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? What population health goals? “ This doesn’t have anything to do with me delivering care to my patients – it’s of no interest to me” 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? It’s too hard to collect the data

What population health goals?

“ This doesn’t have anything to do with me delivering care to my patients – it’s of no interest to me”

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?

It’s too hard to collect the data

The experience of Northland and Wanganui… Agree population health goals Define measures for each goal Define standards (what, how, where, when, why) for data Provide tools to support systematic and consistent recording Provide tools to support delivery of population health in general practice Collect and report data

Agree population health goals

Define measures for each goal

Define standards (what, how, where, when, why) for data

Provide tools to support systematic and consistent recording

Provide tools to support delivery of population health in general practice

Collect and report data

Acknowledgements... The great teams at the Northland PHOs and Whanganui Regional PHO

1. Agree the population health goals Start with the population health goals defined in the Primary Healthcare Strategy For each population health goal, agree on what primary care does to achieve the goal (it might be nothing!)

Start with the population health goals defined in the Primary Healthcare Strategy

For each population health goal, agree on what primary care does to achieve the goal (it might be nothing!)

The Primary Healthcare Strategy: Reduce smoking. Improve nutrition. Increase the level of physical activity. Reduce the rate of suicides and suicide attempts. Minimise harm caused by alcohol, illicit and other drug use to both individuals and the community Reduce the incidence and impact of [breast, cervical] cancer. Reduce the incidence and impact of cardiovascular disease. Reduce the incidence and impact of diabetes. Improve oral health. Reduce violence in interpersonal relationships, families, schools and communities Improve the health status of people with severe mental illness. Ensure access to appropriate child health care services including well child and family health care, and immunisation. How are these relevant to general practice right now? What is the primary care action? Are there services available to treat?

Reduce smoking.

Improve nutrition.

Increase the level of physical activity.

Reduce the rate of suicides and suicide attempts.

Minimise harm caused by alcohol, illicit and other drug use to both individuals and the community

Reduce the incidence and impact of [breast, cervical] cancer.

Reduce the incidence and impact of cardiovascular disease.

Reduce the incidence and impact of diabetes.

Improve oral health.

Reduce violence in interpersonal relationships, families, schools and communities

Improve the health status of people with severe mental illness.

Ensure access to appropriate child health care services including well child and family health care, and immunisation.

2. Define measures for each goal For each population health goal, we will measure: Whether we know who needs intervention. Whether the intervention been provided. If the desired outcome is being achieved. How big the problem is. And answer these for: Patient  GP  Practice  PHO  DHB Maori/Non Maori Time

For each population health goal, we will measure:

Whether we know who needs intervention.

Whether the intervention been provided.

If the desired outcome is being achieved.

How big the problem is.

And answer these for:

Patient  GP  Practice  PHO  DHB

Maori/Non Maori

Time

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… Examples: No systematic recording of physical activity No agreed interventions for obesity No systematic recording of oral health

Examples:

No systematic recording of physical activity

No agreed interventions for obesity

No systematic recording of oral health

3. Define standards

4. Encourage systematic and consistent recording Make it easy to record Advanced forms Make population health data valuable to treating individual patients Patient dashboard

Make it easy to record

Advanced forms

Make population health data valuable to treating individual patients

Patient dashboard

Patient dashboard implements evidence-based rules for: Smoking status CVD screening Diabetes screening Diabetes management Flu vaccination Cervical screening Breast screening Childhood immunisation Blood pressure Height, weight, BMI Alcohol consumption Adolescent assessment (incl. mental health) Care plus status

Smoking status

CVD screening

Diabetes screening

Diabetes management

Flu vaccination

Cervical screening

Breast screening

Childhood immunisation

Blood pressure

Height, weight, BMI

Alcohol consumption

Adolescent assessment (incl. mental health)

Care plus status

You are seeing a 37-year old male - should this patient be screened for diabetes? You need to know: Does patient already have diagnosis of diabetes? Does the patient have impaired glucose tolerance? Has patient previously been screened and if so, how long ago? Patient’s ethnicity Does patient have any of metabolic syndrome, dyslipidaemia, IHD, PVD, polycystic ovaries, gestational diabetes? Does patient have family history of diabetes? What is the patient’s BMI.

You need to know:

Does patient already have diagnosis of diabetes?

Does the patient have impaired glucose tolerance?

Has patient previously been screened and if so, how long ago?

Patient’s ethnicity

Does patient have any of metabolic syndrome, dyslipidaemia, IHD, PVD, polycystic ovaries, gestational diabetes?

Does patient have family history of diabetes?

What is the patient’s BMI.

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 We needed a tool that would: Find patients who are “falling through the cracks” Allow general practice to respond Was attractive to general practice And met goal 6 to collect and report aggregated data for PHO

We needed a tool that would:

Find patients who are “falling through the cracks”

Allow general practice to respond

Was attractive to general practice

And met goal 6 to collect and report aggregated data for PHO

Censored

Current status Population health goals agreed Population health measures agreed Patient dashboard and accompanying forms implemented in Northland, being implemented in Wanganui Dr Info implemented in Wanganui, being implemented in Northland Awaiting implementation of the agreed population health indicators Smoking Alcohol Cervical cancer Breast cancer CVD Diabetes Oral health Childhood immunisation

Population health goals agreed

Population health measures agreed

Patient dashboard and accompanying forms implemented in Northland, being implemented in Wanganui

Dr Info implemented in Wanganui, being implemented in Northland

Awaiting implementation of the agreed population health indicators

Smoking

Alcohol

Cervical cancer

Breast cancer

CVD

Diabetes

Oral health

Childhood immunisation

Key points If you want to know whether you are achieving your population health goals, you will need to: Agree population health goals Agree measures Encourage consistent and systematic recording of data Collect and report on population health data And do it in a way that will be supported by general practice.

If you want to know whether you are achieving your population health goals, you will need to:

Agree population health goals

Agree measures

Encourage consistent and systematic recording of data

Collect and report on population health data

And do it in a way that will be supported by general practice.