‘Nobody missed’: Patients benefit from panel management

Dec 15, 2023

Dr Shireen Alam suspected the rates of mental health diagnoses had risen during the first few years of the COVID-19 pandemic.

Her clinic, the Shelbourne Family Practice & Maternity in Victoria, decided to investigate during recent panel management. Erika Patterson, a panel coach with the Family Practices Services Committee (FPSC), discovered many patients had been coded with a generic health diagnosis, and not flagged for mental health.

Once the coding was corrected, the clinic’s mental health numbers skyrocketed.

“Being able to look at our data that was much better coded allowed us to see that yes, we had doubled our mental health visits over those two years, that the perceived burden was real,” Dr Alam says.

Panel management allows clinics to proactively manage a defined population of patients, using electronic medical records (EMR) data to identify and respond to patients’ chronic and preventative care need. Panel coaches work with the physicians and create between 10 and 15 disease registries including diabetes, hypertension, heart failure and mental health.

“My role is to support the physician and team to better utilize their EMR data to understand and manage their panel,” says Patterson. “Nothing ever happens on my end unless the doctor says, ‘go ahead.’”

Dr Alam and three other physicians took on the Shelbourne Family Practice & Maternity after the clinic’s original physician retired. Panel management offered them opportunity to split the panel between them in a way that made sense, Alam says, as well as review patient profiles. A previous data migration had resulted in inaccuracies in patient profile coding, such as names of diseases that didn’t link up with diagnostic codes.

Patterson’s first step was going through the clinic’s 11,000 files to determine its active patients and the most responsible physician. As a maternity referral clinic, patients are only kept for the duration of maternity and eight weeks post-partum, yet many had never been deactivated.  

She then looked at patients on specific medications or disease registries, pulling EMR reports, and reviewing visit notes, medications and lab reports before advising the doctor of her findings and together verifying if a patient profile should be updated.

For instance, Patterson started with 11 patients coded with a generic health diagnosis, and upon completing her review of patient charts, she found 131 patients that needed updating for mental health diagnoses in the EMR profile.

“She was able to send me lists of patients saying, ‘I think this patient probably meets this criteria’… and she was right on. That was easy, just a quick task in the EMR for me to have a look,” Dr Alam says. “She seamlessly updated my profile without a whole lot of labour from me.”

The volume of mental health diagnoses allowed the clinic to leverage Primary Care Network (PCN) opportunities, bringing in a part-time social worker and part-time mental health clinician, who offers short term counselling and liaison with the Victoria Mental Health and Substance Use Referral Centre.

Dr Alam says the work gave them a more accurate picture of all their patients.

“Being able to easily identify screening opportunities helped us to ensure that we’re delivering quality care and evidence-based care to our patients, and reaching everybody we should,” she says.

The increased focus on panel management comes as family doctors across the province are working on patient panels to upload to the new Provincial Attachment System (PAS). PAS is designed to provide a coordinated approach to connecting patients without a family doctor with physicians who can take on new ones.

Patterson says having an accurate diagnosis in a panel will help the physician care for that patient population.

“Nobody’s going to get missed,” she says. “Not on my watch.”

To get started with panel management, submit a service request, email psp@doctorsofbc.ca, or contact your practice support coach. For more information about panel management, see the FPSC website.