“We felt that it was the best way to see where we rate according to other teams to use for improvement work within our team”- AFHTO Member

Data to Decisions (D2D) is a summary of the performance of primary care teams across Ontario on a small number of indicators that are both meaningful to providers and possible to measure. D2D is grounded in Ontario’s Primary Care Performance Measurement Framework (PCPMF) and reflects Barbara Starfield’s principles of comprehensive, patient-centered care. It’s intended to help members compare their performance to that of peers, focus local improvement efforts and also give primary care teams a voice in the future of performance measurement in primary care. A project of the Association of Family Health Teams of Ontario (AFHTO), D2D was made possible through the investment in more than 30 Quality Improvement Decision Support Specialists (QIDS Specialists) across Ontario. ASSESSING IMPACT Following the release of the second iteration of the D2D report in June 2015, AFHTO began a developmental evaluation to collaboratively understand and increase the impact of D2D on:

• Participation in Performance Measurement
• Access to Data
• Use of Data
• Quality of Care

WHAT’S THE DIFFERENCE?

• Team characteristics: Better scores on team climate and changes in QI goal orientation
• EMR use: Increased data standardization despite no change in EMR functionality
• QI activity: More conversations with physicians and board re: QI and performance
• Physician ambassadors: associated with better team characteristics
• Performance on processes/outcomes of care: No change on the core D2D indicators (old data, 8 month interval)

Learn more about selected findings to date here. WHAT’S NEXT?  The D2D journey continues with release of D2D 3.0 in January 2016. The focus is on increasing participation and encouraging teams to make decisions from data. To that end, AFHTO is assembling strategies for improvement that are aligned with the way teams work to achieve their goals. The information on this page is also available as a pdf here.

Ontario’s primary care sector is moving towards a more comprehensive, patient-centered approach to quality health care delivery. To fully understand whether primary care has reached this goal of quality, there needs to be a way to measure both the comprehensiveness and patient-centered aspects of care. We developed a survey in collaboration with volunteer patient representatives from Patients Canada, incorporating discussions with a broader group of representatives. The main objective was to determine which indicators are most important to patients and in what way. You can learn more about the process here. This information would then be incorporated into a composite quality “roll-up” indicator, based on performance on common indicators weighted according to their relative priority to patients. The resulting indicator would better reflect the comprehensiveness and patient-centeredness of care.

“Over half of the participants indicated that they want an equal partnership with their doctor when it comes to decision-making around their care.”

Results: An important finding of the survey was that over half of the participants indicated a desire for an equal partnership with their doctor when it comes to decision-making around their care. This validates the original premise that it was important to ask patients what is important to them and further emphasizes the need to incorporate patient input concretely into measurement of quality in primary care.

Importance of indicators to patients

The results show that patients do consider certain indicators more important than others, the most important ones being those related to their experience of being heard and involved in their care. Based on these data, weights were derived to calculate a composite measure of quality which was first included in AFHTO’s membership wide performance measurement report, Data to Decisions (D2D) 2.0. Conclusion: Overall, this collaborative project was successful in determining what is important to patients and how it is important. The partnership between Patients Canada and AFHTO is continuing through joint submissions to conferences. Future inquiries into patients’ values regarding their care should similarly involve collaboration with patients throughout the entire development and implementation process. WHAT’S NEXT?  AFHTO is continuing work on measurement in primary care with each iteration of D2D which will include an updated quality “roll-up” indicator with input from patients and doctors. The information on this page is also available as a pdf here.

AFHTO’s Algorithm Project was established in 2014 with a small group of QIDS Specialists interested in data mapping. The group quickly realized that there was a need to develop and test standard EMR queries to enhance the ability of all teams to extract and analyze EMR data, and to facilitate data clean-up initiatives. One year later the Algorithm Project team, composed mostly of volunteers, has established their mission to develop, test and deploy consistent queries based on the formally tested case definitions developed and published by CPCSSN and EMRALD. This work builds on the ALIVE project. The team’s goal is to improve access to clinical data through the development of standard queries for three major EMRs so that teams across the province can collect data on the chronic conditions as shown below.

Goals of having consistent clinical data:

• Deliver consistent searches for multiple disease conditions across multiple EMRs
• Allow for easy and consistent identification of correct patients not previously identified
• Offer early treatment, hopefully mitigating disease progression
• Improve patient outcomes
• Reduce costs to the healthcare system

Results (learn more about the team’s methodology and the results here):

• COPD query: this query was developed in collaboration with the Ontario Lung Association (OLA) and the University of Toronto Practice Based Research Network (UTOPIAN)
• Diabetes query: this query was developed in collaboration with a number of FHT clinicians
• CHF query: this query was developed in collaboration with Cardiac Care Network and eHealth Center of Excellence
• Depression query: this query was developed in collaboration with St Michael’s Hospital, Hamilton FHT and eHealth Center of Excellence

Currently working on

• Hypertension
• Queries on opioid use

Summary of impact:

The Algorithm Project team is a member-driven initiative, established by the QIDS Specialists in response to a need they identified within their teams. The spontaneous emergence of this group is an example of the positive impact of the ground-up approach to effective use of EMRs. Additionally, the team’s success illustrates the value of having the people using the technology bringing about the change. The standardized queries developed have shown that while EMR data quality issues have historically resulted in more emphasis being placed on data standardization efforts, it is possible to work with EMR data in its current state to get started on the QI journey.

• Spread Beyond AFHTO

  • Accuro has uploaded the COPD query and made it accessible to all users across the province via the Accuro Alerts Publisher
  • The OLA has shared the COPD query with their network and continues to encourage all providers caring for patients with COPD to use this as a tool to identify patients with a diagnosis of COPD
  • All Telus PS queries are available for download from the Telus Community Portal
  • Query case definition criteria is being used for OntarioMD dashboard specifications
  • Depression query is being used as the basis for the CAMH Optimum project to identify patients in the EMR with treatment-resistant depression

• A ground-up approach works for getting started

  • Through the development of standardized queries, customized to meet the needs of all teams, it is possible to extract reliable and meaningful data from the EMR without modifying functionality – teams are already doing this!
  • Converting the diabetes case definition into a standard query, we now have teams creating more accurate diabetes registries – physicians are validating the lists, teams are coding their patients in a consistent way and updating their cohorts accordingly

• Getting value out of EMR data starts with people

  • Despite no change in EMR functionality, data standardization is increasing.
  • Feasible solutions for extracting data and using it to improve have been developed and implemented through QIDS Specialists and the EMR CoPs

WHAT’S NEXT? 

Members can see updates about the Algorithm Project team in our Members Only section here.  

Access to data in primary care is difficult, largely because the quality of data in Electronic Medical Records (EMRs) is poor. While it is important to improve the quality of data going into EMRs, it is also worthwhile to get better at using the data and systems as they are. Over 30 Quality Improvement Decision Support Specialists (QIDSS) are dispersed across the province to help members access and use data better to improve care, supported by our Quality Improvement in Primary Care Community of Practice.

Change Concept – EMR Communities of Practice (CoPs): AFHTO convened CoPs for 4 EMRs (TELUS PS, QHR’s Accuro, OSCAR, P&P) to engage EMR vendors, QIDS Specialists, Physicians, Interdisciplinary Healthcare Providers, and practice staff to continuously improve user expertise and access to EMR data. Unlike most EMR “user groups” the CoPs have the following characteristics:

• have equality of members
• focus on issues in common
• are led by users (QIDSS, physician, etc.)
• set priorities collectively via action item list
• solve problems collaboratively through sharing of best practices
• are accountable to the community
• have their own social networking platform
• meet regularly

Objectives

1. Leverage the wisdom of the field
2. Change conversations with EMR vendors to expedite improvement
3. Identify data extraction tools and processes

Lessons Learned Outcome Measures

1. Rapid spread of solutions – 67 teams have implemented standard queries to improve access to data in custom forms, an item assigned high priority by 86% of the Telus PS CoP members.
2. Improved vendor role and engagement – Vendor representatives invited to participate are product managers and developers as well as sales staff. They participate as equal members – with rapid resolution to problems posted on the online forum.
3. Use of solutions beyond AFHTO membership – A query to more accurately identify patients with COPD is being spread to all EMR users through partnership with the Ontario Lung Association.

Access to good quality EMR data remains a challenge, with low maturity in EMR use and low functionality. Integration with other systems is increasing but still problematic. Increase in the spread of standard EMR data entry and extraction tools, however, illustrates that people and processes can increase the value of the technology, with the goal of being able to show improvements in care.

EMR CoPs have transitioned to OntarioMD

The EMR communities of practice (CoP) have transitioned from AFHTO to OntarioMD effective March 31, 2020. AFHTO would like to thank all members for their continuous support and participation. We would also like to sincerely thank CoP leads for their dedication to these groups! We look forward to a smooth transition. 

OntarioMD is in the process of updating membership lists for existing CoPs. Please take a few minutes to fill in this form through which contact info is being collected. OntarioMD will use this information to send all meeting invitations and updates regarding the CoPs after March 31, 2020. Moving forward, the central contact email will be communities@ontariomd.com.

Listserv emails have been updated to: 

• For OSCAR users: oscaromdcop@emaildodo.com
• For Accuro users: accuroomdcop@emaildodo.com
• For Telus PS users: telusomdcop@emaildodo.com
• For P&P users: p-pomdcop@emaildodo.com

If you have any comments, questions or concerns about this transition, please take a few minutes to fill out the following surveys: 

• For OSCAR users 
• For Accuro users 
• For Telus PS users 
• For P&P users 

Thank you for your continued support and participation in these important meetings!