Evidence of Value

D2D 3.0: Progress in meaningful measurement for primary care

Today’s release of Data to Decisions (D2D) 3.0 demonstrates significant progress by family health teams and nurse practitioner-led clinics to advance manageable and meaningful measurement for improved patient care.

AFHTO members are guided by the Starfield Principles – focusing on the relationship with patients and the primary care team’s ability to deliver the care patients value. Its objective is to optimize quality, access and total health system cost of care for patients. D2D uses indicators from Health Quality Ontario’s Primary Care Performance Measurement Framework, with some modifications guided by input from front line providers.

AFHTO members have made progress in:

  • Capturing EMR data to measure outcomes: The composite measure of diabetes is the first time a clinical outcome indicator based on EMR data has moved out of academic research into a performance report. It reflects how the entire interprofessional team contributes to care, and not just physician activity based on billing data. This data capture was made possible through standardized queries across multiple EMR platforms, developed by members but now available to any user of these EMRs within or beyond AFHTO.
  • Using EMR data to measure best practice rather than incentive payment: For the first time, percent of eligible children immunized is measured according to Public Health Agency of Canada (PHAC) guidelines. The results illustrate a difference in definition from that used for physician billing incentives related to Rotavirus immunization which is part of PHAC recommendations but not in the incentive definition.
  • Improving data quality: AFHTO members are measuring and improving the quality of their EMR data as a source of timely information for quality improvement. Measuring can also have a direct and immediate impact on patient care. In the process of measuring their EMR Data Quality for the first time, one team found a systemic issue affecting flow of information from a lab to their EMR. They fixed the problem, improved their ability to detect colorectal cancer, and in their words, “saved lives”!
  • Voluntarily increasing participation in D2D: Nearly two-thirds of AFHTO members submitted their data to D2D 3.0, continuing the growth from D2D 1.0 (27%) and 2.0 (54%). This gives insight into the care of nearly 2 million Ontarians.

All three Starfield elements are now in place:

  1. Quality is reliably and comprehensively measured through a composite indicator. It reflects the experience of the entire patient, not just isolated body parts. It is calibrated according to what matters most to patients in their relationship with their provider. While refinements continue, it is now possible to compare quality over time and between settings in a more meaningful way than is possible by just examining physician billing data.
  2. Capacity of the entire clinical team is being measured for the first time. Forty-six teams contributed data to measure time spent delivering primary care relative to the number of patients served. This approach considers the contribution of the entire team and provides a mechanism for exploring the impact of patient complexity on the human resources required to deliver high quality care.
  3. Total cost of care is now in its third iteration of D2D. It has been refined in conjunction with the Institute for Clinical Evaluative Sciences to help teams explore aspects of costs that might be sensitive to change in primary care delivery. This measure captures more than 85% of the allocatable public spending per person in Ontario; it is adjusted to reflect age, sex, and complexity of patients to allow comparison over time and between primary care settings. This indicator is now identified as a priority by Health Quality Ontario for system measurement.

AFHTO members are well-equipped to take the next steps to improve quality

Results from D2D 3.0 suggest that there is solid and growing engagement with measuring performance. This can be leveraged as we turn our attention now to improving. The D2D interactive report allows teams to compare their own data over time and with their peers across the province. Clinical leadership within and among primary care teams is proving to be the key ingredient in getting people to participate in measurement, improve data capture and act on results.

Measurement continues to become more meaningful: Follow up after hospitalization

To be added to the next D2D, this indicator will use EMR data to capture all hospitalized patients receiving in-person OR phone contact with ANY clinician within 7 days of discharge from hospital. Unlike the current indicator based on physician billing data, this approach encourages more patient-centered and efficient follow-up (e.g. phone call by pharmacist to address mediation issues rather than forcing a patient to come in to see the doctor).

Access to hospital discharge data is the crucial pre-requisite for this indicator – and for excellent quality primary care in general. AFHTO continues to encourage members and external partners such as OntarioMD, eHealthOntario and hospitals to expedite implementation of Hospital Report Manager in all regions.

Ministry and LHINs are encouraged to support spread

  • Cost-effective, high-performing health systems are based on a strong foundation of comprehensive primary care; robust measurement is a key ingredient.
  • D2D provides a way forward. It is grounded in the Primary Care Performance Measurement Framework to ensure consistency and relevance for all Ontarians, and focussed on what is meaningful and manageable for primary care providers. The tools and processes developed by AFHTO are already being adopted beyond its membership.
  • Spread requires support – to further develop clinical leadership and deploy Quality Improvement Decision Support Specialists to enable more teams and other primary care providers participate in measuring and improving quality.

Click here to see D2D 3.0 aggregate results.

The Association of Family Health Teams of Ontario (AFHTO) is the advocate, network and resource centre for interprofessional comprehensive primary care teams.