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Primary Care: Harnessing Data for Improvement
W.L. Clifford, M.D., M.Sc.F., FCFP Paul Murray, M.B.
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The why – high quality primary care
The how – measurement, self reflection, population health awareness, system design/transformation The what – distributed data questions
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“Care is coordinated, continuous and comprehensive with patients having access to an interdisciplinary team”
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NH Community Care Shared EHR
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Physician’s overestimate performance by at least 10% (30% for LDL in diabetes)
Diabetes composite 2.5% McCrate et al. CFP 2010
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Hypertension and BP < 140/90
Steinman et al. Am J Med 2004 Steinman et al. Am J Med 2004
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Practice Routinely Receives and Reviews Data on Patient Clinical Outcomes
Percent Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
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Practice Routinely Receives Data Comparing Clinical Performance to Other Practices
Percent * Question asked differently in Italy. Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
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Measures must be connected to the doers
Collect measures from meaningful documentation Value add from system
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Point of Care Practice Population
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Point of Care Practice Population
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Point of Care
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Point of Care Patient Specific Information Clinical Decision Support Messaging / Tasks Interdisciplinary Care Coordination of Care
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Information Flow - CDM
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Practice
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Patient Specific Information Access Registries and Gaps in Care Recall
Practice Patient Specific Information Access Registries and Gaps in Care Recall
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Test Result Rate of Change
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Population
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Population Demographics Disease Prevalence Screening Prevention Chronic Disease Management Mortality Access Costs Satisfaction / Experience
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Population Level Measurement
Privacy for patient and provider Right measures Timely Available
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Aggregates are often good enough for the population level
Can’t be reworked or linked (“mining”) Provides pointer to population which can then apply usual research methods (ethics/consent)
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Generate Aggregates from Queries
F I r e w a l l EMR Generate Aggregates from Queries Interface Aggregate (e.g. numerator & denominator) Collector F I r e w a l l EMR Generate Aggregates from Queries Interface
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Prince George versus NH as a whole
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Comparison Charts to Identify Best Practices
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