British Columbia Primary Health Care Research Network A

British Columbia Primary Health Care Research Network A

British Columbia Primary Health Care Research Network A Vehicle for Innovation and Transformation Sabrina Wong, Fiona Duncan, Shana Ooms, Annette Garm April 2018 Disclosure Presenters: Sabrina Wong, Fiona Duncan, Shana Ooms, Annette Garm Relationships with commercial interests: Grants/Research Support: BC PHCRN, TRANSFORMATION, and FRAILTY are supported by the Canadian Institutes for Health Research and

the Michael Smith Foundation for Health Research Speakers Bureau/Honoraria: None Consulting Fees: None Other: None 2 Managing Potential Bias Material presented is unrelated to financial relationship with CIHR or MSFHR Wong, Duncan, Ooms provide scientific, clinical and policy leadership to BC PHCRN -BC PHCRN has an advisory committee made up of various stakeholders and a patient advisory committee

3 BC PHCRN Session Overview: Fiona and Shana BC PHCRN data platform: Sabrina Examples Frailty: Annette QI tools, CWL, TRANSFORMATION: Sabrina Response: Fiona and Shana Provincial/Territorial Tripartite Leadership of PIHCI Networks / Leadership Council: Researcher

Policy/Decision Maker Clinician Patients Network Leadership Council and National Coordination NWT Network BC Network AB Network

SK Network Newfoundland and Labrador Network MB Network QC Network ON Network

NB Network PEI Network NS Network Purpose Overall Purpose: To support evidence-informed transformation where the primary care home/patient centered health home plays a central part of the delivery, coordination, and integration of health care delivery Become a member: Visit our website and click on

the Participate tab, or email us at [email protected] BC-PHCRN Tripartite Leadership Science Lead Dr. Sabrina Wong, Director of the Centre for Health Services and Policy Research and Professor, UBC Clinical Co-Leads Dr. Fiona Duncan, Associate Professor of Clinical Practice, UBC Dr. Anne Junker, Investigator, BC Childrens Hospital Policy Co-Leads Heather Davidson, ADM, Planning and Innovation Division for BC Ministry of Health Shana Ooms, Executive Director of Primary Care in the

Primary and Community Care Policy Division at the BC Ministry of Health BC-PHCRN - Advisory Committee Physicians Data Collaborative Vancouver Citizens Health Initiative BC-PHCRN Patient Advisory Engaging clinicians through Divisions of Family Practice Participate in and support projects meant to increase continuity of care: Relationship between clinician and patient panel (frailty, QI tools for EMR)

Information and management continuity between primary care and health authorities (CWL, IHA-KB project) Participate in and support projects meant to increase quality of care: Regional performance measurement; practice based reports using patient medical home framework (TRANSFORMATION) BC-PHCRN Exemplars of Supported Projects Project Title Leads

Divisions Engaged Annette Garm/Grace Park, Fraser Health Authority and Sabrina Wong, University of British Columbia and Whiterock, South Surrey Sabrina Wong, University of British Columbia Various clinicians across BC, Kootenay-Boundary Division

Mylaine Breton, Universit de Sherbrooke Chilliwack, Whiterock Implementing a health information system for program planning across Interior Health Douglas Kingsford, Interior Health Authority and Kootenay-Boundary Division Kootenay-Boundary Division Improving the Science and Reporting of the

Primary Care Patient Medical Home (TRANSFORMATION) Sabrina Wong, Fred Burge (MD-Dalhousie), Sharon Johnston (MD-U of Ottawa) Chilliwack, Abbotsford, Hope/Mission Validation of Administrative and Primary Care Electronic Medical Record Derived Frailty Algorithms Implementation of InQUIRE and Data Presentation Tools with Electronic Medical Records A Comparative Analysis of Centralized Waiting

Lists for Unattached Patients Implemented in Five Canadian Provinces BC-PHCRN Supported Projects Project Title Nominated BC Team Principal Applicant Building Wellness and Resilience in MultiGenerational Indigenous Households: A Scoping Review Dimensions of Quality for Mobile Applications in Chronic Disease Management: A Review of Systematic Reviews

Cheryl Currie, University of Lethbridge Anne Marshall, University of Victoria Jay Shaw, Womens College Hospital Elizabeth Borycki, University of Victoria Andre Kushniruk, University of Victoria Scott Hofer, University of Victoria Integrating Paramedics into Primary Care to Optimize Patient Time in the Community at End of

Life Alexandra Carter, Nova Scotia Health Authority Sabrina Wong, UBC Jennifer Kryworuchko, UBC Kimberlyn McGrail, UBC Jeannie Haggerty, McGill University Jason Sutherland, UBC Leanne Currie, UBC Nelly Oelke, UBCO

Dr. Anne Junker, Clinician Victoria Schuckel, Ministry of Health Erin Strumpf, McGill University Kimberlyn McGrail, UBC Miriam R Lavergne, SFU Heather Davidson, Ministry of Health Policies and Program Innovations that Connect Primary Health Care, Social Services, Public Health and Community Supports in Canada: A Comparative Policy Analysis What are the Impacts of Being Formally Enrolled

with a GP on Continuity and Integration of Care? Evidence from a Comparison of Quebec and British Columbia BC PHCRN EMR data platform: Canadian Primary Care Sentinel Surveillance Network Unique pan- Canadian primary care database The Canadian Primary Care Sentinel Surveillance Network: 1.6 million Canadian patients 1248 practices 12 PBRNs in 8 provinces, 1 territory Some EMR data back to 2003

Started in 2008 $12.5M funding from PHAC Strong partnerships with College of Family ysicians of Canada, Queens and other Universities B.C. (BCPCReN), Alberta (SAPCReN, NAPCReN), NWT, Manitoba (MaPCReN), Ontario (DELPHI, UTOPIAN, EON, MUSIC), Quebec (RRSPUM), Nova Scotia/New Brunswick (MaRNet), Newfoundland (APBRN) CPCSSN Primary Care Research Networks British Columbia BCPCReN, Vancouver Alberta SAPCReN, Calgary AFPRN, Edmonton Manitoba

MaPCReN, Winnipeg Ontario DELPHI, London UTOPIAN, Toronto EON, Kingston McMaster, Hamilton U of O, Ottawa Quebec RRSPUM-Rseau de recherche en soins primaires de l'Universit de Montral Nova Scotia/New Brunswick MaRNet, Halifax Newfoundland APBRN, St. Johns

12 PBRNs in 8 provinces using 17 EMRs across Canada CPCSSN Partner Universities 17 EMRs supported Vendor Product In Provinces Telus Telus Telus

Telus Telus Intrahealth QHR QHR PS Suite Wolf Med Access Nightingale Medesync Intrahealth Accuro Healthscreen OSCAR

Telin Healthquest Dossier CIS EMR Dossier Xwave Da Vinci JonokeMed AB, ON BC, AB, NL, NT BC, AB ON, NS, NL QC BC

MB, ON ON BC, ON AB AB QC ON QC ON QC MB (open source product VARs) Telin

Healthquest Purkinje P&P Data Systems Purkinje Bell Canada Da Vinci Jonoke Privacy and Ethics Opt-out consent 12 Research Ethics Board approvals Stored in a highly secure facility

Data are deidentified CPCSSN Data Provider profile Patient sociodemographics Disease/ health condition Encounter data Risk factor data Examination data Medications Laboratory data Referral data Procedure data

Patients in database: Chronic Obstructive Lung Disease 29,146 Depression Diabetes 108,775 67,651 Hypertension 148,300 Osteoarthritis

77,235 Dementia Epilepsy Parkinsons Disease 18,199 8,477 2,675 Using the CPCSSN Platform: Fraser Health Authority CARES project Community Actions and Resources Empowering Seniors: Frailty Assessment

in Primary Care Annette Garm, RN/Grace Park, MD Family Physician, Park McDonald Inc. WR/SS Division of Family Practice, PAH Fraser Health Home Health Regional Medical Director Proactively Delaying Frailty in At-risk Seniors CARES: Community Actions & Resources Empowering Seniors) Is a targeted initiative which partners primary care physicians with at-risk seniors and health coaches for

3-6 months to prevent frailty and frailty-related health care use Uses the Comprehensive Geriatric Assessment (CGA) and the Frailty Index (FI) as a measure of the seniors progress toward or away from frailty Embeds CGA-FI into the physicians EMR for point of service calculation of the FI Frailty the noun: unmeasured heterogeneity Vaupel J, Manton K, Stollard E. The impact of heterogeneity in individual frailty on the dynamics of mortality. Demography 1979; 16:439-54 Combined in a frailty index, the

variable patterns of deficit accumulation show a steady increase with age Rockwood et al., Sci Rep 2017 Feb 21;7:43068 Geriatric Giants immobility sensitive but nonspecific signs of illness in instability older adults

incontinence impaired intellect/memory impaired independence Isaacs B. The Challenge of Geriatric Medicine. OUP 1980 CGA & Care Planning The purpose of the CGA is the care plan. The initial contact captured in the CGA needs to be verified and updated to serve as an accurate baseline. It needs to be completed with the best available information, not simply a record of what the client says. BC PHCRN: Using the CGA (and other data) in

Practice CPCSSN: Translate these data Into visual format to view in QI tools Engaging clinicians through Divisions of Family Practice Participate in and support projects meant to increase continuity of care: Relationship between clinician and patient panel (frailty, QI tools for EMR) Practical Uses of the Data

Practice Quality Improvement Data Coding/Cleaning Results 1. Practice Population Management 1. Practice Population Management Web-Based Quality Improvement Tools 1. InQuIRE: Interactive Quality Improvement Reporting Environment 2. DPT: Data Presentation Tool Secure web applications, accessible from clinicians computer Summary Compare of patient with rest of panel

site and BC InQuIRE + + DPT + + Interactive

filtering Detailed search, patientlevel Save reports for re-use Re-ID capability +

+ + + InQuIRE Demographics (Intrahealth clinic) InQuIRE Prevalence (Intrahealth clinic) InQuIRE Hypertension indicators InQuIRE Framingham risk score DPT dashboard

DPT detailed search DPT reports and saved searches DPT search for active patients not seen in 3 years DPT Trends in lab/exam results DPT re-identifying patients CPCSSN database Internet DPT in web browser

CPCSSN data Encrypted CPCSSN mapping file Decryption key Clinicians computer Patient details Read into web

browser EMR ID, Name, Address, PHN, .. .. .. .. Engaging clinicians through Divisions of Family Practice Participate in and support projects meant to increase continuity of care: Information and management continuity between primary care and health authorities (CWL, IHA-KB project) Centralized Waiting Lists: Chilliwack and Whiterock

Divisions Analyze the centralized waiting lists implemented in seven Canadian provinces and identify characteristics to promote attachment of complex patients to primary care providers Make recommendations on ways to improve the design of centralized waiting lists. Centralized Waiting Lists Outcomes ecommendation by Division to BC MoH for core funding

est practice from BC implemented in other jurisdictions (e.g. NS, ON) ideo creation [insert URL here] Creating a Learning Health System and Increasing Continuity of Care Kootenay-Boundary/Interior Health Authority Primary Care EMR + Organizational Survey + Administrative data Hospital Records Emergency Department Records Social Determinants of Health (e.g. neighbourhoods, income, education)

Engaging clinicians through Divisions of Family Practice Participate in and support projects meant to increase quality of care: Regional performance measurement; practice based reports using patient medical home framework (TRANSFORMATION) Portrait of Performance in Primary Care The Patients Medical Home (PMH) is the CCFPs vision for what the future of family practice in Canada will be. The information provided in this portrait shows results in three regions: Central Zone, NS; Fraser East, BC, and Easter ON Health Unit, ON. Crossprovincial regional reporting allows decision makers to reflect on strengths/weakness in primary care that may be shaped by different provincial/regional policies. Create regional level performance portraits using data from

quantitative (surveys, administrative data such as billing codes) and qualitative (document review, interviews, focus groups) sources We link the information from these different sources to show how practices perform on some elements of the key pillars of the PMH: patient-centred care,

team-based care, and electronic medical records. PMH Pillar: Patient-Centred Care Definitions of Dimensions Relationship-based care: The clinicians demonstrate whole-person knowledge of their patients, are willing to talk about sensitive issues and listen well during visits. Relationship-based care 10

9 8 7 6 Equity orientation 5 Promoting health Self-management support Fraser East, BC Central Zone, NS

(n=504 patients. 22 clinics) Eastern Ontario Health Unit, ON (n=547 patients, 26 clinics) Promoting health: Patients receive health advice and health promotion appropriate to their life context, and the staff actively encourages patients to attend groups or classes to help manage their health concerns.

Self-management support: For patients undergoing treatment. Clinicians engage in shared decision-making with patients receiving treatment and patients consistently report feeling better enabled to stick to treatment and care for their health. (n=878 patients, 39 clinics) Equity orientation: Patients experience respectful treatment from front office staff and clinicians respect the patients time,

Contextual information: Innovations in interprofessional teams ON has implemented the most extensive interprofessional teams of three study regions. BC and NS are moving towards more interprofessional teams, with adoption of the Patients Medical Home (BC) / health home (NS) models. So I have to go at one place, you know, my needs are taken care of right there. Everybody knows everything. [ON patient] When we started looking around the province, there's collaborative practice teams all over the province, except in the densely populated areas. So we have a misaligned sort of distribution right now. [NS key informant] Examples of interprofessional teams in comprehensive primary care practices British Columbia: Fraser East Ontario: Eastern Ontario Health Unit

Nova Scotia: Central Zone 1 Community Health Centre (CHC) in Fraser East / 29 in the province CHCs: 5-7 CHCs in EOHU / 74-87 in the province CHCs: 2 in Central Zone / 25 in the province Family Health Teams (FHTs) were implemented in 2004.

2 in EOHU / 184 in province Nurse practitioner (NP)-led clinics were first implemented in 2007 1 in EOHU / 27 in province Community Health and Wellness Centres: 2 in Central Zone / 2 in province Collaborative Emergency Centres (CECs), were first implemented in 2011. 2 in Central Zone / 8 in province PMH Pillar: Team-Based Care Fraser East, BC (n=22) Eastern Ontario Health Unit, ON

(n=26) Central Zone, NS (n=39) Health Professionals in PC Clinics (Mean FTEs) Family physicians Nurse practitioners Registered nurses Dieticians Other The ON region: higher average FTE for all types of health professionals working in primary care. Team Effectiveness (Mean Scores) (n=20 clinics)

Participation in the team Support for new ideas Team objectives Task orientation (n=21 clinics) (n=22 clinics) PMH Pillar: Team-Based Care (contd) Fraser East, BC Eastern Ontario Health Unit, ON

Central Zone, NS Extent of ability to work with multiple providers outside clinic for care of complex patients Very great extent Some extent Undecided Not really Not at all When clinicians work with multiple providers outside of their clinic for complex patient care, clinicians across all regions reported being better able to have timely communication than effective collaboration. More clinicians in the BC region reported that having a very great extent of ability to collaborate and communicate in a timely manner with other clinicians for complex patient

care. Contextual information: Innovations in information technology EMR implementation is high; variation in functionality within PC practices and across PC systems. Data privacy issues impact the potential uses for such systems to the point where you cant share information to get best outcomes. [BC key informant] Personal health records are still in an early stage of implementation across the three regions. Telehealth and other health information technologies are also being used within the study regions to a limited extent Examples of innovations in information technology within PC practices British Columbia: Fraser East

Ontario: Eastern Ontario Health Unit Nova Scotia: Central Zone The Physician Information Technology Office (PITO) (2006) is responsible for facilitating general practitioners and specialists in the implementation of information technology (IT). OntarioMD (ONMD) and eHealth Ontario support physicians moving from paper records to electronic medical records (EMRs) and electronic health records (EHRs)

The Frailty Portal supports physicians to assess and care for patients with frailty through a web-based tool The PHC Information Management and Electronic Medical Records (PHIM) project supports EMR implementation for the province. PMH Pillar: Electronic Medical Record Fraser East, BC Eastern Ontario Health Unit, ON Central Zone, NS

Information technology Patients have the option to... Request appointments or referrals online Send a medical question/ concern via email Request refills for prescriptions online View test results on a secure website (n=22 clinics)

(n=26 clinics) (n=37 clinics) Clinics in the ON region reported having less functionalities for patients to access IT services at their clinics. Clinicians in the BC and ON regions (mostly) use EMRs in their clinics; 83% of clinicians used EMRs in the NS region. Organizational adaptiveness Practice Integration BC PHCRN: Engaging Clinicians Divisions of Family Practice: Whiterock,

South Surrey, Chilliwack, Abbotsford, Mission/Hope, Kootenay-Boundary, North Shore Projects of interest to membership, value add GPSC: Input on support for various projects Various clinicians: QI tools https://twitter.com/home: @BC_PHCRN

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