医联体内知识共享的范畴研究

目的　探讨医联体内知识共享的范畴，为医联体内各级医疗机构间知识共享机制的建立奠定基础。方法　于2016-07-26至2016-08-22在“周康航新”医联体内选取社区卫生服务中心管理人员、全科医生及上海市浦东新区周浦医院（周浦医院）管理人员、专科医生共39名进行半结构化访谈，主要内容为在临床、科研及其他方面需要上/下级医疗机构提供的支持、可以向上/下级医疗机构提供的支持。对访谈结果进行提炼和汇总，得出社区卫生服务中心需求导向、周浦医院需求导向的医联体内知识共享范畴。将社区卫生服务中心需求导向的医联体内知识共享范畴设计成问卷，于2016-11-15至2016-12-06选取90名社区卫生服务中心人员进行调查，以了解其对各项内容的重要性评分。结果　访谈结果显示：周浦医院基本可以满足社区卫生服务中心在临床、科研方面以及在协助培养青年医生、专业发展指导方面的需求，但在临床检验中心建立、行政和卫生管理、信息化建设方面未予回答；社区卫生服务中心尚不能完全满足周浦医院的需求。最终形成的社区卫生服务中心需求导向的医联体内知识共享范畴包括临床支持（92类疾病规范诊治/相关知识、医患沟通4项、辅助资源11项）、科研支持（10项）、其他支持（5项）3个部分，重要性评分分别为4.16~4.96、4.58~4.62、4.66~4.76分。根据重要性评分，排在前6位的病种分别为高血压（4.96分）、冠状动脉粥样硬化性心脏病（4.94分）、慢性阻塞性肺疾病（4.94分）、糖尿病（4.94分）、脑梗死/脑栓塞（4.94分）、脑卒中（4.94分），排在第1位的医患沟通技巧为急性病或危急情况下沟通处理指导（4.91分），排在第1位的辅助资源为辅助检查的适应证、禁忌证、检查前准备工作及辅助检查指导（4.89分）；排在第1位的科研支持为论文撰写指导或专项培训（4.62分）；排在第1位的其他支持为协助培养青年医生（4.76分）。结论　目前医联体内知识共享需以满足社区卫生服务中心需求为主，且以社区常见慢性病的规范诊疗为重。建议从社区常见慢性病的联合管理方案入手，以知识共享为契机，不断提升社区卫生服务机构的临床技能。

Scope of Knowledge Sharing in a Medical Consortium

Objective　To explore the scope of knowledge sharing in a medical consortium，providing a reference for the development of inter-agency knowledge sharing mechanism in the medical consortium.Methods　From July 26 to August 22，2016，we conducted semi-structured interviews with 39 persons from Zhoukanghangxin Medical Consortium〔including the managers and general practitioners from 4 community health centers（CHCs） and the managers and specialty physicians from Shanghai Pudong New District Zhoupu Hospital〕 for collecting the data mainly about needed support concerning clinical，scientific and research，and other aspects from higher-level or lower-level institutions，and support can be provided for higher-level or lower-level institutions.Data from interviews were organized into two themes covered by the scope of knowledge shared in the Zhoukanghangxin Medical Consortium：CHCs-centered needs and Shanghai Pudong New District Zhoupu Hospital-centered needs.Then，based on the CHCs-centered needs，we developed a CHCs-centered Needs in the Medical Consortium Questionnaire（CNMCQ），and used it to survey 90 primary care providers from the 4 CHCs from November 15 to December 12，2016 for obtaining the importance assessment of the items and subscales.Results　Participants from Shanghai Pudong New District Zhoupu Hospital said that they could basically satisfied the needs of CHCs，such as clinical and scientific research support，cooperative training of young doctors and professional development guidance，but did not give any response to the needs of CHCs concerning the establishment of a clinical testing center，administrative and health management，and informatization construction.Participants from CHCs said that they could not yet fully meet the needs of Shanghai Pudong New District Zhoupu Hospital.The CNMCQ consists of 3 subscales，namely，clinical support〔knowledge about the standardized diagnosis and treatment of 92 diseases，doctor-patient communication（4 items），auxiliary resources（11 items）〕，scientific research support（10 items） and other support（5 items），with the importance score of 4.16-4.96，4.58-4.62，4.66-4.76，respectively.Furthermore，according to the importance score，the most needed knowledge listed in the clinical support subscale was the standardized diagnosis and treatment of 6 diseases〔hypertension（4.96），coronary atherosclerotic heart disease（4.94），chronic obstructive pulmonary disease（4.94），diabetes（4.94），cerebral infarction/cerebral embolism（4.94） and stroke（4.94）〕；the most needed doctor-patient communication skill was the communication guidance for coping with acute or critical conditions（4.91）；the most needed important knowledge about auxiliary examinations was the indications，contraindications，pre-test preparation and guidance for the auxiliary examinations（4.89）．Meanwhile，the most needed knowledge listed in the scientific research support subscale was the guidance or special training for research paper writing（4.62）；the most needed knowledge listed in the other support subscale was cooperative training of young doctors（4.76）．Conclusion　At present，the knowledge，most about the standardized diagnosis and treatment of common chronic diseases in community-dwelling residents，shared in a medical consortium is mainly for meeting the needs of CHCs.Sharing knowledge in the medical consortium is of great significance in improving the clinical service capabilities of CHCs via the consortium management of such common chronic diseases.