CPAR Uncovered: A closer look at the

Central Patient Attachment Registry

PCN Strategic Leads Forum – September 9, 2017

Dr. Tobias Gelber, Chinook PCN, President Section of Rural Medicine Barbra McCaffrey, EMR Lead, Toward Optimized Practice Chris Diamant, EMR Advisor Toward Optimized Practice

Presenter Disclosure

• Presenter: Dr. Tobias Gelber Chris Diamant Barbra McCaffrey

• Relationships that may introduce potential bias and/or conflict of interest: – No relationships to declare.

Introductions

Where did the Central Patient Attachment Registry come from?

• Part of the amending agreement between AMA and AH

• Need for greater continuity in Alberta

• Desire to have primary provider information appear in Netcare

• Joint initiative with AHS and AH

Panel ID, Maintenance and CPAR

Current State of Panel Maintenance

At every interaction ask who the patient identifies as their primary provider Record it in the EMR & Date Stamp It Maintain & Review the panel List Utilize the panel list to plan care delivery starting with ASaP

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Current State of Panel Maintenance

• Patients seen for primary care (panel) are distinguished from patients seen for episodic care (caseload)

• Clinic can produce a file/list of each primary provider’s panel

Panel Maintenance with CPAR

At every interaction ask who the patient identifies as their primary provider Record it in the EMR & Date Stamp It Maintain & Review the panel List Utilize the panel list to plan care delivery Submit the Panel List to CPAR

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Three Panel Conflict Signs

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Rx Test

Result

CPAR – Phase One

CPAR - Phase One

• December 2017 • Blended Capitation clinics will be required to

participate • CPAR will be the source of truth in Alberta for

roster management and compensation for all blended cap programs (currently 3 programs)

CPAR – Phase One

• April 2018 • Limited production rollout? • Clinics must meet readiness criteria (handout) • Registration process will proceed participation

– Panel Access Administrator – Panel Administrator – Panels

• Participants will export panel lists from their EMRs and upload to CPAR quarterly

• Name, DOB, PHN, Gender, Last Visit Date, Last Confirmation Date

How Will CPAR Work for Panel?

Clinics confirm panel at practice

Produce confirmed panel list at practice for each primary provider

Save list as csv file and submit to registry via

secure portal

Registry receives the list and looks for duplicates and mismatches to PCR

Provider receives list of panel conflicts and

mismatch notifications

Clinics are already doing this: • Name • PHN/ULI • DOB • Gender • Date of last visit • Date last confirmed

CPAR Registration for Panel Access

Administrator, Panel Administrator &

Panels

START

CPAR – Phase One

• Panel Administrator will receive two reports: – Panel conflict report by provider – Mismatch notifications report

Panel Conflict Report MOCK REPORT FOR DR. TEST IN EDMONTON

Panel Conflict Report MOCK REPORT FOR DR. TEST IN EDMONTON

John Doe – was paneled to Dr. Y 9 days after being paneled at my clinic 3 months ago. Joan Chan – was paneled at my clinic and 2 others, all in April 2016 Chris Lee – was paneled by Dr. V in St. Albert last but was paneled at my clinic and 3 others over 1.5y Manish Padwal – was paneled last at my clinic by 11 months Fredrick Caron – was paneled at Dr. K in Sherwood Park 11 months after he was paneled at my clinic

Mismatch Notification

Clinic EMR does not match Patient Client Registry (PCR) for PHN/ULI, Name, Date of Birth, Gender or is Deceased. • In some cases the clinic EMR may be correct

• E.g., Patient changed name, informed clinic and didn’t complete the paperwork for Alberta Health

• In some cases the PCR data may be correct • E.g., A team member made a typo when entering the patient’s date of

birth

How Will it Work for Panel?

Clinics confirm panel at practice

Produce confirmed panel list at practice for each primary provider

Save list as csv file and submit to registry via

secure portal

Registry receives the list and looks for duplicates and mismatches to PCR

Provider receives list of panel conflicts and

mismatch notifications

Clinic team acts on panel conflicts and

mismatch notifications. CPAR verifies panel

Repeat Quarterly

Who Should Upload Panels?

Panel • Provide comprehensive

longitudinal primary care

• Include long-term care patients in panel (may be separate panel)

Caseload/Episodic Care • Specialty services

– Vasectomies – Maternity Care – Sports Med – Pap clinic – Aesthetic services

• Patients seen for episodic care

Questions?

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The Value Proposition

CPAR – Phase One

• Learning from those who went before…

With cross referenced lists of patients that are paneled at other clinics in our PCN, we have been forced to create a clear concise script to facilitate our staff starting these conversations with patients. The conversations are often awkward and uncomfortable for the patient and the panel manager but ultimately a better common ground is found, where the patient feels supported not attacked and recognizes the behind the scenes work we do on their behalf even when they don’t come to the clinic regularly.

Dr. Christine Luelo MD CCFP & Margo McMillan, RN, Panel Manager

Testimonial from South Calgary

Why CPAR?

Relational Continuity

Informational Continuity

Data & Information

System Enablers

• Better health outcomes • Better quality of care • Better coordination of

care • Reduced overall health

cost to the system

• Potential Reports • Provider/Clinic • PCN • System

• Provincial level attachment data & information for secondary use

• Unattached patients • Provincial level planning of

care services delivery • Foundation for chronic

disease registry

• Better handoffs • Better

communication • Less duplication

• Enabler for potential new compensation models for

• Physicians • PCNs

Value – Patient

With increased continuity, patients: • Healthier • More satisfied • Receive better care • Take better care of

themselves • Have better outcomes

Value – Initial Phase

Physician and Team • Identify panel conflicts • Manage panel conflicts • Create VERIFIED panel

– Use for panel management – Patient value of improved

continuity • Clarify demographic

mismatches • Be in position for future

continuity of care incentives

PCN • Additional phase of panel

supports • Verified panels for panel

management • Identify panel conflicts • Population data on attached

& unattached patients • Be in position for future

population health data reporting

Value - Future Phase

Physicians and Team • Receive clinical panel-based

data reports on verified patients

• Use reports for pro-active panel-based care

PCN • Data based on attached and

unattached patients in the PCN will inform planning and service delivery – population health and

business intelligence reports from registry data

– clinical and health system utilization population reports

• Be in position for new PCN funding models

Questions?

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CPAR – Next Steps

CPAR – Next Steps - Tools

Developed • Key Messages • FAQ’s for Physicians and EDs • EMR Panel Guidance

– How to panel – How to produce panel list

• IF and Panel Manager training (phase appropriate)

• Readiness checklist • Roles and responsibilities of

Panel Administrator

In Development • Leader Slide Decks • Registration Package • EMR – csv file generation • How to use Registry • Managing Panel Conflicts

– Guide – Scripts

• Patient Communications

CPAR – Next Steps

Training Tools • IF training, Panel in Action Training • Incorporate into Panel Management (screening

care, disease management, care planning) • Strategies for panel conflict management How can the AMA help? • Training videos • Full suite of supports, resources and tools for

PCNs, Teams and Providers

CPAR – Next Steps

Handouts: • Glossary • Readiness Checklist • Roles and

Responsibilities of a Panel Administrator

CPAR – Next Steps

• Patient Consultation (Alberta Health) – Consultation is initiated and ongoing – AH has engaged with IMAGINE Citizens

Collaborating for Health on Panel and Continuity – Patient input – Results have potential to influence

• Patient communication materials • Physician office scripts

CPAR – Next Steps

We’re all on board! What do we do next? • Decide on a strategy for your PCN • Start talking to your members • Encourage Panel ID & Maintenance Processes

– Use the STEP documents – Use the Checklist for Panel and CPAR Readiness

• Discuss your plans with your AMA (TOP/PMP) contact

Questions?

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CPAR – Future State

CPAR – Future State

CPAR Attachments in Netcare: • Once the registry is populated and conflicts

managed: – The patient’s Netcare record will include the name of

their primary provider and practice contact information

– Clinic can be contacted in urgent care situations – Enable hospital/ER reports to reach primary provider – Increased integration

CPAR – Future State

Community Information Integration (CII): • Registry automatically

populated from provider’s EMRs: – CII team currently in talks

with EMR providers

CPAR – Future State

Patient Portal: • CPAR information linked to the patient portal? • When a patient is paneled to more than one

provider, they could select the provider they want to be paneled to?

• See their primary provider in the portal?

CPAR – Future State

Consolidation of data from multiple databases • Patient Client Registry • Provider, Panel ID • Panel elements (Name, PHN, DOB, Gender, Last

visit, last date confirmed) • Unattached patients • PCN membership of providers – via AH PCN

Membership • Provider Registry • HQCA

CPAR – Future State

Future PCN Reporting: • What would PCN Executive Directors, Boards,

Medical Directors and team members find of most value?

Thank You!