai to see an expert before. Not only is it very difficult to register, but I have to stay in Shanghai one day in advance, and I will queue up at 4 or 5 in the morning the next day. It is already afternoon after seeing the doctor." Ms. Wang, who lives in Ningbo, said that now, she can see the expert number from Shanghai Renji Hospital in just over an hour by driving from Ningbo to Hangzhou Bay New District, saving a lot of time and energy.
Ningbo Hospital, Renji Hospital affiliated to Shanghai Jiaotong University School of Medicine, located in Hangzhou Bay New District, Ningbo, Zhejiang Province, has become a high-end medical and health center in northern Ningbo since its opening at the beginning of this year. Once, like Ms. Wang, she traveled to Shanghai to see a doctor, but now she can easily make an appointment to see a Shanghai expert for outpatient service and surgery. "In the future, residents of Nantong, Jiangsu Province will also be able to make appointments for experts in Renji Hospital at their doorsteps." Zhang Jidong told the research team that after the completion of Renji Nantong Hospital, 30— people will be selected from the existing functions and heads of clinical and medical departments; A team of 50 excellent hospital managers and experts went to Nantong to work together in medical services, discipline construction, personnel training and scientific research.
In order to promote the extension of high-quality resources to the grassroots level and effectively realize the functions of resource sharing, regional linkage and complementary advantages, Shanghai has established a number of medical associations and specialist alliances in the Yangtze River Delta region.
Relying on three-level hospitals such as Pediatric Hospital affiliated to Fudan University, Shanghai Children’s Medical Center, Shanghai Children’s Hospital, Xinhua Hospital and Ruijin Hospital, five "pediatric medical associations" of "East, South, West, North and China" have been built in the city. At present, there are 86 member units, including 8 tertiary hospitals, 15 secondary hospitals and 63 community health service centers. Fudan Pediatric Medical Association has also continuously strengthened technical support and radiation, and implemented the homogenization of service quality and safety in the pediatric medical association. By the end of 2018, more than 20 pediatric appropriate technologies had been steadily popularized. The number of pediatric outpatient and emergency visits in 19 general hospitals in Fudan Pediatric Medical Association was more than 1.24 million, down by 9.26% compared with 2017. The number of pediatric outpatient visits in the community health service centers in the five districts of Shinan District of Shanghai was more than 280,000, up by 9.87% compared with 2017. The regional pediatric medical association’s graded diagnosis and treatment service system has achieved initial results.
This kind of specialized medical association led by "big specialty" was quickly spread in Shanghai, and specialized medical associations such as obstetrics and gynecology and oncology were also established. For example, the "Obstetrics and Gynecology Specialist Medical Association" is a network of obstetrics and gynecology diagnosis and treatment formed by the Obstetrics and Gynecology Hospital affiliated to Fudan University in conjunction with 12 hospitals in the city; The "Medical Association for Cancer Prevention and Treatment" is a medical association in which the Cancer Hospital affiliated to Fudan University cooperates with Baoshan, Minhang, Jinshan and other regions to carry out cancer screening, follow-up and rehabilitation to alleviate the "difficulty in seeing a doctor" of tumor patients in outer suburbs. At the same time, in order to promote the improvement of regional medical service capacity, Shanghai launched inter-provincial medical cooperation. Ruijin Hospital established cooperative relations with 28 hospitals all over the country, and took the lead in setting up the first medical association of hematology specialty in China, radiating high-quality resources throughout the country.
5. Thoughts on the Construction of Shanghai Medical Association
— — The construction of medical association needs to strengthen top-level design and system guarantee, and become a community of service, responsibility, interest and management. Shanghai has implemented the government’s main responsibility for running medical services, given full play to the supporting role of medical insurance in the construction of medical associations, improved the personnel security and incentive mechanism, and established an assessment and evaluation mechanism for medical associations. A series of institutional and institutional innovations have provided a strong guarantee for the construction of medical associations. From 1.0 to 2.0, the continuous development of medical association has put forward higher requirements for all participants. We should further strengthen the internal responsibility sharing and benefit sharing, open up all links within the medical association, and form a joint force among medical institutions, medical insurance, finance and other departments to promote the realization of "people-to-people communication", "finance communication" and "medical communication" from top to bottom. We should avoid over-reliance on administrative orders, but stimulate the endogenous motivation of medical institutions through mechanisms such as financial support, incentive mechanism and performance distribution within the medical association, and finally realize the transition from "managing diseases" to "medical communication"
— — Through graded diagnosis and treatment, we can realize the sinking of high-quality resources and the shift of work focus, and improve the overall efficiency of the primary medical service system. Through graded diagnosis and treatment in Shanghai, the expert resources of tertiary hospitals have sunk, which has significantly promoted the medical level of secondary hospitals and community health centers, and solved the problems such as unreasonable medical structure, unbalanced resource distribution and weak primary health service capacity. In view of this, to promote graded diagnosis and treatment, it is necessary to improve the cooperation mechanism within the medical association, realize the sharing of medical resources, and optimize the two-way referral mechanism. We should establish a green channel for two-way referral, simplify the referral process, and build a bridge between primary hospitals and clinical specialties in tertiary hospitals, so that people can enjoy high-quality medical services in large hospitals conveniently. At the same time, lectures on popular science knowledge and free consultation are held in medical institutions at all levels of the medical association to publicize and promote the medical association and the two-way referral model to community residents, so as to improve the first-time consultation rate of the masses in primary medical and health institutions.
— — The reform of medical association focuses on "association", and information technology makes hospital management glow with new vitality. In Shanghai, the research team saw that HIS (Hospital Information System), EMRS (Electronic Medical Record System), PACS, etc. have already become the most critical links in hospital information management. However, the reform of Shanghai Medical Association opened a demonstration clinic in district hospitals by exporting technology, sending experts, carrying out standardized training, and building a remote network cooperation platform, so as to promote the homogenization of medical treatment process, diagnosis and treatment norms and medical service quality between district hospitals and tertiary hospitals through information interconnection. At present, in order to further improve the "internet plus" medical insurance management, two-way referral green channel, and medical quality management informationization, Shanghai Medical Association actively explores advanced technical means such as smart platform, big data, artificial intelligence, etc., so that the medical resources and information in the medical association can reach the end of patients, from passively accepting patients’ consultation to actively providing all-round and full-cycle medical and health services.
— — Establishing a specialist alliance across regions is a "high-level version" of the medical association. Shanghai is dominated by one or more tertiary hospitals, combined with the same expertise of other medical institutions, forming a number of key specialty medical associations such as pediatrics, obstetrics and gynecology, hematology, oncology, etc. It can be said that it is a "high-level version" of the medical association. While improving the ability to treat major diseases of the specialties, through deep docking, it radiates and promotes the improvement of medical services within and between the Yangtze River Delta region, amplifying the overall efficiency of high-quality medical resources, and finally realizing the same city for patients to seek medical treatment. (Guangming Daily Research Group Cao Jijun Jing Zhao Yan Weiqi Ma Shanshan Lan Yani)
