Background: General practice is the key organisational setting in terms of offering people with complicated multimorbidity high-quality patient-centred, integrated care. However, there is limited knowledge of the most appropriate organisation of healthcare services for this patient group. Based on the evidence we developed the care model “Complex intervention for patients with complicated multimorbidity model” (CIM). The CIM was tested in a feasibility study and based on the results an improved version 2 of the model was developed (CIM2). The CIM has contributed to part of the Agreement between Danish Regions and The Danish Organization of General Practitioners (PLO) approved for 2022-2024 (OK22).

Aim: The overall aim of this study is to test the CIM2. The aim of this abstract is to present our experience in recruiting general practices, patients, and the findings from the intervention practices on how they implemented and carried out the extended overview consultation.

Methods: Fourteen general practices will be included in the pilot study taking place in the two Regions of Denmark; five municipalities and one hospital in each region. The intervention elements in CIM2 include training of healthcare professionals, an extended overview consultation in general practice, an individual care plan, and improved integration of care between primary and secondary care. The intervention period is 12 months. Data are collected at baseline and at 12-month follow-up.

Results: The following data are reported: CIM2 and usual care population characteristics (age, sex, multimorbidity patterns, medications, socioeconomic factors), results from patient questionnaires, and experience in recruiting general practices and patients.

Conclusions: The intervention is designed to improve the quality of care for patients with complicated multimorbidity (primary outcome) by supporting integrated care. Furthermore, the results from the CIM2 project are important evidence for the planning of “The National Multimorbidity Project” in the OK22.

1. Designing healthcare services for patients with multimorbidity is very complexed
2. Important challenges when conducting intervention research in general practices
3. How patients with multimorbidity experienced their burden of care.

Problem-oriented medical record (POMR) was first designed by Lawrence Weed to address issues in medical practice that often made it ineffective and prone to errors, e.g. unorganised patient data, neglected problems, and healthcare providers’ challenge to comprehend patients’ complexity. By using the medical record in a more organized and systematic manner, errors could be prevented, healthcare teams could collaborate effectively, and neglect could be reduced.

Electronic medical records (EMR) are now widespread and vary greatly in their organization. They may fully adopt POMR organisation, partially adopt it, or ignore it altogether. Over the years, other methods of collecting and storing patient data have been proposed, but there is no universal systematic approach. However, as Weed states in his famous article "Medical Records that Guide and Teach," these changes could lead to "a more positive attitude about the use of computers in medicine."

This study aims to systematically review the literature and gather published articles on the application of POMR in electronic medical records, including its development and outcomes evaluation. To date, there has been no review addressing this issue.

The review was conducted by three reviewers. The search involved PubMed as the only database. Only articles in English or Portuguese languages and those that involved some application of POMR in EMRs were included. Of the 315 articles that met the inclusion criteria, the titles and abstracts were screened by the three reviewers, and any disagreements were resolved during team meetings. The full articles were randomly assigned to each reviewer for evaluation. The review is still ongoing.

The presentation will showcase the methods and preliminary results of the review, provide an overall discussion on the applications of POMR in EMRs, and highlight research gaps that may require further attention.

The key points to be taken away from my presentation are: 1. There are many possible ways to apply problem-oriented medical record (POMR) concepts in an electronic medical record (EMR), either partially or totally. 2. POMR is a systematic approach that can be applied in EMRs and benefit medical practice. 3. There is a big research gap with respect to POMR approach in the EMR and patient outcomes evaluation.

Background:
Trust constitutes an important component in healthcare, as it is pivotal to the establishment of robust patient-doctor relationships. Better relationships of trust can result in increased patient satisfaction, improved compliance with treatment, and enhanced health outcomes. However, the underlying factors and processes that contribute to the development of patient-doctor trust remain elusive. The aim of this study was to shed light on the various factors and processes that contribute to the formation of trust between patients and doctors in primary care settings.

Summary of work:
We conducted a qualitative research approach utilizing semi-structured interviews. The data collected were used for inductive thematic analysis in collaboration with general practitioners, internists, a public health researcher, a philosopher, and an anthropologist. The theoretical framework used was Niklas Luhmann's concept of trust. The study was approved by the Okayama University Ethics Committee.

Summary of results:
Nine patients (five women and four men) in their 40s to 80s were interviewed. Patients’ expectations were key roles in process of establishing a patient-doctor relationship of trust. Patients' expectations were categorized into four themes: expectation for psychological and emotional closeness to patients, expectation for appropriate medical diagnosis and treatment, expectation for future care, and expectations of the organization and healthcare system.

Discussion and conclusion
Luhmann noted that the concept of trust, in the broadest sense of confidence in one’s expectations, is a basic fact of social life. Trust plays an important role in reducing social complexities that cause personal anxieties. In this study, patients had a wide range of expectations that included expectations for individual doctors and expectations for organizations and healthcare systems, and their hope was to reduce their complexities and anxieties by trusting doctors and healthcare systems. A reduction of complexities, facilitated by trust, has the potential for improving the healthcare outcomes of patients.

1. trust
2. patient-doctor relationship
3. patients' expectations

Eating disorders are relatively common psychiatric disorders encountered by primary care physicians. In severely malnourished cases, patients need to be hospitalized due to hypoglycemia, refeeding syndrome, and infection. Care must be provided by a multidisciplinary team that understands that the care continuum is complex, as their condition changes rapidly and repeatedly during a single hospitalization. The need for a good hand-over of the patient into the community is also essential at the time of discharge to prevent re-hospitalization. Thorough planning and discussion with the family members and their primary care physicians are also essential as eating disorders require family-oriented care.
A 37-year-old famale with severe eating disorder with a BMI of eight was hospitalized in the department of psychiatry. The following key learning lessons were identified.
(1) BMI<10 is a life-threatening condition with persistent risk of hypoglycemia and sudden cardiac arrest.
(2) Support for the medical staff will be needed to prevent burn-out as care for these patients are often emotionally exhausting. One unusual strategy may be to transfer patients back-and-forth with a collaborating hospital to give both the medical team and the patient a “time-out” from each other.
(3) Multidisciplinary nutritional support team meetings should be held regularly. Patients should be educated and counselled on healthy eating habits while receiving psychiatric care.
(4) Young patients with eating disorders should also receive rehabilitation for their sarcopenia but caution is required as patients are easily overworked.
(5) Successful handed-over to the community care team must include psychological care for the family members and discharge planning meeting involving the family members, the primary care physician, and the outpatient care team.

At the conclusion of my presentation attendees will take away
1. how to manage the severe eating disorders physically
2. how to collaborate a multidisciplinary team
3. how to make a successful handed-over to the collaborating hospital