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Over the last decade, electronic medical records (EMRs) have become ubiquitous throughout primary care in Canada. Unfortunately, the transition from a paper world to an electronic one has had varying levels of support from clinic to clinic. As a result, only a few practices excel with the ability to leverage the EMR to audit entire populations, while most struggle even with basic referral processes and form maintenance.

When used well, mature digital systems can provide timely access to data about individuals, populations and their care, allowing timely intervention to improve population health. With new digital health tools entering primary care at a rapid pace, support to embed these tools into day-to-day workflows is needed. Unfortunately, the burden of facilitating these digital enhancements is shouldered unequally throughout the country and usually rests with the folks who would rather be spending that providing direct patient care.

An audit of clinics in the South West LHIN found that clinics are spending between three to five hours per week simply building and editing new referral forms in their EMRs. As clinics digitize their own version of each form, quality varies significantly. With over 500 forms and an abundance of custom tools, clinicians are spending more and more time in front of a computer, which can negatively impact the provider experience. Adding to increased levels of provider stress and burnout are inefficient EMR workflows, hard-to-use user interfaces, and confusing and unstandardized terminology—all of which take time away from direct patient care.

Meanwhile, organizations in other sectors are impacted by the quality of referrals received (e.g., distorted faxed forms), low uptake on the most current forms, and missing or illegible information.

We talked to Partnering for Quality (PFQ) team members Rachel LaBonté, Program Lead, and Dr. Paul Gill, South West LHIN Digital Clinical Lead, about the work they are leading in the South West to optimize the use of digital tools to support a digitally enabled and integrated primary care sector.

What is Partnering for Quality (PFQ)?

PG: The PFQ program supports primary care and health system partners to improve chronic disease prevention and management through the optimized use of their EMR and through the implementation of quality improvement (QI) methodology.

Since 2012, we have been focused on improving chronic disease prevention and management (CDPM) by:

• Using Ontario’s CDPM framework
• Strengthening collaboration between system partners
• Sharing information across the continuum of care
• Enabling improved information management, and
• Actively engaging patients in self-care

RL:We currently support close to 400 primary care physicians and their staff—altogether, that’s upwards of 2500 stakeholders. We work with an extended network of individuals from primary care practices across the South West region, including solo practice physicians, Family Health Teams, Family Health Organizations, Family Health Groups, Family Health Networks, Nurse Practitioner Led Clinics and Community Health Centres.

How does the PFQ program support clinicians?

PG:When we first got started, it became apparent that primary care practices faced many challenges with the transformation agenda:

• the need for optimized use of EMR to input/extract quality data;
• the need to build a QI foundation;
• team effectiveness/efficiency of practice;
• building relationships beyond the clinic walls, etc.

To address these challenges, we use a range of organizational development, project management, QI, and practice improvement methods to build the internal capacity of a practice.

RL:Practically speaking, our work is designed around practice facilitation as a supportive service provided to primary care practices. This aims to assist engagement in improvement activities over time and support practices to reach incremental and transformative improvement and patient safety goals.

PG:We really want to find ways to seamlessly embed the high-quality tools that providers need to care for their patients into their EMRs and practices in a way that makes sense for their natural workflows. We will be most successful when we can do this in a behind-the-scenes, coordinated fashion across the system, while not vulturing away direct patient care time.

Can you tell us about the activities the PFQ program supports through practice facilitation?

RL:Practice facilitation may involve a wide range of activities, depending on the needs and goals of the practice. Taken together, these form a coherent set of activities for practice change and redesign. They include, but are not limited to, the following:

• Assessment of and feedback to practices regarding organizational, clinical, and business functions to drive change
• Use of practice-level data to drive change
• Training of staff in QI methods and specific transformation processes, such as team-based care
• Formation and facilitation of practice QI teams
• Executive coaching and leadership training
• Project and change management
• Capacity building in the use of health IT to support improved clinical care and office efficiency (e.g., EMR and/or Digital Health enablers)
• Cross-pollination of good ideas and best practices between primary care practices
• Capacity building for improved linkages to outside resources
• Technical assistance in implementing particular models of care, such as the Chronic Care Model

What are the key success factors for the PFQ model?

PG: The PFQ Program is able to provide vital services to our primary care partners because of the dedication of the PFQ staff, trust, and buy-in of the clinicians and teams. A lot of our work is relationship-based; we build trusting relationships with the primary care practices we work with and listen to our stakeholders to understand each clinic’s workflow and their pain points. One of the reasons the PFQ Program works is because we work with clinicians as opposed to dictating to them what they should and shouldn’t be doing.

RL:Another success factor are the skill sets of the core team who do the practice facilitation in the community. The PFQ team understands the primary care environment and the primary care practices we work with recognize their knowledge and expertise. They know how to listen to family doctors and their staff to understand the pain points and drive change not only at a practice level, but also at a system level.

One of the PFQ supports is the Digital Coalition. Can you tell us more about that?

PG: The Digital Coalition (DC) is an active partnership of information technology champions, be they physicians, executive directors, or IT personnel from clinics throughout the South West. These folks work with our PFQ team to coordinate the creation and spread of digital tools that they need throughout their practices. By bringing these champions together, we enable them to share their time, expertise, and experience towards collective QI gains rather than siloed efforts. Our role is to coordinate these efforts, allowing the collective to create the capacity to broaden QI efforts which is not possible in a siloed environment.

RL:Since launching in December 2018, we have seen a significant increase in the number of members and clinics the DC is reaching. Membership is expected to grow significantly by end of this fiscal year. Although the initial priority of the DC is to assist in the digitization of referrals form for two main EMRs in the region, the intent is to evolve beyond ‘forms’ to other digital tools (e.g., COPD, Diabetes, Cancer Survivorship, Palliative Care, etc.) as well as support the deployment/meaningful use of other digital priorities like eConsult, MyChart etc.

Undertaking something of this scale is not for the faint of heart. This work has disrupted the status quo. It takes time, patience and a true coalition of the willing who want to partner in new ways. It also helps to have key champions who are able to facilitate the Coalition itself (shout out to: Phil Dalton and Candice Beselaere who have been the driving force behind the nuts and bolts of the DC for the PFQ Team. I would be remiss if I didn’t also acknowledge how the rest of the team supports in countless ways the least of which has been building the relationships that the coalition is comprise of (the boots on the ground if you will). This has truly been a team effort.

What kinds of challenges does the Digital Coalition tackle?

RL:If we look at forms management in primary care alone, we face challenges related to consistency, capacity, and quality. First, consistency is challenged because new digital health resources are entering primary care at a rapid pace and data needs tend to shift from year to year. In terms of capacity, support can vary: some teams don’t have dedicated information management/IT support and knowledge-building/training opportunities are limited. Team members play multiple roles to fill needs while other teams rely on partners. Finally, quality is compromised when old referral forms remain in circulation, or when incorrect or illegible information is shared. The DC shares the workload to improve the consistency, capacity, and quality of digital health human resources.

What has been the impact of the Digital Coalition?

PG: For the patient, we see improved organized care, improved access, more timely care, and improved patient safety.For clinicians, we can point to improved quality of referral, decreased workload through automation, reduced referral ‘chaos’ (redirects and rejections), and improved workflow.At a system level, we are starting to see that we as a coalition have a rather strong voice. Having multiple forms for the same test, procedure, or referral at different locations makes little sense and we have been getting strong interest from stakeholders to help steer the system toward more high-quality centralized pathways. We are also getting out in front of specialists to help them design forms that are more EMR friendly to begin with which saves significant time and resources on the back end of primary care.

RL:Consider that in a 17-week timeframe (Dec 2018 – Mar 2019), the DC co-designed 54 forms across 28 clinics, which amounts to total time savings of ~1900hrs! That’s all time that can be devoted to direct patient care instead of forms management administrative work.

To date, the DC has completed a total of 66 forms, with anywhere between 8-12 in the queue at any given time. By distributing the workload across DC members, we have been able to increase health human resource capacity. We are also seeing improved ‘quality’ standards when forms are converted into EMR friendly versions, improved ‘physical’ quality of referrals received (no more distorted/faxed/illegible forms), improved uptake of ‘most current’ form (replacing old versions with most up-to-date version), and improved clinical quality of referrals (accurate, up-to-date information on clear forms). There is still a LOT more to do, but early outcomes tell us that we are on the right path.

What advice do you have for other primary care practices wishing to make the most of their digital tools?

PG: The biggest advice is that you are not alone. The clinic down the street may have done what you are attempting. We can accomplish far more far more quickly if we share our learnings with each clinic to allow rapid QI with individualized adoption. Build a coalition. Work together. Or just join us!

RL:Two things in my opinion: Simplicity and Knowledge Translation into day-to-day practice. Tools need to be simple (as little clicks possible) and sustainable. They need to be developed with a clinician’s workflow in mind (and tested with active practices across various models). What might work with one clinics workflow might not work with another simply because of the makeup of the team itself. There are so many “tools” that exist but so many impede current workflows which results in being underutilized or completely stopped because busy clinicians don’t have the time to figure out HOW to translate the great tool into action.