PSS Clinic Toolkit Resources

1. Diabetes Management
2. Opioid Prescription Management
3. Consultation and Referral Management
4. Test Results Management
5. Prevention and Screening
   1. Breast Cancer
   2. Cervical Cancer
   3. Colorectal Cancer
6. Earn Mainpro+® Credits by Using the i4C Dashboard and Advisory Service

Diabetes Management

OntarioMD (OMD) offers an Advisory Service for clinicians who use an OMD-certified EMR. OMD staff can advise you on best practices and develop customized solutions tailored to meet your practice needs. They are available to help you improve how you manage your diabetic population by implementing measures to find patients who have not been properly diagnosed and to proactively treat your diabetic population.

Diabetes in Canada

• 1 in 3 Canadians – 11 million – have diabetes or prediabetes today
• A Canadian is diagnosed as diabetic every 3 minutes
• 1.5 million Canadians have type 2 diabetes  and don't know it
• 6 million Canadians live with prediabetes; half of them will develop type 2 diabetes if nothing is done*
  *https://www.diabetes.ca/DiabetesCanadaWebsite/media/Campaigns/NDAM/Diabetes-by-the-numbers-infographic_FNL.pdf

Managing your patients who have been diagnosed as diabetic in your EMR

• Review active patients' demographic status and the accuracy of documenting diabetes (i.e., coded diseases using a coding system such as ICD-9 or SNOMED vs. manually typed entries). This is an opportunity to highlight discrepancies in documentation of your diabetic population.
• Measure the number of diagnosed diabetic patients and calculate the percentage of your total patient population.  According to Diabetes Canada, in March 2019, approximately 10% of the population in Ontario was living with diagnosed Type 1 or Type 2 diabetes.
• Determine how often diabetic patients are seen (i.e., number of K030 billings in the past 12 months or run reports in the EMR).

Review data Accuracy 

Data accuracy is key and the foundation for any improvement initiative. 

If you realize the data is not a true reflection of your practice and patients:

• Review how a diabetes diagnosis is recorded in the EMR and whether it is consistent across the practice
• Perform a chart review of diagnosed diabetic patients to understand how and where it is documented in the EMR
• Find the percentage of diagnosed diabetic patients with at least one K030 billing code within the past 12 months and the number times billed in that period
• Find the percentage of diagnosed diabetic patients with a Q040A billing code within the past 12 months
• Survey diagnosed diabetic patients with at least one LDL in the past 12 months
• Survey diagnosed diabetic patients for HbA1C test results in the past 12 months and identify patients requiring follow up
• Survey diagnosed diabetic patients with out-of-range or no recorded blood pressure in the past 12 months

Use change ideas for improvement:

• Review how using a standardized coding system for disease coding can be integrated into workflow
• Refine workflow with standard or customized diabetes flowsheets
• Define the process for scheduling appointments every three months for diagnosed diabetic patients
• Define follow up processes for patients overdue for appointments or tests
• Consult with the OMD Advisory Service to leverage native functionality within the EMR and develop tools to make the EMR work better for you
• Measure progress along the way
  

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Opioid Prescription Management

The OMD Advisory Service can advise you on best practices and develop customized solutions tailored to meet your practice needs. They are available to help you improve your ability to identify patients for whom you have prescribed opioids through the Medication Management Dashboard in your EMR that includes a new opioid indicator to visualize this patient population and keep them safe. 

Opioid-Related Harm in Canada

• Almost 14,000 Canadians died of an opioid-related overdose between 2016 and 2019
  
• Between January 2016 and September 2019, 19,490 hospitalizations occurred due to opioid-related poisoning in Canada
• More than 17,000 suspected opioid-related overdoses occurred between January and September 2019 based on available Emergency Medical Services data from 9 provinces and territories.*
  

Managing your patients who have been prescribed opioids

• Review active patients' demographic status and the accuracy of active medication records
• Measure the percentage of your patients who have been prescribed opioid medications, patients on high doses, and identify high-risk populations

Review data accuracy 

Data accuracy is key and the foundation for any improvement initiative. If you realize the data is not the true reflection of your practice and patients:

• Review the patient enrollment process with your administrative staff
• Cross-reference capitation reports with your EMR
• Clearly define how to distinguish active from inactive patients e.g., define cut-off dates for 'last seen'
• Run a report to identify patients who have been prescribed opioids
• Review the prescription workflow (i.e., how you identify a prescription as active, expired, discontinued, etc.)
• Take corrective measures to fix gaps in data quality
  

Use change ideas for improvement:

• Define the goal that you want to achieve
  
• Identify high-risk patients (i.e., patients on Benzo co prescriptions)
• Determine the ratio of patients over 90 MMEQ
• Define processes to follow-up with patients
• Review medication prescription workflows
• Undertake medication reconciliation
  
• Measure your progress using metrics
  

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Consultation and Referral Management

The OMD Advisory Service can advise you on best practices and develop customized EMR solutions tailored to meet your practice needs. They are available to help you improve your ability to manage consults and referrals within your EMR.

The CPSO has updated its policies in four areas (Availability and Coverage, Managing Tests, Transitions in Care and Walk-in Clinics) in response to physician feedback in October 2019.  OntarioMD has developed guidance for referral and consultation management based on the updated CPSO transitions in care policy.

Family Physicians

Managing your referrals and consultations: 

• Identify patients with outstanding referral letters and consultation requests
• Identify outstanding referral letters or consultation requests without a response in 14 days
• Review how referral letters and consultation requests are generated, sent, and tracked through completion (i.e., native EMR tracking functionality/customized tools vs. paper)
• Determine how the priority level of referral letters and consultation requests are documented (urgent vs. non-urgent)
• Determine how additional information requested by a specialist for outstanding referrals and consultations is provided
• Review the communication process with specialists and patients
• Review the communication process within the practice (i.e., messages or reminders)
• Determine how referrals and consultations are reconciled once completed

Review data accuracy 

Data accuracy is key and the foundation for any improvement initiative.

If you realize the data is not a true reflection of your practice and patients:

• Review whether referral letters and consultation requests are generated in the EMR and whether it is consistent across the practice
• Review how urgent referral letters and consultation requests are documented
• Review how referral letters and consultation requests are sent and confirmed as received by the specialist
• Review how and when follow up for referral letters and consultation requests is done
• Scan for pending or outstanding referral letters and consultation requests
  
• Review how patients are informed of wait time/appointment confirmation and how it is documented
• Ensure specialists, their specialty, and full contact information is readily available in the EMR

Use change ideas for improvement:

• Review how using native EMR tracking or customized tools can assist with referral letters and consultation requests management workflow
• Develop a process for creating and sending referral letters and consultation requests within the EMR
• Define the process for assigning priority level of referral letters (i.e., urgent vs. non-urgent)
• Develop a process for tracking pending or outstanding referral letters and consultation requests within the EMR, and when to follow up
• Define the process for follow up on overdue referral letters and consultation requests with specialists
• Define follow up processes with patients
• Consult with OMD staff to leverage native functionality within the EMR and/or develop tools to make the EMR work better for you
• Measure progress along the way

Specialists:

Managing your referrals and consultations:

• Review how referral letters and consultation requests are received and tracked through completion (i.e., native EMR tracking functionality/customized tools vs. paper)
• Review how to add a new patient to the EMR
• Determine how priority level of referral letters and consultation requests are documented (urgent vs. non-urgent)
• Determine how additional information required for outstanding referrals and consultations is requested
• Identify patients with outstanding referral letters and consultation requests (under/over 14 days)
• Review the wait list and wait times workflow
  
• Review the appointment scheduling process
• Review whether appointments and wait times are communicated to patients and referring physicians

Review data accuracy

Data accuracy is key and the foundation for any improvement initiative. If you realize the data is not a true reflection of your practice and patients:

• Review how referral letters and consultation requests are received and reviewed at the practice
• Review how referral letters and consultation requests are documented in the EMR
• Review how urgent referral letters and consultation requests are documented
• Review how referral letters and consultation requests are confirmed as received.
• Review the wait list and wait times
• Scan for pending or outstanding referral letters and consultation requests (under/over 14 days)
• Review how patients and referring physicians are informed of wait time/appointment confirmation and how it is documented
• Ensure full contact information for referring physicians is accurate in the EMR
• Review the reporting and reconciliation process once the referral or consultation is complete

Use change ideas for improvement:

• Review how using native EMR tracking or customized tools can assist with referral letters and consultation requests management workflow
• Develop a process for receiving, reviewing and documenting referral letters and consultation requests within the EMR
• Define the process for assigning priority level of referral letters and consultation requests (i.e., urgent vs. non-urgent)
• Develop a process for tracking pending or outstanding referral letters and consultation requests within the EMR to meet follow up guidelines
• Define the process for communicating appointments or wait time to patients and referring physicians within 14 days
• Determine how referrals or consultations are reported and completed
• Consult with OntarioMD staff to leverage native functionality within the EMR and/or develop tools to make the EMR work better for you
• Measure progress along the way
  
  

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Test Results Management

The OMD Advisory Service can advise you on best practices and develop customized solutions tailored to meet your practice needs. They are available to help you improve your ability to manage test results in your EMR.

The CPSO has updated its policies in four areas (Availability and Coverage, Managing Tests, Transitions in Care and Walk-in Clinics) in response to physician feedback in October 2019. OntarioMD has developed guidance based on the updated policy specific to managing test results.

Managing your requisitions:

• Identify outstanding requisitions and number of days overdue
• Identify patients with outstanding requisitions
• Identify trends among outstanding requisitions (i.e., requisition types, specialists and/or facilities commonly unreconciled or long overdue)
• Review how requisitions are generated, sent, and tracked through completion (i.e., native EMR tracking functionality/customized tools vs. paper)
  
• Determine how priority level of requisitions are documented (urgent vs. non-urgent)
• Review the communication process of results with patients (clinically significant vs. no news is good news)
• Review the communication process within the practice (i.e., messages or reminders)
• Determine how requisitions are reconciled once completed
• Review whether there are delegated processes and to whom they are delegated

Review data accuracy 

Data accuracy is key and the foundation for any improvement initiative. If you realize the data is not a true reflection of your practice and patients:

• Review whether requisitions are generated in the EMR and whether is the process is consistent across the practice.
• Review how urgent or clinically significant requisitions are documented
• Review how results are received and reviewed
• Review how and when follow up for results occurs
  
• Review how patients are informed of results and how it is documented
• Scan for pending or outstanding requisitions

Use change ideas for improvement:

• Review how using native EMR tracking or customized tools can assist with requisition management workflow
• Develop a process for creating and sending requisitions within the EMR
• Define the process for assigning priority level of requisitions (i.e., urgent vs. non-urgent)
• Develop a process for tracking pending or outstanding requisitions within the EMR, and when to follow up.
• Define follow up processes with patients
• Define the process for reconciling requisitions, who is responsible for reconciliation and close-out messaging to MRP (if required)
• Consult with OntarioMD staff to leverage native functionality within the EMR and/or develop tools to make the EMR work better for you
• Measure progress along the way
  

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Prevention and Screening

The OMD Advisory Service can advise you on best practices and develop customized solutions tailored to meet your practice needs. They are available to help you improve how you manage cancer screening for your patients.

Cancer screening programs have saved the lives of thousands of Ontarians. Cancer screening may detect cancer early before there are any symptoms and before it has had a chance to spread. Cancer screening detects pre-cancerous changes, when clinicians have a better chance of treating it successfully.

Breast Cancer

Using your EMR, you can identify and manage patients who need breast cancer screening and are eligible for screening under the Ontario Breast Screening Program (OBSP).  

Managing patients for prevention and screening:

• Identify patients eligible for breast cancer screening.
  • Female 50-74 years - mammogram every 2 years.
• Identify patients at high risk for breast cancer who are eligible for screening:
  
  • Female 30-69 years old - mammogram and MRI annually (ultrasound if MRI is contraindicated).
    • Category A (personal or family history) or Category B (genetic assessment) Ontario Breast Screening Program (OBSP).
      
• Identify patients excluded from breast cancer screening.
• Identify patients overdue for prevention/screening activities.
• Identify patients who have declined screening.

Review the accuracy of your data 

Data accuracy is key to identifying patients for breast cancer screening and is foundational for any other improvement initiative. If you realize your EMR data is not a true reflection of your practice and patients, take these steps to improve your data quality:

• Review how patients at high risk for breast cancer are documented in your EMR, i.e., standardized nomenclature, patient history, family history, genetic testing, OBSP enrollment, etc.
• Review how patient prevention/screening activities are tracked in your EMR.
• Determine if other tools are utilized to keep your EMR up to date, such as the Cancer Care Ontario Screening Activity Report (CCO SAR) or OBSP report.
  
• Review your billing processes, i.e., billing, tracking, and exclusion codes.
• Review your scheduling process for prevention and screening activities.
• Review your management of test results.

Review your workflows and responsibilities with staff

Ideas for improvement:

• Review how using EMR tracking or customized tools, e.g., the i4C Dashboard, can assist you with identifying patients who are due or overdue for screening (point-of-care and proactive approach)
• Develop a process to find patients who are due or overdue for prevention/screening activities.
• Develop a process to follow up with and schedule patients who are due or overdue for prevention/screening activities, including enrollment into OBSP for eligible high-risk patients.
• Define how to track the reason for patients who are overdue for screening, such as declined screening, waiting for appointment, or waiting for results.
  
• Assign responsibilities within the follow up process.
• Consult with OMD staff to leverage the functionality within your EMR and/or tools, e.g. i4C Dashboard, to make your EMR work better for you.
• Measure progress along the way.
  

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Cervical Cancer

Your EMR can also help you screen your patients for cervical cancer under the Ontario Cervical Screening Program.

Managing patients for prevention and screening:

• Identify patients who are eligible for cervical cancer screening:
  • Female 21-70 years old who have been sexually active - pap test every 3 years.
• Identify patients at high risk for cervical cancer who are eligible for screening:
  • Female 21-70 years old - pap test annually.
• Identify patients excluded from cancer screening.
• Identify patients who are overdue for prevention/screening activities.
• Identify patients who have declined screening.

Review the accuracy of your data

Data accuracy is key to identifying patients for cervical cancer screening and foundational for any other improvement initiative. If you realize your EMR data is not a true reflection of your practice and patients, take these steps to improve your data quality: 

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Colorectal Cancer

Patients who should be screened for colorectal cancer under the ColonCancerCheck Program can also be identified with the help of your EMR.

Managing patients for prevention and screening:

• Identify patients who are eligible for colorectal cancer screening:
• 50-74 years old - FIT (fecal immunochemical test) every 2 years, or optionally, sigmoidoscopy every 10 years.
• Colonoscopy within 8 weeks of an abnormal FIT result.
• Identify patients at high risk for colorectal cancer who are eligible for screening:
• 50 years old, or 10 years younger than the age the patient's first-degree relative was at the onset of colorectal cancer - colonoscopy every 5 years if diagnosed relative was under 60 years at onset, or every 10 years if diagnosed relative was over 60 years of age.
• Identify patients excluded from cancer screening.
• Identify patients who are overdue for prevention/screening activities.
• Identify patients who have declined screening.    
  

Review the accuracy of your data. 

Data accuracy is key to identifying patients for colorectal cancer screening and foundational for any other improvement initiative. If you realize your EMR data is not a true reflection of your practice and patients, take these steps to improve your data quality:

• Review how patients at high risk for colorectal cancer are documented in your EMR, i.e., standardized nomenclature, patient history, family history, test results, etc.
• Review how patient prevention/screening activities are tracked in your EMR.
• Determine if other tools are utilized to keep your EMR up to date, such as the Cancer Care Ontario Screening Activity Report (CCO SAR).
• Review your billing processes, i.e., billing, tracking, and exclusion codes.
• Review your scheduling process for prevention and screening activities.
• Review your management of test results.
• Review your workflows and responsibilities with staff.
  

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Earn Mainpro+® Credits by Using the OMD Advisory Service

The MD Advisory Service  works directly with clinicians using certified EMRs. OMD staff can support you to earn and claim Mainpro+ credits from the College of Family Physicians of Canada. 

You may earn Mainpro+ credits by completing several assessment activities including practice audits, quality assurance programs, Linking Learning exercises, provincial Practice Reviews, Pearls™, and/or examiner for certification exams. Find more on activity categories in this PDF.

• Any non-certified activity is generally eligible for one non-certified credit per hour
  
• Practice audits and provincial practice reviews are eligible for six certified credits per form
  
• Linking Learning exercises are eligible for five certified credits per form

Earn Mainpro+Credits by working with the OMD Advisory Service on Practice Improvement

There are several opportunities to earn credits while working with the OMD Advisory Service. You can develop a plan for quality improvement activities in consultation with OMD staff who are experienced in practice enhancement.

Getting Started and Implementing a Plan

Working with the OMD Advisory Service team, you can identify priority areas for practice improvement. Through the support of the OMD Advisory Service, you can assess your practice's workflow, prioritize improvement activities, develop tools and measure progress to evaluate improvements in your priority areas.

Introduction Meeting  – the starting point for improvement

• Scheduling a meeting with the i4C Advisory Service team is a great start to identify areas of improvement, align resources, set goals and measures, plan for changes, implement changes and measure success.
• The i4C Advisory Service is available to clinicians across Ontario who use certified EMRs. You do not have to be an i4C Dashboard user to take advantage of the service.
• To learn more about how to earn Mainpro+ credits with the support of the i4C Advisory Service in your practice, email us at support@ontariomd.com.
  

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