BC family doctors are working to improve services for their patients with the patient medical home (PMH) model of care. As part of their PMH journeys, more than 400 doctors have improved the quality of their patient data using PSP’s new set of EMR-based tools. The Understanding Your Patient Panel tools support doctors in managing their patient panels so that they can use the data to inform planned, proactive care. 

So far, doctors who are using the assessment have:

  • Decreased by 25% the number of patients listed as active but unseen, so that doctors can now have patient registries that accurately reflect active patients. 
  • Improved disease documentation by five percent by improving use of disease codes rather than text documentation, so that doctors can have accurate patient registries.
  • Improved representation of disease prevalence by  more appropriately classifying patient conditions, with the top five most improved areas including: hypertension, depression, diabetes, anxiety, and osteoarthritis , so that doctors can now proactively monitor and meet patient needs.

Physicians and MOAs can receive compensation for much of their time spent on understanding their patient panels. With the support of PSP’s Regional Support Team (RST) coordinators, doctors and their MOAs can use the panel assessment tools to update their patient information to better understand their patient population, create registries of patients with complex care needs, and identify needs of the patient registry. The tools help:

  • Improve day-to-day clinical and practice workflows, such as:
    • Enabling easy tracking of CDM billings.
    • Helping identify patients who quality for incentive billings.
    • Assigning generic care plans to patient panels.
  • Enrich doctor experience, such as:
    • Helping ensure patients are getting appropriate care.
    • Identifying patients with similar conditions and care needs.
    • Supporting succession planning.
    • Assigning PSP learning module tasks to patient charts.
  • Enable better access to care and services, such as:
    • Supporting working with other family doctors and in multidisciplinary teams.
    • Providing patients with continuous care across primary care providers in practice.
    • Providing patients with comprehensive care that reflects their needs. 

This set of assessment tools are currently available on Intrahealth, Med Access, Wolf and Osler EMRs. 

To participate or to learn more, contact your RST.