Data elements 1)      Data from patient experience surveys: Teams which already have questions on the following topics in their questionnaires may be able to contribute data for these elements.  Teams which have not yet included these questions may consider including them in future patient experience surveys so they can contribute data to later iterations of D2D.  The decision regarding acceptable wording was based on whatever wording was used most commonly among AFHTO members, based on a recent review of approximately 30 questionnaires in use by AFHTO members.  Since then, the HQO Patient Experience Survey has generated a set of ‘standard questions’ for these and other topics.  The suggestions from that survey are included with the common AFHTO wording in the data dictionary.     a)      Patient involved in care b)      Courtesy of office staff c)       Wait for appointment was reasonable d)      Patient was able to access an appointment on the same or next day 2)      Data from ICES: Teams can access team-level data for the following elements from ICES by submitting their request to AFHTO as outlined in the request form below.  As noted above, teams that wish to access their ICES data directly without going through AFHTO may do so via the HQO portal , with the collaboration of one or more of their physicians.  For the most part, these indicators require information from other providers and institutions, not just data from the teams themselves.  See data dictionary  for technical definitions of each indicator. a)      Readmission to hospital: % of patients with specific conditions readmitted to hospital within 30 days of discharge. b)      regular care provider: % of patients who visited the same doctor, assuming they visited a doctor at least 3 times in the time period.  An additional version of this indicator will also be provided specifically for D2D by ICES that tracks the % of patients who visited the same team.  The team-based variant of this indicator will only be available to teams requesting data from ICES via the request form below (ie not via the HQO portal). c)       health system cost: Average of the total health system cost for all patients of the team (rostered and virtually rostered).  Breakdowns of the total cost according to primary care related costs, services, care in other settings and institutional care will also be provided.   Prior to Dec 2015, data for this indicator will only be available to teams requesting data from ICES via the request form below (ie not via the HQO portal). d)      Cervical and colorectal cancer screening rates: % of eligible patients receiving appropriate screening tests, according to the definitions in CCO’s SAR reports.   3)      Data from EMR: These items are grouped together because they are accessed from the EMR. a)      childhood immunization: The % of eligible 2 year old patients immunized, using standard queries developed by and shared among QIDSS, based on the definition in the data dictionary.  Teams not participating in QIDSS partnerships or otherwise not able to access the QIDSS Communities of Practice online forums (ie Trello) can access copies of the standardized EMR queries from Marg Leyland. b)      Cervical and colorectal cancer screening rates: The % of eligible patients screened for cervical and colorectal cancer, based on the definitions in CCO’s Screening Activity Reports (SAR).  While this appears to be a duplicate of similar data from ICES (above), it is intended for the purposes of populating a “data quality” indicator, not reporting on progress with cancer screening. 4)      Data for the “developmental” indicator: 7-day follow-up after hospitalization is included as a “developmental” indicator.  To that end, data may come from a variety of sources as noted below. a)      team-specific follow-up after hospitalization: The % of eligible patients followed up in the an appropriate manner within 7 days of discharge from hospital.  The data are intended to be accompanied by a description of exactly how the team has defined eligibility and appropriateness.   The rates of follow-up are not expected nor intended to be comparable between teams.  The intent instead is to illustrate the various approaches used by teams to support the generation of consensus and momentum towards a more consistent, manageable and meaningful definition of this indicator for subsequent iterations of D2D. b)      MOHLTC-defined follow-up after hospitalization: The % of eligible patients followed up by a billable office visit to a family physician within 7 days of discharge from hospital.  The data are intended to be extracted from materials made available to teams on the Health Data Branch portal.  This measure is included for the purposes of comparing/contrasting the relative performance, timeliness and usefulness of this indicator relative to the team-specific suggestions (above). 5)      Team description: These items form the basis for choosing peers for comparison purposes. a)      teaching status: Teams self-describe themselves as “academic” (based on participation in a formal agreement with and designation by a medical school), “teaching” (a self-described status reflecting whether the team hosts a variety of clinical trainees) and “non-teaching” (for teams who may host non-clinical, undergraduate and/or high-school students) b)      rurality: Self-described rurality of the team. c)       patients served: The total number of patients served by the team as well as a separate total of the number of patients rostered by the team.  This is intended to increase awareness of the extent to which teams are already serving non-rostered patient populations (as appears to be the emerging direction from MOHLTC) as well as help teams choose peers with similar workloads for comparison purposes.   6)      Login credentials: These items establish the identity of the team and confirm how the team wishes to have their data represented in the final report. a)      Team code:  The same 8-digit code used in the sign-up process. b)      Anonymity request:  Teams that do not ever want their identity released to any other team can indicate that on their data submission. c)       Participation in roll-up quality indicator: Teams that do not want their data included in the roll-up quality indicator can indicate that on their data submission.  Inclusion in the roll-up indicator is possible for all teams, regardless of how much data they submit.  However, the roll-up indicator may not be as meaningful for teams with less complete data.   7)      Expanded data submission (for roll-up quality indicator): Teams interested in contributing additional data for inclusion in the roll-up quality indicator have the option of submitting data for the following items from the respective sources below. a)      ICES data elements: All teams that request ICES data via the form below will receive data for the D2D 2.0 indicators as well the additional indicators listed below. i)        Ambulatory Care Sensitive Hospitalizations ii)       Mammograms iii)     ED visits iv)     % of diabetics with management or assessment codes (Q040 or K030, respectively) b)      EMR data elements: Some teams may be able to extract data for some or all of the following indicators from their EMRs.  Those that are able to do so are invited to submit these data for inclusion in the roll-up quality indicator.  These data elements will be added to the data dictionary, pending further clarification of definitions. i)        % of patients screened for hypertension, diabetes and smoking ii)       % of smokers counseled in last year iii)     A review within the past year for all patients on the following registries: Hypertension, Stroke / TIA, CHF, Depression, ASHD, Bipolar Affect Disease, Schizophrenia, Asthma, COPD, Epilepsy, Hypothyroidism iv)     % of patients with reconciliation of diagnosis list in the last year v)      % of patients with reconciliation of medication list in the last year vi)     % of patients with hypertension with systolic pressure =<150 in last year vii)   % of patients on Coumadin with INR level at 2-3 in last 6 months viii)  ChartStar Record on admission in 24 Hrs. ix)     % of patients admitted to an acute care hospital with Chart Communication x)      % of patients with flu immunization c)       Patient experience survey elements: Some teams may already have these questions in their patient experience survey.  Those that do are invited to submit these data for inclusion in the roll-up quality indicator. i)        Do you have confidence in your doctor? ii)       How confident are you that your doctor will look after you no matter what happens with your health? iii)     Do you feel that the practice can be described as your medical home? iv)     Did your doctor really find out what your concerns were? v)      Chance to ask questions vi)     Did your doctor let you say what you thought was important? vii)   Did your doctor help you feel confident about your ability to take care of your health? viii)  Did your doctor take your health concerns very seriously? ix)     Enough Time Spent? x)      How comfortable do you feel talking with your doctor about personal problems related to your health condition? xi)     Was your doctor concerned about your feelings? xii)   How much importance did your doctor give to your ideas about your care? d)      Office info i)        % of Palliative and LTC Pts. with coverage 24/7 ii)       Access bonus

1)      Who is the service provider? Cliniconex was selected as the provider by a small review committee of AFHTO members, following a formal Request for Quote process. 2)      What is the cost for AFHTO members? There is no fee for implementation and the first year of service or 500 transactions. If teams are interested in continuing the service beyond that, they may negotiate usage fees with the service provider (about $.75 or less per patient contact, depending on volume). 3)      Are all AFHTO members eligible for participation in the project?    All AFHTO members are eligible to participate.  Pilot members will be selected based on their EMR system and readiness to participate in March 2015. Please note, this patient contact management system is currently integrated with Telus PS, Accuro, OSCAR, AbelMed, YMS, Med Access, and GlobeMed. Nightingale is not a part of this pilot project; they have a pre-existing patient contact system that is integrated into their EMR. 4)     What is required from the team?

• Teams formally commit by signing a service agreement with Cliniconex. ED and medical lead signature will be required.
• Teams commit to having Cliniconex access their EMR server remotely for installation of the software tool that will automatically generate a list of patients and initiate contact by email or voice, according to a standard set of criteria to be used by all teams.
• Teams allocate their IT staff, QIDSS, and/or other staff members as contacts for the project.
• Teams agree to participate in the evaluation of the project, including sharing how many patients were contacted, in what way and what the nature of the patient response was (quantitative and qualitative data). Most of this data will be generated by the patient contact management system.

5)   How much work is the pilot for participating teams? Teams can expect to spend a total of about 1 day with the service provider, spread over several sessions (e.g. GoToMeeting calls).  On these calls, the service provider will review survey administration work flow including how to set up the voice system, and use a portal for editing voice survey questions, managing voice survey results, and creating email instructions for online surveys. 6)      What version of the patient experience survey will be used? Teams will have full control over the content of information shared when the system is used to contact patients.  If teams choose to use the system for patient experience surveys (as planned for the pilot), the team will decide what questions they want to ask their patients and whether they want to do that via phone survey or by pointing patients to an online survey etc. 7)      What analysis features are available in the system? The system will track and generate reports of the voice survey responses, and progress in contacting patients (i.e. number of attempts and successes in making contact with patients etc).  Otherwise, teams would continue to use whatever analytic tools they want. 8)      Whose voice is on the phone call to patients? Teams can choose whose voice will be on the messages to patients and what that voice will say. 9)      Where is the data from the patient experience surveys stored? Teams will tell the service provider where they want any data generated by the patient contact management system to be stored within their own computer systems.  Teams that use the patient contact management system to point patients to an online survey will access the data in those online surveys in the same way they do now. 10)   What other approaches can teams use to contact patients? Telus PS, OSCAR, and Nightingale are EMRs which may be able to provide some (or all) aspects of this functionality within existing systems.  Visit the relevant EMR CoPs for more information on this.  Alternatively, teams may choose to design and implement their own patient contact management system by exporting patient contact information from their EMRs and importing it into an ‘off the shelf’ auto-calling service or system, many of which are available in the market place (e.g. Phone Dialer Pro). 11)   What is the advantage of the Cliniconex system as opposed to just using our postal service or subscribing to an ‘off the shelf’ auto-calling system? The Cliniconex system combines many of the patient contact and survey administrative functions into one platform. Unlike ‘off the shelf’ voice systems, the Cliniconex platform is already built, is integrated with your EMR, includes a user portal with templates to set up voice survey questions and randomization, and a mechanism within the portal to set up the standard email invite to patients. Patient contact statistics and voice survey responses are anonymous, data can be located locally, and is managed by the team, not the service provider. Please contact Carol Mulder for more information.