Using data to improve can be as simple as starting a conversation. Those conversations can lead to all kinds of ways to improve. Maybe the improvements are first about getting better access to your data or cleaning up your EMR data. All these improvements eventually lead to better care. Some of the ways teams are doing this are listed below. Your team may already have done these things a while ago – or maybe your team is trying them out now. Either way, you know who you are but probably nobody else does. So please consider the following ways to use data to improve and please consider sharing your story so others can learn from and with you.
1. Talking about data
Bringing D2D to the Board to set a focus for QI work for the next year.
Setting up a QI committee to keep track of progress on indicators in your QIP or D2D.
Posting your team’s (or maybe individual doctor’s) performance compared to peers in the lunch room.
Reaching out to peers with better performance on indicators of interest in D2D.
Deciding what indicators your team can track to know if their programs are making a difference to patients.
2. Getting better access to data
Enrolling your team in EMRALD or CPCSSN for better access to EMR data to improve performance.
Signing up physicians for their own profile reports (eg from HQO portal or CCO SAR) to drill down into D2D performance.
Running the COPD query developed by QIDSS to get started on a COPD registry.
Printing cards for patients to hand in to you when they get their flu shot somewhere else (so you can update their EMR record).
3. Improving data quality
Offering a pizza party to the physician with the highest % of patients with complete data for smoking status.
Moving to monthly or quarterly patient experience surveys instead of annual so you can better track the impact of changes you are making.
Trying out tablets or email or phone calls to make it easier to patient experience surveys more often.
Hiring a student to clean up EMR data about cancer screening.
Reconciling your rostered patient list to the MOHLTC list and maybe even creating space to enrol more patients.
Adding questions to your patient experience survey to make it easier for you to compare to your peers.
Quality roll-up indicator: An “acceptable” measure of comprehensive, patient-centered primary care
The quality roll-up indicator, introduced in D2D 2.0, shows promise as a measure of comprehensive, patient-centred primary care. Statistically speaking, it is classed as an “acceptable” measure of quality; this means that while there is still room for improvement, this composite indicator really does reflect the quality of care being delivered. Read on to learn more about how the indicator works, what we’ve learned from it so far, and how we’re working to develop and refine it.
Questions asked and answered
The indicator was created as a “leap of faith,” with a goal of creating a single measure of quality that would reflect the comprehensive nature of primary care while honouring what is important to patients. The idea was to compare quality to cost to better understand the value of team-based primary care. It sounded good in principle but would it actually work? Thanks to the over 100 teams who contributed data to D2D 2.0, with 60 contributing even more than the core D2D indicators, AFHTO is now able to answer that question and several more besides! Here’s what we learned when we analyzed all that data with the able support of Chris Meaney, statistician with UTOPIAN and the University of Toronto: Does the quality roll-up indicator “work”? Yes! First of all, it was possible to access enough data to calculate scores. Second, there was enough data to assess the “reliability” of the measure. Reliability is a statistical term that reflects how well the items included in a scale (or in this case a composite measure) represent the concept being measured. The analysis of D2D 2.0 data suggests that the quality roll-up indicator has what is called “acceptable” reliability – see below how reliability is measured. However, our work on this is not done yet – i.e. it is not “excellent”. And at “acceptable”, it is good enough as a starting place to measure the overall quality of comprehensive patient centered care. How much data is needed to make the quality roll-up indicator work?About 14 indicators (see table below). The “acceptable” reliability described above is based on these. It could be that these are the only 14 indicators that matter. And it could be that data from a few additional indicators might help move the needle from acceptable closer to excellent. So while the immediate focus for D2D 3.0 is on the 14 listed below, teams that can provide more data are invited to do so, in hopes of making the quality roll-up indicator work even better.
Patient experience survey data
Administrative data (ie from ICES)
Reasonable wait for an appointment
% of physicians visits to same team
Patients involved in decision-making
Cervical cancer screening
Patient opportunity to ask question
Colorectal cancer screening
Providers spend enough time with patients
Mammograms (ie for breast cancer screening)
Availability of same/next day appointment
Physician billing claim for diabetes assessment
30-day readmission
EMR data
Ambulatory-care sensitive hospitalizations
Childhood immunization
ED visits
Does higher quality comprehensive patient-centered care cost less? The data are looking very encouraging! Looking at the overall results teams with higher scores on the quality roll-up indicator had lower overall system costs. This is very promising – and it does not mean we draw a direct line between quality and cost yet. There are a LOT of other things that are related to cost besides quality, not the least of which is the complexity of patients involved. And the roll-up indicator is still “acceptable”, not excellent yet. However, even when considering all of that, it is very encouraging to see hints of a relationship between high quality and lower costs.
Next steps
These are exciting but early days for the quality roll-up indicator. There is much work yet to be done. Next steps include the following:
Getting better at telling the story of what and how the quality roll-up indicator works. This is a complicated way of measuring quality. It is distinctly different from the kinds of reports AFHTO members are used to making and seeing. It takes a bit of work to get familiar with the concept and members understandably have little spare time to do that work. AFHTO will be working with QIDS Specialists and others to find ways to make this easier.
Moving forward from “acceptable” towards “excellent”. This means getting more data from more teams for D2D 3.0. Please watch ebulletins and connect with your QIDS Specialists to learn about how your team can help with that.
Setting “threshold” levels of performance. To get to a place where the quality roll-up score means something concrete to individual teams, thresholds for good performance need to be set for each of the 14 (or more) indicators included in the score. Please help set these thresholds by completing this survey by Nov 5.
Learning more about the “domains” of quality. The theory (as described here) is that there are 6 domains in the relationship between patients and their providers that is at the heart of comprehensive primary care. The analysis so far are not conclusive about these 6 domains. Data from more teams is needed to sort this out definitively. As noted above, please consider how your team can help with this.
What do the quality roll-up scores tell teams at this point?
The data teams submitted for D2D 2.0 made it possible to start to answer the three important questions above. However, in themselves, the scores are still too raw to support action to improve at the team-level. This is not about being lazy or sloppy – the leap of faith members made in contributing these data made it possible to do the analyses that are necessary to identify and properly address these issues. In subsequent iterations, as more of the questions get answered through the data contributed by teams, the quality roll-up indicator will work better and therefore be as useful at the team level as it currently is for the membership as a whole. For more information, including technical details of the statistical analyses please contact Carol Mulder or check out the quality roll-up indicator FAQs.
How is reliability measured?
Reliability is measured with a statistic called Cronbach alpha, the most important characteristic of which is that higher values are better. Figure 1: Reliability of the Quality Roll-Up (source: Patients Canada survey, n= 200, pat weights 4.sav) Figure 1 shows that the roll-up indicator has some reliability even with just core D2D 2.0 indicators (0.587). This increases to 0.697 with the addition of the ICES data from the expanded set of measures listed below. Since these additional indicators are already available to any team that has requested ICES data for D2D 2.0, contributing them may generate increased value in the roll-up indicator without much additional effort. The reliability of the roll-up indicator increases to 0.846 with the addition of the “high priority” indicators listed below in bold. This increase in reliability may need to be balanced by the extra effort associated with getting access to these data. Contributing data from the lower-priority set of indicators does not increase reliability much at all (i.e. increase to 0.855), something teams might weigh against what might be considerable extra effort to access and contribute these data.
Issue: Ontario (and Canada) have high ED visit rates. A large part of the rationale for investment in primary care, and primary care teams in particular, is to reduce ED visits. In addition, the MOHLTC has signalled an intent to include ED visits as an indicator to monitor primary care performance in the future. There are several approaches to tracking unnecessary Emergency Department visits including “ED visits Best Managed Elsewhere”, “less urgent ED visits – CTAS 4-5” and patient self-report of ED visits. For various reasons, none of these definitions are believed to generate a useful estimate of the number of patients for whom primary care providers could provide an alternative to ED care. Clinicians will receive information about the relative advantages and limitations of various definitions and the related challenges in accessing data. Questions for clinical input 1) What are the key characteristics of “unnecessary” ED visits? 2) Do we really need a different measure than “triage score 4 or 5”?
Issue: Follow-up of patients by primary care providers after hospital or ER department visits is a valuable way to improve patient outcomes. However, lack of access to data in primary care settings about hospital events makes it difficult to both measure and improve follow-up care. The available data is currently too old and excludes too many important concepts (ie follow-up by non-physicians, follow-up by phone etc) to be useful to support measurement and improvement by local primary care providers. Clinicians will receive a summary of emerging local solutions to measure follow-up as well as published evidence of the impact of follow-up on patient outcomes for the purposes of developing a consistent approach across the members of AFHTO and possibly beyond. Questions for clinical input 1) What do you think constitutes clinically helpful “follow-up” after hospitalization: appointment is set up? Phone consultation done by nurse? Other? 2) Which patients should be included in follow-up measure: discharged from a medical ward only? Patients NOT attended by family physician in hospital? Others?
July 9 – The Peterborough Examiner described the Peterborough Networked FHT partnership with the YMCA “as the next step toward a healthy community. It should also be the next step toward a comprehensive “green prescription” program across Ontario.” The first of its kind in the province, The Prescription … to Physical Activity … to Better Health initiative aims to address the increase in sedentary lifestyles with more than 100 family doctors, nurse practitioners and dietitians prescribing exercise for patients who need it. Patients can then redeem their prescription at the Balsillie Family YMCA for a free 60-day membership along with advice on exercise programs they might enjoy and how to do them properly. Green prescriptions are referrals with exercise or lifestyle goals instead of drugs. Research has shown that patients are more likely to change their lifestyles if the advice comes from a health care professional. For further information you can read the editorial or the original article.
Preparing to host a student is a multi-faceted task. At this point you will have already determined what school you will be hiring a student from; or, if you are hiring a student independently, you will have already posted a job description, started the interview process and be ready to hire the student of choice. Now is the time to prepare to host the student in your environment.
Enrol your team to participate in/send a student to an orientation session:
This may be in person or via webinar, depending on timing and number/location of students. AFHTO may host session(s) to provide EMR basics and build familiarity with the work of health teams. Timing of the sessions will be determined by the start date of the placement and the need from our members. You may also have orientation programs already in your teams and we encourage you to provide an orientation session for your student. Should you wish AFHTO to host a session, please contact Catherine Macdonald.
Prepare to host the student
Complete the following administrative duties for the student:
A letter or e-mail of introduction outlining when the student will start their term, where to meet the person who will be introducing them and your organizations policies such as sick days, dress code etc. An example of an e-mail and/or letter has been provided in Appendix G. (Thank you to the Queens Family Health Team for providing their example)
Complete payroll information
Arrange for physical space
Prepare introductions to clinical and clerical staff – Internally you will want to let your team know a student will be joining you, when that person is starting, and what that person’s duties will be. (ie asking them to do photocopying for the whole office is not a good use of their skillset). This introduction should also include who the student will be reporting too and who will be providing guidance and work assignments.
Arrange for access to EMR/charts. – If the student is to be working within your EMR they will need their own ID and Password as well as authorization to view files.
Confidentiality agreements See Appendix C for a sample confidentiality agreement to sign.
Onsite Orientation of Student
Introduce the student to staff. – Take the student around to meet everyone in the office. This will give them a face to face introduction and allow them to determine who does what. It will also give them the layout of the office.
Provide written instructions – review with the student what was outlined in their initial letter, any agreements they need to sign and outline their duties. This will allow the student to ask any questions prior to getting started.
Set goals – you will have already decided what the student will be doing and setting realistic goals is important. That way the student understands what is expected of themand will provide a framework to measure their work. A review of the goals is recommended part way through the placement and then again at the end of the placement.
Provide instructions to student – see Appendix F for an example of a Student Handbook courtesy of North York Family Health Team. You will want to create your own documentation as each practice will have their own policies and each EMR will have different commands and rules. Below is an example of a Table of Contents to help you fill in the blanks for your organization.
Student Handbook Contents Outline
Introduction – Before You Start …..Orientation to your team members …..Electronic Medical Record (EMR) Possible Activities for student: …..Roster Management …..Chronic Disease Prevention and Management ………..Risk factor standardization (tobacco, alcohol, etc) ………..Coding chronic diseases ………..Updating billing registries ………..Preventative reminders ………..Coding family history …..Procedure documentation cleaning …..Referral management …..Phonebook cleaning and update …..Using data from Cancer Care Ontario
“Pre” Data Extraction from EMR
Do “pre” data extraction from EMR: This will ensure your ability to demonstrate progress and the benefit of the student work. This is highly recommended as an important first step to ensure that you have a baseline of what was originally in the EMR to compare to what was changed by the student. Here is an example for diabetes tracking. It is a “pre” data extraction form that would make it possible to evaluate the impact of the student’s work on data quality.
July 3 – Dr. Ruth Wilson, a Queen’s FHT physician and former AFHTO board member, was named a member of the Order of Canada on Canada Day. The recipient of numerous awards, Dr. Wilson, who’s also a professor in the Department of Family Medicine at Queen’s University, was moved by the honour, saying “it’s not specific to my profession, it’s an award on behalf of the nation.” According to The Kingston Whig- Standard, Wilson said family medicine’s biggest accomplishment is the establishment of new models of care. “Family health teams has been terrific,” Wilson said. “So patients have access to a team of family doctors with other providers like nurses, nurse practitioners, dietitians and pharmacists.” She also provided her perspective on poverty, the lack of a national pharmacare program and aboriginal health. To learn more read the full article.
July 3 – Mothers attending the Waterfront Festival in Cobourg will have no trouble finding a comfortable spot to breastfeed and change their babies. The Northumberland Breastfeeding Coalition, of which Northumberland FHT is a member, has arranged a line-up of hot pink Adirondack chairs in an open-sided tent for their convenience. Coalition members will also be available to offer information about breastfeeding and community resources that support families. Their aim is to increase positive attitudes toward breastfeeding in public. To this end, they hope to take the chairs and tent to all the area’s big summer events, creating more breastfeeding-friendly environments for families to enjoy. Members also include, among others, representatives from the Haliburton Kawartha Pine Ridge District Health Unit, the La Leche League, Port Hope Community Health Centre, breastfeeding mothers, physicians and social workers. Read the article for further details.
A new Electronic Medical Record (EMR) query to identify patients with Chronic Obstructive Pulmonary Disease (COPD) is available to all primary care providers using Accuro EMR. The query was developed by QIDS Specialists from the Windsor FHT and East GTA FHT and validated by other QIDS Specialists.
The query was developed in collaboration with the Ontario Lung Association, and the University of Toronto Practice Based Research Network (UTOPIAN). It is intended for all those in primary care that do not yet have a reliable list of COPD patients and don’t have the time or resources to start from scratch in reviewing all their patients to generate such a list for those wanting to start a lung health program. The earlier patients are identified with COPD and started on a treatment regime will slow the advancement of this chronic condition.
At the end of the session, participants will be able to:
Describe the health care needs and barriers of medically complex patients (MCP) being addressed by the MedREACH project
Describe the different components of the MedREACH project and how they work together to support the medically complex patient
Describe the preliminary results of the MedREACH project.
Summary
The MedREACH pilot project (Medical Rapid Education and Assessment for Complete Health) is a demonstration pilot funded jointly by the Ministry of Health and Long-Term Care and the Ontario Medical Association. The goal of MedREACH is to improve the overall health of the medically complex patient (MCP) by seeking to re-forge the therapeutic relationship between the MCP and their family physician and interprofessional team. MedREACH consists of three distinct yet coordinated health care delivery models:
Primary MedREACH involving clinical nursing outreach to MCPs;
Specialist MedREACH involving integrated health care delivery by specialists and allied health professionals at McMaster University Medical Centre; and
Mobile MedREACH involving facilitated interaction between specialists and primary care providers enabling direct and timely consultation for patients with barriers to health care access in their family practice setting or home environment.
The MedREACH project aims to address current gaps in the following areas:
Medical service provision for MCPs in the primary care and tertiary care setting in order to ensure more timely and coordinated care
Existing silos of operation in primary and specialty care by building bridges for communication and partnership between primary care and specialty care.
This session will familiarize participants to the MedREACH project framework, how each component of the project was operationalized, and the program evaluation strategy with preliminary results.
Presenters
Henry Siu, Physician, MedREACH Evaluation Lead, McMaster FHT; McMaster University, Department of Family Medicine
Laurel Cooke, BES, BScN, RN, Nursing Program Manager, Hamilton FHT
