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Keep the Story Flowing: A Family Doc Perspective on the Coming of Connect Care and CII/CPAR

Connect Care and CII/CPAR will be a transformational change for the health system in Alberta. Connect Care will bring under one umbrella all of the varied health information systems working within Alberta Health Services, and whether you work in an AHS facility or not, this change will impact all health care providers.

As a front-line family physician and working on the Connect Care project, I have had to reflect on how this initiative will impact my practice and my patients, as well as answer some questions many doctors may have.

How will Connect Care and Community Information Integration/Central Patient Attachment Registry (CII & CPAR) impact me?

More relevant to community family physicians, the CII/CPAR project will impact many family doctor offices, especially those who are in the midst of, or have completed, their transition to the Medical Home. All of us are aware of the informational gap that occurs when an Albertan transitions from an AHS facility back into the community. The health story generated from their journey is often complex, convoluted and fragmented. On the same footing, an Albertan who needs to enter an AHS facility does not have the benefit of a curated and clinically relevant information that is housed in the various EMR’s used in the community. Some readers may be wondering if Connect Care will facilitate this transfer of information, and what will be required to keep the patient story going. At this time, these questions remain unanswered.

But within the midst of this transformation, remember: history has taught us that things change slowly in health care. I expect my day on day one of Wave One will look pretty similar to my other clinical days. Community docs adopt change in an incremental way, and only if there is some sort of value add to the care of their patients and the efficient workflows in our respective community clinics. Once a particular functionality of Connect Care impacts one of my patients, I will probably react somewhat skeptically and test the added value of a certain feature of Connect Care. Like most community docs, those aspects of Connect Care that prove useful to me in my day to day work will be those features I will continue to use, and I will not use features that do not provide any visible benefit.

I can only ask that the introduction of these features be done in a way that engages community providers in a collegial and thoughtful manner. I also ask of my community colleagues to realize the importance of sharing the relevant portions of those curated, up-to-date, and insightful EMR patient stories with our often equally beleaguered AHS colleagues, who also take on the task to care for our patients. If we can leverage technology to make this job easy and manageable, then is this not better for both physicians and patients?

In the end, I realize that the Connect Care implementation is a huge deal for our colleagues within the AHS fold, but for those in the community very little will change on the first day of Wave 1. But things will change, and hopefully the introduction of Connect Care to the community will be constructive, beneficial and, at worst, tolerable. I do hope this endeavour will inform us on the importance of the patient story and the need to keep that story flowing.

What WeNeed to Make it Work

It is clear that when a patient story flows easily and efficiently across the continuum of healthcare in Alberta, it is beneficial to patients. To this end, a list of principles has been developed to serve as a guide for those tasked with the construct and implementation of Connect Care in the hopes to maintaining, at a minimum, the current work environment for community physicians and to act as a blueprint for the future.

1. Keep what is present and move forward (i.e., no backwards steps).
2. Maintain eDelivery of lab and reports, as it is the main way community physicians see their health information
3. Engage patients in this process of implementation
4. Netcare and Connect Care must co-exist after Wave 1
5. Work smart to move forward
6. Watch for unintended consequences
7. Don’t make things worse when Connect Care comes.
8. Maintain information flow across the continuum.
9. Patients need access to their information
10. Maintain current levels of EMR integration and move forward positively
11. Change management for physicians (that means support and acknowledgement of the impact of Connect Care on community physician workflows)
12. Evaluation – it is important to know how we are doing

What About Community Docs Sharing?

I think by now, most of us have heard about this Community Information Integration (CII) project that has been coupled with the Central Patient Attachment Registry (CPAR) initiative. This project is an important component of the Medical Home initiatives being implemented in all parts of the province. Many of us are not in the mindset of continued sharing of health information with the health system outside of our clinic walls, but the CPAR project actually offers us a route to providing a key piece of information for AHS physicians and providers. At present, finding a patient’s family doctor happens in an informal process of directly asking our patients. What happens if the patient does not remember, is mistaken, or may be too sick to respond to this standard question? Needless to say, this ad hoc process is not overly reliable on a system level but imagine the benefits of reliably attaching an Albertan to a particular physician in a way that is continually updated and verified. It would be a significant step to maintaining flow of health information, and this is the potential power behind the CPAR project. Take a minute to reflect on if there is a way to link your patients to your name in a reliable and continually updated fashion, and how it would benefit the care of your patients when they end up in an acute care facility.

Linked to CPAR is the CII initiative, which will enable the sharing to Netcare of particular parts of the clinical information held in the patient records housed in our various community EMR’s. CII also provides a route to allow curated and updated health information and makes it visible to other Netcare-enabled physicians and providers. Again, only specific parts of our EMR information (and not progress notes) is shared. In the very near future, CII will also begin to provide notifications in a push fashion of when ou patients seek out emergency care.

At the present time, the CII/CPAR initiatives have not yet formed strong information flow linkages to Connect Care, but this does need to happen. As we move past day one of Wave 1 of the Connect Care implementation, keeping this vision of bidirectional flow of information by integrating CPAR information with Connect Care needs to be a key foundational goal for our healthcare system.

Thus, a patient panel which is curated, regularly updated and is dynamic has the potential to be a key enabler of health information flow. On the community side, it serves the Medical Home model of care, and to those who provide care in AHS facilities, there will be increased certainty that information will get back to a patient’s family physician. Ultimately, this can only lead to improved patient care and safety. The CPAR project offers the health system a technological solution that links a primary care provider with an Albertan, and making this information visible to all physicians involved in the care of our common patients.

When it comes to Connect Care and its related systems, patients will need to be key partners in each endeavor. Providing patients with an ability to see and add to their story, along with interacting with providers, will prove an important part of keeping the story flowing.

Wayne Chang, MD
South Calgary Medical Clinic, Calgary

Read Full Version of Vital Signs April 2019 Issue 

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Urgency and the Hot Hand

Sounds like a fantastic name for an Arcade Fire tribute band. Unfortunately, this sentiment rings true for an ongoing challenge: continuity with patient flow between care in the Acute setting,  to follow-up in the Community clinic.

A thousand years ago (timescale used to make a point that it was a while ago) I started my journey here in Alberta pro-viding locum ER and inpatient coverage for small town hospitals throughout the province. During this time, I became exquisitely familiar with the CTAS triage system of urgency when addressing the wide variety of care concerns that would grace our ER from the rural setting. After my time in the field, I formulated a similar approach in my community clinic with the hope of addressing my patient’s con-cerns in a timely fashion, based on their acuity needs. Nowhere near as fancy as CTAS, I, with my care team, derived a colorimetric scale vis-à-vis a traffic light to guide our appointment strategy and weekly scheduling.

Day to day, our Red-Orange-Green algo-rithm works fairly well, with fit-in spots available each day for red zone needs, and a grouping of slots for orange zone folks who I then address within the week. Although it runs pretty smoothly overall, I’m sure from the patient’s perspective on urgency, it isn’t perfect. Over the years, where I’ve found this to be most conflicted is when a patient completes his or her journey in acute, and I receive either an earnest call or a template-based discharge summary regaling me on their adventures. The scenario that unfolds in these cases has evolved as I’ve grown my practice over the years. It’s looked something like this.

Years 1-5 (Fresh and Eager): Call from patient

“I’ve just been discharged from hospital and doctor X here says I have to be seen in one week.” Okay. Do you know why? “Nope. They just told me to tell you.” Go to (if available) D/C summary. Follow-up: To be seen by FP in one week. Patient to arrange.” No help there. Must be something urgent though. Move time, shuffle space. Await with bated breath. See patient. How are you? “Looking good and feeling fine. How’s by you?” Hmmm. Where was the fire?

Years 5-15 (Busy and Harried): Call from patient

Same opening as above. Rant to staff that Acute has no clue about how Community runs. Stomp around office until calm. Move time, shuffle space. See patient. Diatribe to patient on how Acute doesn’t get to tell me when I should see my patients and how sneaky it is to use the patient as the messenger (for I tradition-ally don’t shoot same). Rant to spouse at end of day. Move on.

Years 16-onward (Even busier and more Harried): Call from patient

Same opening. Resigned sigh. Move time and shuffle space. Play out with my inside voice my poignant quid-pro-quo for my next referral:

Dear Dr. X,
Please see patient Y with problem Z. Must be seen in one week. Patient to arrange.

Give patient Dr. X’s office number. Stand back and watch world go all Purple Minion. Now, this will always remain an internal dialogue as I was once read something by a colleague that said “You are the professional. Be the professional.” From this, I know my compatriots in Acute are exemplary as embodiments of professionalism, but the scenarios above reflect the frustra-tions that have challenged the keystone to the collaboration required for contin-uation of care: communication.

As a resident, my attending believed that inter-collegial communication was an important element for the care of the patient. Thus, she expected that I and my fellows would call the patient’s FP at the time of discharge to close the loop on care in-house, and bring community up to speed on what the patient may need going forward. Each call was well received and put a positive tick mark on my clinic day. To this day (contrary to what has been written here might suggest) contact with one of my colleagues from acute is still a high point in my day. 

As a resident, my attending believed that inter-collegial communication was an important element for the care of the patient. 

First, it allows me to put a voice to what would otherwise be just a name at the bottom of a sheet (and vice-versa). Second, it allows me to understand my patient’s care needs going forward, and learn something that will enhance the care of others with similar concerns in the future. Finally, it closes the loop on continuity, ensuring an upward trajectory on the patient’s recuperative curve.

Aspirationally, this idealized interac-tion unfortunately conjures the theme song from our favorite medical game show: “Who is the Biggest Martyr?” From Acute’s side (which I still know pretty well as a locum hospitalist), time is precious, as making a call for rounds, clinic, teach-ing and administration responsibilities, admissions, and call consume the day almost entirely. From Community’s side, there is no time to take a call, for the clinic is an hour behind, there are ten 3M’s from the staff that need address-ing, the carpet guy is here for a quote for the exam room flooring, and there is a PCN meeting that one is going to be late for. 

Between the two settings, the common denominator that challenges connections is the rarest of non-renewable resources: time. In the wisdom of the system, to breed efficiency of communication and thus better manage time, template-based D/C summaries were created to stream-line information dispersement and bridge continuity of care. My experience would argue that in some ways these documents have challenged this, where stock statements pertaining to follow-up need have been more enigmatic than clarifying. From this, time management has been effectively hamstrung.

So, where to go from here? I person-ally have no quick answer on how the system can forgive more time to allow colleagues to connect in person or by phone to hand-over care from acute to community. I hope that great minds from both the Primary Care and the Acute worlds will examine this issue going for-ward to identify ways for connections to be made, without creating greater burdens on already weary souls. At that point, the title of my column would be something akin to a group seen at Lilith Fair: Empathy and the Clasped Hands. Until then, as the alpha and omega in my own little microverse, I will continue to bend the time space continuum and provide the best care I can.

Scott F. Beach, MD, CCFP
Medical Editor, Vital Signs

Read Full Vital Signs March 2019 Issue 

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The famous writer Robert Louis Stevenson once said, “Politics is perhaps the only profession for which no preparation is thought necessary.”

There is an upcoming election here in Alberta, and a number of doctors have added their names as candidates. There are a reported 234 physicians per 100,000 people in Canada (1), and when statistics show that only 6 per cent of Canadians would consider running for political office (2), it’s no surprise that physician politician numbers in our country are so small.

Doctors are certainly not the most common profession elected to office. That position is taken by law, business and diplomacy. The so-called “professional politician” — someone with a career entirely in and around politics — has been on the rise in democracies like Britain and the U.S. (3).

Given the merits of experience in the medical field, should we begin to more seriously consider doctors for political office? When we vote, does the consideration rest on the politician as a person and a professional, or do we weigh more heavily on how well they will do the job of representation?

If we consider physicians as a group, we can look at how the profession might positively reflect suitability for public office. Integrity is a word often used to describe the ideal political candidate, and physicians rate high in trustworthiness — 92 per cent of people polled in one study trusted a physician to tell the truth (4). Working doctors have skills necessary to get through the selection process to enter medical school, and have demonstrated rigorous academic, personal and professional skills to complete medical training.

By its very nature, the practice of medicine involves the physician being intimately involved in the lives of other people. Dr. Bob Turner, MLA for Edmonton Whitemud, listed the crossover skills from his career in medicine: “Social determinants of health, human rights, patient autonomy, listening skills, research skills, record keeping, staff management…” (5). Furthermore, the health care budget in Alberta makes up 40% of the overall provincial budget (6), and physicians (and other healthcare professionals) have nuanced insight into a system that consumes a large number of government dollars.

While the merits and transferable skills are clear, the question becomes: can a physician do the job of representation?

A physicians’ intent in their career is to positively affect the lives of their patients, whereas a politicians’ intent is to improve the lives of their constituents. Dr. David Swann, commenting on his turn in government, stated, “As a doctor, I would affect the lives of hundreds of people, but as a politician, you influence the lives of thousands, millions of people with policies that either improve their opportunities, or, in some cases, reduce their opportunities for healthy and successful lives.” (7).

While each candidate should be judged by their individual merit, I believe doctors should be given the same measured consideration as those entering politics from other fields of expertise. This should be based on what the medical profession says not just about their personal character, but the skills they bring to the tough job of being in government.

Alayne Farries, MD FRCP(C) Anesthesiologist, Red Deer Alberta

Read Full Vital Signs March 2019 Issue 

References
1. 
Physicians in Canada: https://.cihi.ca/en/physicians-in-canada
2. 
Politics Anyone? Who Would Run for Office In Canada, by Bruce Anderson and David Coletto. December 9, 2014, Abacus Data.
3. 
“There was a lawyer, an engineer and a politician…” The Economist. (Link: https://.economist.com/international/2009/04/16/there-was-a-lawyer-an-engineer-and-a-politician)
4. 
Ipsos: https://.ipsos.com/sites/default/.../veracity_index_2018_v1_161118_public.pdf
5. 
“Transitioning from Physician to Politician.” Vital Signs. October 2017: https://static1.squarespace.com/static/568eb5bbd82d5eecf06026c4/t/5a6f5a41419202096a41b177/1517247054396/VS1017.pdf
6. 
“Alberta spends $2.4 million an hour on health care: here’s what’s being done to reduce it.” CBC. March 2018: https://.cbc.ca/news/canada/calgary/alberta-spends-2-4m-an-hour-on-health-care-here-s-what-s-being-done-to-reduce-it-1.4589048
7. 
“Alberta Liberal MLA David Swann says he won’t seek re-election next year.” Calgary Herald, March 2018: https://calgaryherald.com/news/politics/alberta-liberal-mla-david-swann-says-he-wont-seek-re-election-next-year

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Open any medical dictionary and under the ‘ f ’, you will find a rich cadre of polysyllabic constructs one can use to connect with colleagues and wow your friends. Amidst all of them are two four-letter elements that, upon utterance, tend to bring on a hyperbolic adrenal response: FREE and FORM.

For my good friends recently arrived from Mars, a quick FYI: healthcare is not free. As I sat with a patient not so many days ago, she regaled me with the details of her recent journey through urgent care. At the conclusion of her narrative, she expressed her gratitude for the ‘free’ care she received. As the extolled emote of this folksy mythology grated across my dorsal root ganglia, I inhaled deeply, prepared to deliver my patented lecture on the true costs of healthcare. But at the apex of inspiration, I paused. The clinic that day was unfolding well, and I liked this nice lady, who has been a friend of the practice for a long time. I exhaled slowly and let the teachable moment pass.

In my heart, I know that she knows (like the majority of thoughtful Canadians) that healthcare is indeed not free. At the macro and meso levels, better humans than I with far greater minds wrestle constantly with the perpetual conundrum: getting high value care as a return for dollar investment. One of our former Premiers once stated that healthcare was a bottomless pit that can never be filled. 

From my perspective, I feel that the Sea Captain’s observance on Homer S. summed up our system best when he described our friend from Springfield as a “remorseless eating machine.” Any way you slice it, as time goes on, the indolent grind of healthcare continues to consume greater portions of provincial budgets, challenging system stability on the grand scale. Solutions to this challenge are diligently being sought, though they remain frustratingly elusive.

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On the front lines of delivery, physicians are intimately aware of the cost of providing care to our patients. For me, the notion of ‘free’ immediately conjures a need to give the listener insight into monetary investments docs makes before the lights go on and patient one has been seen. At one point, I listed to a captured soul the tolls physicians pay to pursue our craft: CPSA, CMPA, CCFP/FRCP, AMA, and a myriad of insurances well before one code is submitted or recompense received. 

In a place to call the medical home, it is nice to have a light on and chairs to welcome your guests (which IKEA was happy to provide at quite a reasonable price). Additionally, that pleasant and infinitely patient young person at the front desk’s smile broadens ever so slightly every second Friday of the month. I will not go on, but suffice to say doctors have the double honor of both providing and paying for care. This does not jive with the dictionary definition of ‘free’.

FORM is the second four-letter F-word that derives a response akin to an unwelcome IBS flare. Oft clutched in our patient’s hands, these 81/2” x 11” bundles of advocacy are at best an occupational irritant. At worst, they are one more opportunity to erode our professional value. Now, to be clear the patients are merely the messengers, and I don’t make a habit of shooting same. My frustrations arise from the smug assurance of governments and insurers that do-gooder docs will happily waive the fee when small print “patient responsible for any fees associated” catches the eye. This is done knowing that many, if not all patients could not embrace the cost as charged by comparable professions — our ‘street value’ if you will. 

One of my all-time favourites is what I call self-deflation. It goes a little something like this: Insurance Company A asks to be informed of any cost over offered price B. Next, Dr. C. gives price reflecting fair-value for service D. In response, Insurance Company A asks Dr. C. to lower their price, requesting self-deflation. My desired (and to date inside voice) response has been, “Okay my friend, I will devalue my service if you work today for free.” Quid pro quo Clarice. Quid pro quo.

In the construct of our system, we as doctors are asked to be both physician-healers and physician-advocates. Completion of what seems to be a never-ending stream of forms can instead create a harried state of physician-secretary. When governments, insurers, and at times our leadership bodies encourage devaluation of our professional services under the guise of what may be deemed an ‘occupational hazard’, the ‘death by a thousand invalidations’ ensues, creating physician-irritated. If Lotto Max were to ever deem me worthy, I may be tempted to go and explore the occupational hazards of physician-bartender in the Bahamas.

Before that windfall arrives, I, like all my colleagues, will soldier on until a solution that results in just reward for just work is found. Until then, feel ‘free’ to carry on!

Scott F. Beach, MD, CCFP
Medical Editor, Vital Signs 

Story from Vital Signs February 2019 Issue

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I recently had a dream that I was swimming — not too out of the ordinary,since this is my exercise of choice. In it, I was gliding peaceably through the water, until I turned my gaze to the matter before me. As I looked more carefully (which I usually find rather challenging, since I’m highly myopic), an endless sea of digits came into view, and I realized that the fluid before me was not water, but data, enveloping everything it touched.

In reality, this dream isn’t so far-fetched: no matter where we are or what we do, we are surrounded by data. With the expansiveness of wireless networks, we are, quite literally, awash in a sea of it. Good data management involves navigating this vast sea, charting courses through streams, and working to control and regulate never-ending flows of information.

The waters in healthcare can be a bit troublesome. There are many ships trying to navigate through the sea of healthcare data, but as they do, they risk sending waves of it crashing outside of safe confines. If these waves break beyond the banks of control, it can be disastrous for patients, their families, and the broader healthcare community. As we embark on a major change here in Alberta by adopting the new Connect Care Clinical Information System, we must be certain that data will be both secure and appropriately managed.

The AHS describes Connect Care as a “common provincial clinical information system” meant to make healthcare data more secure and accessible between physicians and their patients, as well as among healthcare providers in general. The AHS has partnered with the company Epic Systems Corporation (referred to here at EPIC) to help run this new program.

At a recent Connect Care information session, I approached Sansira Seminowich, who is a Connect Care Beaker application specialist, to ask her some questions about data management, security and privacy. I wanted to be sure that Albertans’ medical data were being stored in Alberta — not in the U.S., or in a cloud-based platform. This stemmed from my concern that EPIC data could be subject to the U.S. Patriot Act, which might theoretically violate Alberta’s information privacy laws (1). I was assured that none of Connect Care’s data would be stored within the U.S., and that EPIC would not have direct access to any of the Alberta content within the system.

But the aegis of the Patriot Act — which, put simply, makes it easier for the government or law enforcement to access sensitive data if they believe there is a threat at hand — might extend to the EPIC Care Everywhere function. This tool allows EPIC users to share data between different information centers. An example might be sending patient data for a “second opinion” to another EPIC-enabled center. In the lab where I work, we occasionally send materials for review to leading U.S. medical centers, and it would be very convenient to do this through the EPIC Care Everywhere function. Data sent to a U.S.-based EPIC center from Alberta might therefore be subject to the broad powers of the Patriot Act, which includes healthcare data (2). If and when Care Everywhere is used to pipe Alberta information to outside systems, I was reassured that such data exchanges would be subject to an AHS/Alberta Privacy Commissioner Privacy Impact Assessment.

We should also be aware of Connect Care’s mandate for clinical data dissemination to patients. The system will allow patients the opportunity to access much, if not all of, their own clinical charts, made possible through the EPIC MyChart functionality. While noble in intention, this might raise the ire of concern for both clinicians and laboratorians. For those physicians in the former category, the literature notes that “open access” medical records might impact a physician’s ability to relate medical information in a fully honest manner (3). In certain specialties such as psychiatry, in which highly sensitive information might be perceived negatively by patients accessing their charts, the concern is that clinicians may err toward less candid assessments.

In contrast, for those of us in lab medicine, patient access to their charts might embolden us and our specialty. Indeed, a well-informed patient with access to the completeness of their medical record would see their laboratory diagnoses rendered by laboratorians, rather than interpreted through their primary care-giver. Thus, we laboratorians will need to take greater care still to ensure the perpetual accuracy, contemporariness and timeliness of the reports we produce.

Turning back to an area of medicine that I find very stimulating — research — there is optimism to be found. The Connect Care initiative promises to include a breadth of research and research-related components. The EPIC system offers levels of data analysis and integration, ranging from routine quality assurance to population-based data analyses. Once implemented, the Connect Care system promises to be one the vastest seas of clinical data in North America. Notwithstanding the serious need for state-of-the art security, data integrity, and ethics oversight, I am hopeful that Connect Care will make cutting-edge medical research in Alberta all the more fruitful. But for now, the goal should be to have all the right hands on deck when it comes time to steer through the changes ahead in this sea of important data.

Etienne Mahe, MD, MSc, FRCPC, FCAP
Consultant Pathologist with the Division of Hematology of Calgary Lab Services. Clinical Assistant Professor in the Department of Pathology & Laboratory Medicine at the University of Calgary. President of the Calgary Lab Services Medical Staff Association.

References
1. Province of Alberta. Freedom of Information and Protection of Privacy Act. Sect. RSA 2000, c. F-25, s. 92(3).
2. Lenzer J. Doctors outraged at Patriot Act’s potential to seize medical records. BMJ. 2006 Jan 14;332(7533):69.1.
3. American College of Physicians Ethics, Professionalism and Human Rights Committee, Sulmasy LS, López AM, Horwitch CA. Ethical Implications of the Electronic Health Record: In the Service of the Patient. J Gen Intern Med. 2017 Aug;32(8):935–9.

Story from Vital Signs February 2019 Issue