The Fort Family Practice is a group of seven family physicians who provide full service medical care to their patients in the suburban community of Fort Langley, and at Langley Memorial Hospital. The practice patients range in age from newborn to the frail elderly. The clinicians work together as a cohesive health care team to provide comprehensive care to their patients, with a team-based approach using a registered nurse (RN), a licensed practical nurse (LPN), and enhanced medical office assistants (MOAs).

Doctors Grace Brouwer, Windy Brown, Alister Frayne, Mark Miller, Lucinda McQuarrie, Andre van Wyk, and Hester Vivier, and have all either completed, or are close to completing, the panel management process. They have done so with the support of Shefali Raja, a member of the Practice Support Program’s regional support team. According to Dr Vivier, the most difficult component of the panel management process was logistical:

“We all found it worthwhile and satisfying. But without the assistance of Shefali from the Practice Support Program, it would have been very difficult to schedule the process into our busy office schedule.”

While the practice didn’t know what to expect at the outset, the team is happy with the achievements realized. They are able to improve quality of care, focus on proactive care, and capture a significantly greater number of their chronic care patients through the data retrieval search process.

Examples of using information from panel data for quality improvements   

Dr Grace Brouwer has set up a process via the interventions feature of the Profile EMR to remind her to do breast exams for female patients aged 50+ who have not had a breast exam in the past 12 months. She did not want to miss early signs of breast cancer. MSP no longer pays physicians for complete physical exams, so breast exams are not routinely done.

“A woman I called in specifically for the exam ended up having breast cancer. It gives me piece of mind to do this.”

Dr Brouwer is also able to keep better track of patients with chronic kidney disease and chronic pain utilizing the queries that Shefali and Dr Brouwer created.

“We learned that just listing a diagnosis doesn't translate to it getting flagged on a follow up list. So now we are adding it in the correct area of the EMR for follow up and recall.”

Dr Windy Brown wants to reduce the inappropriate use of the emergency room (ER). Patients are asked to follow up with their family doctor post discharge from the hospital but due to age, or forgetfulness, they don’t always do so, and end up at the ER again from complications or crisis.

“I feel that we could prevent patients from returning to the emergency department by seeing them in a timely way in the office post-discharge from hospital. I am working on a way to trigger an automatic intervention to call my patients, once I’ve received a discharge summary from the hospital.”

Dr Alister Frayne is looking to decrease the trajectory of chronic disease downwards. He is working with his team to proactively call patients age 25+ with a BMI of greater than 30 and utilizing a lifestyle management approach, is targeting those patients to forestall the development of chronic obesity related illnesses.

 “Formalizing the mechanism to identify and target this cohort of patients is immensely satisfying and goes to the heart of the concept of preventative medicine.”

Dr Lucinda McQuarrie is organizing data retrieval and analytical processes in the EMR for all her patients on opioids, and for preventative screening.

“With my mentally unwell people, one of things I wanted to do was improve their general screening. We get bogged down in treating depression and anxiety, but these people aren’t going for their cholesterol or FIT tests. We created intervention reminders and are now accessing appropriate forms from the patient encounter area of the medical record. It is really satisfying.”

Dr Mark W. Miller wanted all to offer his patients aged 65+ the Prevnar 13 and Pneumovax 23 vaccine, according to the recommended protocol. Currently, pneumonia vaccines are offered only on an ad hoc basis. Structuring the process within the database was extremely helpful and personally satisfying for Dr. Miller.

“Adding these scheduled interventions gives me the ability to routinely ask my patients about these important immunizations – I feel so much better that I am providing the best care to my patients. I couldn’t have done this without Shefali’s help and patience.”

Dr Andre van Wyk is doing chart reviews of all of his patients to ensure problem lists are accurate, outstanding lab and investigations have been done, and reminders are added to the charts for follow-up. In doing so, he identified several patients who needed emergent care. In one case, he caught a positive lab result for colon cancer that had fallen through the cracks because of a breakdown in the transfer of lab results.

“I was able to catch this critical result via a standard chart review. This is a classic example of a proactive, versus a reactive approach to health care.”

Dr Hester Vivier is proactively screening patients for risk of cardiovascular disease by identifying all male patients 40+ and female patients 50+ that have not had lipid profile labs in the past 5 years.

“This is what we always talk about: we should be doing preventative medicine. It has an intangible benefit – not one that you can easily show, but one which I feel is better and is an intervention that I believe works.”