It takes a dedicated team and a drive to help patients

Panel management can be a daunting prospect for a GP running a busy family practice. Abbotsford family physician Dr John Chan and office manager/MOA Becky Chan recently worked with their office team members to complete the process, with coaching from Regional Support Team member Ranjit Sekhon.

Why did you undertake this work?

Dr Chan: I’m a more senior physician, so adjusting to EMR was more challenging for me. But you know, we wanted to improve. We want to do what’s best for our patients. That's our number one goal. We want to maintain a certain standard, and keep up to date with the guidelines. This process helps me to know the exact number of patients I have, and what kind of diseases they have. We can be more proactive. That’s part of our job as a family doctor: to prevent disease.

Becky: We were using our EMR at the very basic level. We wanted to know how to take it to the next level. So we learned how to do searches, follow-up, messaging, preventative care profiles, panel management. We learned how to maximize our software’s potential.

Ranjit: I introduced the phases of panel management as a foundational piece towards creating patient medical homes and primary care networks leading towards an integrated system of care. And eventually there will be additional resources for GP practices to be a part of this integrated work.

How is it helping with patients and quality care?

Dr Chan: It’s getting the whole office up to standards of practice. COPD, for example, is a common problem. I now know how many patients I have with COPD and who they are, so I can make sure that they get an action plan and are updated every time they come in. I use the BC health guidelines. It helps prevent a patient from going to emergency, and ending up in the hospital with COPD exacerbation. That’s one of my goals.

Diabetic patients need an eye examination, foot care, and A1C, blood pressure and cholesterol checked regularly. If they don’t come in, now my MOAs will call them up. So we are giving proactive care. I think it is making a big difference in our practice.

Becky: The main and easiest change was the chronic disease management. I had a system prior to this project and I thought it was quite thorough. After I had run the panel management I realized I had missed quite a number of patients.

Another way we’re using it is for FIT Tests (Fecal Immunochemical Test). We can search patients aged 50 to 74 who haven’t had their FIT test over the last two to three years. So now we’re following up on that. After that, we’ll do the PAPs and mammograms. Controlling medication and keeping them up to date is also helpful. Before this project, our system was a mess.

What has changed for practice processes?

Becky: When a patient comes in, there’s prior work done already. I send the doctor a message so the next time the patient comes in he knows, ‘you need to do your feet care; you need to do this and this.’ He doesn’t have to flip back and forth to see what he has or hasn’t done. It’s all there in the EMR: all the doctor has to do is click.

Ranjit: Billing was an eye-opener too. Once they cleaned up their panel, they looked at their [PSP] tools/dashboard in the EMR, and they could see all the patients that came for complex care and chronic disease that had come in but had never used GPSC incentive fees.

What helped to manage the process?

Dr Chan: For any office, this is something new. Most doctors have to go out of their way to take up this challenge [of panel management]. I have good office manager who is interested in detail work, and who put in lot of time, some outside of office hours. They’ve been doing a doing a major part of the panel management and helping out with complex care. But once it’s done, it’s easy, and a continuing ongoing process.

Ranjit was instrumental in the process. First, we met as a group with other physicians and she guided us through the whole purpose of this initiative, and then went hands-on and helped us through it.

Ranjit: Reminding the clinic of their intrinsic motivation for doing this work - “we want to do what’s best for our patients” - and sharing how this work upfront will benefit both the patient and clinic in the long run. Breaking it up into more manageable pieces, celebrating small successes, and documenting the process into the workbook.

After the processes are in place, it can be more manageable if they have a regular check in. They can spend an hour a month on this work, as opposed to it getting so overwhelming at the end of the year.

Becky: Eventually it becomes smooth, with more coordination and better patient care. Once you work it out into the workflow of the office, then it’s easy. Just stick to it and eventually you get there.

What are you seeing at the end of the process?

The biggest win was when I checked back with them six months later and the strategies they had created for their sustainment plans for some of the quality improvement goals were being utilized.

Dr Chan
: Like anything else, the learning part takes time. But I think in the long run it will help. And once you become efficient, I think you save time.

Understanding and using the data makes a big difference. We spend more time in the office on the computer, but we get much more accuracy about our patients. Accountability is much better, and I accept that. We have to use that as a motivation.