A population health information framework for primary care Ken Leech HINZ Conference September 2009
There are few PHOs or DHBs who know whether their population health goals are being achieved
Why is this? <ul><li>What population health goals? </li></ul><ul><li>“ This doesn’t have anything to do with me delivering...
The experience of Northland and Wanganui… <ul><li>Agree population health goals </li></ul><ul><li>Define measures for each...
Acknowledgements... The great teams at the Northland PHOs and Whanganui Regional PHO
1. Agree the population health goals <ul><li>Start with the population health goals defined in the Primary Healthcare Stra...
The Primary Healthcare Strategy: <ul><li>Reduce smoking. </li></ul><ul><li>Improve nutrition. </li></ul><ul><li>Increase t...
2. Define measures for each goal <ul><li>For each population health goal, we will measure: </li></ul><ul><li>Whether we kn...
Using the example of “Reduce Smoking”
Do we know who needs intervention? The numerator
Do we know who needs intervention? The denominator
Are we delivering the intervention? The numerator
Are we delivering the intervention? The denominator
Is the intervention working?
How big is the problem?
Gaps identified… <ul><li>Examples: </li></ul><ul><ul><li>No systematic recording of physical activity </li></ul></ul><ul><...
3. Define standards
 
4. Encourage systematic and consistent recording <ul><li>Make it easy to record </li></ul><ul><ul><li>Advanced forms </li>...
 
 
 
 
Patient dashboard implements evidence-based rules for: <ul><li>Smoking status </li></ul><ul><li>CVD screening </li></ul><u...
You are seeing a 37-year old male - should this patient be screened for diabetes? <ul><li>You need to know: </li></ul><ul>...
Has patient dashboard increased systematic and consistent recording of population health data?
Recording smoking status
Recording alcohol consumption
5. Providing tools to support general practice in delivering population health <ul><li>We needed a tool that would: </li><...
 
Censored
Current status <ul><li>Population health goals agreed </li></ul><ul><li>Population health measures agreed </li></ul><ul><l...
Key points <ul><li>If you want to know whether you are achieving your population health goals, you will need to: </li></ul...
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A Population Health Information Framework for Primary Care

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Ken Leech
Procon Ltd
www.procon.co.nz
(P20, 1/10/09, Skellerup Room, 5.02)

Published in: Health & Medicine
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A Population Health Information Framework for Primary Care

  1. 1. A population health information framework for primary care Ken Leech HINZ Conference September 2009
  2. 2. There are few PHOs or DHBs who know whether their population health goals are being achieved
  3. 3. Why is this? <ul><li>What population health goals? </li></ul><ul><li>“ This doesn’t have anything to do with me delivering care to my patients – it’s of no interest to me” </li></ul><ul><li>What should I record, why should I record it, how should I record it, who should I record it for, when should I record it? </li></ul><ul><li>It’s too hard to collect the data </li></ul>
  4. 4. The experience of Northland and Wanganui… <ul><li>Agree population health goals </li></ul><ul><li>Define measures for each goal </li></ul><ul><li>Define standards (what, how, where, when, why) for data </li></ul><ul><li>Provide tools to support systematic and consistent recording </li></ul><ul><li>Provide tools to support delivery of population health in general practice </li></ul><ul><li>Collect and report data </li></ul>
  5. 5. Acknowledgements... The great teams at the Northland PHOs and Whanganui Regional PHO
  6. 6. 1. Agree the population health goals <ul><li>Start with the population health goals defined in the Primary Healthcare Strategy </li></ul><ul><li>For each population health goal, agree on what primary care does to achieve the goal (it might be nothing!) </li></ul>
  7. 7. The Primary Healthcare Strategy: <ul><li>Reduce smoking. </li></ul><ul><li>Improve nutrition. </li></ul><ul><li>Increase the level of physical activity. </li></ul><ul><li>Reduce the rate of suicides and suicide attempts. </li></ul><ul><li>Minimise harm caused by alcohol, illicit and other drug use to both individuals and the community </li></ul><ul><li>Reduce the incidence and impact of [breast, cervical] cancer. </li></ul><ul><li>Reduce the incidence and impact of cardiovascular disease. </li></ul><ul><li>Reduce the incidence and impact of diabetes. </li></ul><ul><li>Improve oral health. </li></ul><ul><li>Reduce violence in interpersonal relationships, families, schools and communities </li></ul><ul><li>Improve the health status of people with severe mental illness. </li></ul><ul><li>Ensure access to appropriate child health care services including well child and family health care, and immunisation. </li></ul>How are these relevant to general practice right now? What is the primary care action? Are there services available to treat?
  8. 8. 2. Define measures for each goal <ul><li>For each population health goal, we will measure: </li></ul><ul><li>Whether we know who needs intervention. </li></ul><ul><li>Whether the intervention been provided. </li></ul><ul><li>If the desired outcome is being achieved. </li></ul><ul><li>How big the problem is. </li></ul><ul><li>And answer these for: </li></ul><ul><ul><li>Patient  GP  Practice  PHO  DHB </li></ul></ul><ul><ul><li>Maori/Non Maori </li></ul></ul><ul><ul><li>Time </li></ul></ul>
  9. 9. Using the example of “Reduce Smoking”
  10. 10. Do we know who needs intervention? The numerator
  11. 11. Do we know who needs intervention? The denominator
  12. 12. Are we delivering the intervention? The numerator
  13. 13. Are we delivering the intervention? The denominator
  14. 14. Is the intervention working?
  15. 15. How big is the problem?
  16. 16. Gaps identified… <ul><li>Examples: </li></ul><ul><ul><li>No systematic recording of physical activity </li></ul></ul><ul><ul><li>No agreed interventions for obesity </li></ul></ul><ul><ul><li>No systematic recording of oral health </li></ul></ul>
  17. 17. 3. Define standards
  18. 19. 4. Encourage systematic and consistent recording <ul><li>Make it easy to record </li></ul><ul><ul><li>Advanced forms </li></ul></ul><ul><li>Make population health data valuable to treating individual patients </li></ul><ul><ul><li>Patient dashboard </li></ul></ul>
  19. 24. Patient dashboard implements evidence-based rules for: <ul><li>Smoking status </li></ul><ul><li>CVD screening </li></ul><ul><li>Diabetes screening </li></ul><ul><li>Diabetes management </li></ul><ul><li>Flu vaccination </li></ul><ul><li>Cervical screening </li></ul><ul><li>Breast screening </li></ul><ul><li>Childhood immunisation </li></ul><ul><li>Blood pressure </li></ul><ul><li>Height, weight, BMI </li></ul><ul><li>Alcohol consumption </li></ul><ul><li>Adolescent assessment (incl. mental health) </li></ul><ul><li>Care plus status </li></ul>
  20. 25. You are seeing a 37-year old male - should this patient be screened for diabetes? <ul><li>You need to know: </li></ul><ul><ul><li>Does patient already have diagnosis of diabetes? </li></ul></ul><ul><ul><li>Does the patient have impaired glucose tolerance? </li></ul></ul><ul><ul><li>Has patient previously been screened and if so, how long ago? </li></ul></ul><ul><ul><li>Patient’s ethnicity </li></ul></ul><ul><ul><li>Does patient have any of metabolic syndrome, dyslipidaemia, IHD, PVD, polycystic ovaries, gestational diabetes? </li></ul></ul><ul><ul><li>Does patient have family history of diabetes? </li></ul></ul><ul><ul><li>What is the patient’s BMI. </li></ul></ul>
  21. 26. Has patient dashboard increased systematic and consistent recording of population health data?
  22. 27. Recording smoking status
  23. 28. Recording alcohol consumption
  24. 29. 5. Providing tools to support general practice in delivering population health <ul><li>We needed a tool that would: </li></ul><ul><ul><li>Find patients who are “falling through the cracks” </li></ul></ul><ul><ul><li>Allow general practice to respond </li></ul></ul><ul><ul><li>Was attractive to general practice </li></ul></ul><ul><li>And met goal 6 to collect and report aggregated data for PHO </li></ul>
  25. 31. Censored
  26. 32. Current status <ul><li>Population health goals agreed </li></ul><ul><li>Population health measures agreed </li></ul><ul><li>Patient dashboard and accompanying forms implemented in Northland, being implemented in Wanganui </li></ul><ul><li>Dr Info implemented in Wanganui, being implemented in Northland </li></ul><ul><li>Awaiting implementation of the agreed population health indicators </li></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Alcohol </li></ul></ul><ul><ul><li>Cervical cancer </li></ul></ul><ul><ul><li>Breast cancer </li></ul></ul><ul><ul><li>CVD </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Oral health </li></ul></ul><ul><ul><li>Childhood immunisation </li></ul></ul>
  27. 33. Key points <ul><li>If you want to know whether you are achieving your population health goals, you will need to: </li></ul><ul><ul><li>Agree population health goals </li></ul></ul><ul><ul><li>Agree measures </li></ul></ul><ul><ul><li>Encourage consistent and systematic recording of data </li></ul></ul><ul><ul><li>Collect and report on population health data </li></ul></ul><ul><ul><li>And do it in a way that will be supported by general practice. </li></ul></ul>

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