Technology for Integration and ContinuityOctober 4, 2018

CII-CPARCommunity Information Integration

Central Patient Attachment Registry

PCN Strategic Leadership Forum 2019 - Workshop

Presenter Disclosure

• Faculty:

– Barbra McCaffrey

– Chris Diamant

– Sheena George

• Relationships with financial sponsors:

– No relationships to declare.

3

Partners

Why Technology for

Continuity & Integration?

4

Current Patient Journey

Patient is paneled

Recorded in EMR

Refer to Specialist

Referred to another Specialist

Patient ends up in hospital or ER

No reliable notification to Family

Physician

ER docs have limited access to information

Patient follow-up may fall through

the cracks

Rationale/Benefits

• Evidence shows that when a patient has a continuous relationship with a family physician/nurse practitioner and care team, the overall result is better than when care is disjointed or broken

• Higher continuity is associated with improved health, quality of life, and reduced mortality

6

CII/CPAR Alignment with PCN Initiatives

7

Transitions

of Care

Opioid

Response

Patient’s

Medical

Home

Continuity

Of

Care

What are CII and CPAR?

8

• A provincial system that captures the

confirmed relationship of a primary

provider and their paneled patients.

• Receives information automatically

from clinic EMRs on a monthly basis

• Next logical step for practices that

have invested in panel management

• Foundational for future enhancements

of informational continuity

Central Patient Attachment Registry (CPAR)

9

CII is a system that collects select patient information

from community Electronic Medical Records (EMRs) and

shares it with other members of the patient’s care team

through Alberta Netcare.

Community Information Integration (CII)

10

Community Physician Office

EMRs

CII Data Hub

Alberta Netcare

Healthcare DataRepository

11

CII/CPAR in Primary Care

CommunityPhysician Office

EMR

1.Encounter Data

2. Panel Lists

CII Data Hub

Alberta Netcare

Central Patient Attachment Registry

CED Report

Panel Conflict Report

Demographic Mismatch Report

Consult Report

3.Consult Reports

What is the Role of the PCN?

12

PCN Journey and AMA/AH Supports

Knowledge

Resource Determination Training

Member Engagement

Guidance,

Support &

Facilitation

13

AMA/ AH teamPlanning Tactical support

Engagement toolsPresentationsHandouts and FAQs

Team Toolkit for PCNs and Clinics

PCN Resource Training EMR Guides, CPAR Application

Guide & Videos Privacy Seminar Privacy Questionnaire Privacy Guidance

Clinic Journey

Engagement and Interest

Registration and Participation

Onboarding

Go-Live

Panel Management& Process Improvement

Post Implementation Evaluation

PCN Facilitation

AMA Support

Alberta Health&

EMR Vendors

PCN Facilitation

AMA Support

Alberta Health

PCN Support

How do PCNs and Members

get Ready?

15

Criteria for CII/CPAR Participation

16

Prerequisites Commitment Compliance

CII PIA endorsement signed by custodian(s)

Clinic PIA is accepted by the Office of the Information and Privacy Commissioner (OIPC) and reflects current environment

Custodians have a Health Information Act (HIA) compliant Information Management Agreement (IMA) with their EMR Vendor

Clinic willing to assign a CII/CPAR site liaison to:

o manage readiness requirements

o assist with CII/CPAR data quality testing

o coordinate awareness and training

o support issue management

Participate in evaluation activities

Sign participation agreement

Clinic Live on Alberta Netcare

Clinic PIA is up-to-date

EMR

o Vendor is conformed to CII/CPAR

o Use latest version of MQ EMR

Panel Readiness

16

they are obligated to place a Health Collection Notice poster within a patient’s view.

A customizable template is provided to the clinic.

If patients have further questions, CII Patient Brochures are also provided.

A Custodian Script for Patients is provided which outlines how to discuss patient’s expressed wishes

and the use of confidential flags as well as masking in Alberta Netcare.

The Patient Frequently Asked Question (FAQ) document explains the CII/CPAR initiative and its

implications to patients of CII/CPAR clinics. It also provide patients with contact details if they have more questions.

The CII/CPAR Privacy & Security FAQ further details the sharing of health information.

Health Collection

Poster

Patient Brochure

? Custodian & Team Script

Patient FAQ

Privacy & Security FAQ

CII/CPAR falls under the Alberta Netcare umbrella, which is covered by the Health Information Act.

Providers are not required to have directconversations with their patients, however… About Privacy…

PCN CII/CPAR ReadinessPCN *Clinic

CountLive On AlbertaNetcare

Conformed EMR vendorsMQ + TELUS

**Non-Conformed

PIALast 5yrs

PIA>5 yrs

***No PIA found Panel Readiness (Y/N)

ICE 20 100% 80% 20% 0 13 7 TBD

FIRE 20 70% 40% 60% 0 20 0 TBD

*From PCN website** Unknown EMR or paper based*** 3 data sources (OIPC, AH, POSP)

Things for the PCN to consider:

• Are there PCN Change Agents (Improvement Facilitators) to facilitate CII/CPAR implementation?

• Can the Change Agent offer the privacy self-assessment to the clinic to formulate a response to eHealth Support Services?

• Is the Change Agent in a position to assess panel readiness?

Westeros PCN CII/CPAR ReadinessFamily Clinics Lords/

LadiesLive On Netcare

ConformedEMR Vendors

% MQ + TELUS

**Non-Conformed

PIALast 5yrs

PIA>5 yrs

***No PIA found

Panel Readiness (Y/N)

HouseBaratheon

6 0

HouseLannister

20

0

House Stark 5

Yes

HouseTargaryen

10 0

HouseGreyjoy

1 No

0

*From PCN website** Unknown EMR or paper based*** 3 data sources (OIPC, AH, POSP)

Are there Tools to Support

PCN Implementation?

20

Tools ( www.topalbertadoctors.org/CII-CPAR)

21

CII/CPAR Guide for:

• PCN Change Agents

• Participating clinic teams

Team Toolkit

• Process Guide– Responsibilities of various groups:

• PCN, AMA, eHealth Support Services, EMR

Vendor, Clinic Team

• Content guide

– Improvement Facilitation related to

CII/CPAR and Continuity of Care

Team Toolkit – A Guide for PCN Change Agents

• Background

• Prerequisites

• Privacy and

Security

• Teamwork

• Clinic Journey

• CPAR Web Portal

Guides

• Conflict and

Mismatch Report

Management

• Scripting

• Glossary

• Roles and

Responsibilities

• FAQ

Team Toolkit - Contents

Why Invest in Change Agents?

25

Change Agents – Enablers for Improvement

26

Accelerates the Rate

Augments Effectiveness

Builds Capacity for Improvement

Practice

Change

Improvement Facilitator Physician Champion

Panel Manager

• Require

– Training

– Sponsorship for the initiative from leadership

• Transfer learnings from one practice to another in

the PCN

• Networks of Practice support the change agents and

the transfer of better practices across the province

Lessons from Early Adopters – Change

Agents:

27

• PCN Investments

– Proactive preventive screening care (ASaP, ASaP+)

– Chronic disease management

– Care planning for patients with complex health needs

(PaCT)

– Transitions of care

– Opioid Response

CII/CPAR – Next Logical Step in Proactive,

Panel-based Care Delivery

28

• Patient’s primary provider (MRP) is identified

– Care is coordinated and services are not duplicated• In the PCN or in the province

• Gaps in transitions in care are closed with e-

notifications

• Attached and unattached populations can be

identified

CII/CPAR – A Direct Fit with PCN

Investments to Ensure

29

Short Term

Medium Term

Long Term

More Information and Resources

30www.topalbertadoctors.org

Questions

& Next

Steps

Information

32

• Contact: Chris Diamant, EMR Advisor

Chris.Diamant@topalbertadoctors.org or (780) 266-4147

• Contact: Barbra McCaffrey, EMR Lead

Barbra.McCaffrey@topalbertadoctors.org or (780) 231-0254

http://www.albertanetcare.ca/learningcentre/CII.htm

http://www.topalbertadoctors.org/CII-CPAR/