Wonca 2015. Coding and Improving GP practice
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Coding in primary care supports key tasks of general practitioners (GPs) and improves patient care in three main ways: 1. It allows GPs to measure their productivity and outcomes based on the number of patient episodes treated rather than just activities, and compares costs and activities to identify more and less productive clinicians. 2. It provides GPs visibility into the full scope of health problems in their local patient population so they can better manage population health needs. 3. Coding captures detailed information on problems solved which facilitates more sensitive evaluation of clinical performance and identifies opportunities for improvement.
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Wonca 2015. Coding and Improving GP practice
- 1. How does coding support the key tasks of the GP and improve patient care? Ángel Ruiz Téllez Fernando A. Alonso López October 2015 Concept & Methodology in Primary Care (Ltd.) Technological semFYC Partner CYMAP Director. Spain semFYC (Spanish society of community and family practice). Spain
- 2. Angel Ruiz Téllez Director. www.cymap.es Twitter : @artcymap Linkedin (Español /English) angelruiztellez@cymap.es +34 637532359 Rambla Nova 2-4; 3º 1ª 08100 Mollet del Vallès – Barcelona Spain angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Concept & Methodology in Primary Care (Ltd.) Technological semFYC Partner Fernando A. Alonso López Technology commission semFYC. Twitter : @bolaredo fernandoalonsolopez@gmail.com +34 606585471 Centro de Salud de Dobra Torrelavega (Cantabria) Spain
- 3. How does coding support the key tasks of the GP and improve patient care? angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Primary CareHospital & specialist Care Evolution of hospital and specialized spending vs Primary Care. 1984-2012 2006 2007 2008 2009 2010 2011 2012 900 800 700 600 2009 ? Income Trend Crisis
- 4. Transition Centers Project© angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Barcelona 100,000 inhabitants
- 5. How was that possible? angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Health Information System Valuable based on the medical essence: Try to solve the 100% of health population needs Sensitive able to discriminate differences in clinical practice Reliable High confidence on figures and reports.
- 6. The critical keys. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 We needed five critical conditions to do it.
- 7. 1st condition: To code everything, around the Episode of Attention. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 ‘Encounter’ ≠ Activity ‘Encounter’ = Cost Activity = No. Episodes treated
- 8. Productivity - Outcome angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 For the real life, the best one outcome appears when the firefighter does not work and the worse one, when is working. In our Health Service, managers think in opposite sense. Outcome = Episodes of Attention Costs Use of Resources Time of use Outcome =
- 9. 2nd condition: To code everything, around the Episode of Attention angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The Cost-activity Professional Cloud Activity : • Total annual number of Episodes treated, in relation to the whole health epidemiological needs. Manageable Costs : • Cost of drug prescription + • Cost of medical leave days + • Cost of referrals to hospital Paradoxical distribution, away from the model of ‘higher activity - higher cost’. ?????? Productivity = Activity Costs
- 10. 2nd condition: To code everything, around the Episode of Attention angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The Cost-activity Professional Cloud Professional “A” High Productivity Productivity = Activity Costs In standardized populations
- 11. 2nd condition: To code everything, around the Episode of Attention angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The Cost-activity Professional Cloud Professional “A” High Productivity Productivity = Activity Costs Professional “C” Low Productivity In standardized populations
- 12. 2nd condition: To code everything, around the Episode of Attention angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The Cost-activity Professional Cloud Two professionals – the same population Productivity = Activity Costs Dr. ‘A’ =9119*1000/787844€ = 11.57 Dr. ‘C’ =6931*1000/1014347€ = 6.83 169.37% A > C
- 13. 2nd condition: To code everything, around the Episode of Attention angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The Cost-activity Professional Cloud y = 0.0045x + 0.0437 R² = 0.0054 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% RANKINGOFGLOBALPRODUCTIVITY RANKING OF CLASSIC PRODUCTIVITY Correlation between rankings incentive for classical or global evaluation. 2014. Vallcarca Health Center.
- 14. 2nd condition: To code everything, around the Episode of Attention angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The Cost-activity Professional Cloud y = 0.0045x + 0.0437 R² = 0.0054 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% RANKINGOFGLOBALPRODUCTIVITY RANKING OF CLASSIC PRODUCTIVITY Correlation between rankings incentive for classical or global evaluation. 2014. Vallcarca Health Center. we can see the low representation of reality with the classical set of quality or activity indicators.
- 15. Keys for excellent HIS angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Health Information System Valuable based on the medical essence: Try to solve the 100% of health population needs Sensitive able to discriminate differences in clinical practice Reliable High confidence on figures and reports.
- 16. 2nd condition: To code everything, around the Episode of Attention angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 E. Goldratt “Tell me how you measure me, and I will tell you how I will behave”
- 17. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The critical need for professionals to work against the real size of their own local morbidity.
- 18. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 in order to change their way of thinking. Without that reference every professional would think The critical need for professionals to work against the real size of their own local morbidity.
- 19. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 that those problems attended by him in his surgery are the whole health needs in their area. The critical need for professionals to work against the real size of their own local morbidity.
- 20. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015
- 21. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015
- 22. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 SR = Supply Rate = E / T ER = Effectiveness Rate = S / T SPR = Social Profitability Rate = S / E Efficiency Rata = SPR / Costs
- 23. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 ER = Effectiveness Rate = S / T SPR = Social Profitability Rate = S / E Efficiency Rata = SPR / Costs SR = Supply Rate = E / T
- 24. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Before to start his job in the health center, the professional can check the real size of his morbidity, according to his population pyramid.
- 25. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 ICPC-2 Ep. Expected Before to start his job in the health center, the professional can check the real size of his morbidity, according to his population pyramid.
- 26. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 And, so, at the end of every month will be able to know the real outcomes.
- 27. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Ep. Expected Ep. Treated Ep. SolvedSupply Rate Effective. Rate S.Prof.Rate
- 28. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Big professional differences in standardized populations.
- 29. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Big professional differences in standardized populations.
- 30. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Big professional differences in standardized populations.
- 31. 3rd condition: To work in front of the own epidemiological local universe. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Big professional differences in standardized populations.
- 32. Keys for excellent HIS angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Health Information System Valuable based on the medical essence: Try to solve the 100% of health population needs Sensitive able to discriminate differences in clinical practice Reliable High confidence on figures and reports.
- 33. 4th condition: Measuring the ability to solve problems. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015
- 34. 4th condition: Measure the capability of solve problems. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015
- 35. 4th condition: Measure the capability of solve problems. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015
- 36. 4th condition: Measure the capability of solve problems. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015
- 37. 4th condition: Measure the capability of solve problems. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015
- 38. 4th condition: Measure the capability of solve problems. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015
- 39. 4th condition: Measure the capability of solve problems. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015
- 40. 4th condition: Measure the capability of solve problems. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015
- 41. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Health Information System Valuable based on the medical essence: Try to solve the 100% of health population needs Sensitive able to discriminate differences in clinical practice Reliable High confidence on figures and reports. Keys for excellent HIS
- 42. 5th condition: Confidence in information records. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015
- 43. 5th condition: Confidence in information records. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015
- 44. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Health Information System Valuable based on the medical essence: Try to solve the 100% of health population needs Sensitive able to discriminate differences in clinical practice Reliable High confidence on figures and reports. Keys for excellent HIS
- 45. Consequences and conclusions. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Every dot at the image represents a GP.
- 46. Consequences and conclusions. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The horizontal median line is the average activity, the number of ‘Episodes treated’ by standardized inhabitant,
- 47. Consequences and conclusions. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The vertical median line is the average of manageable costs per standardized inhabitant.
- 48. Consequences and conclusions. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The activity grows up, and the cost increases to the right.Activity Costs
- 49. Consequences and conclusions. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The ‘More by less GPs’. Our excellent professionals A B C D
- 50. Consequences and conclusions. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The ‘More by More Gps’, Our ‘Dr Houses’ or internists-like in Primary Care, A B C D
- 51. Consequences and conclusions. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The ‘Less by Less GPs’, The inaccessible. A B C D
- 52. Consequences and conclusions. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 A B C D The ‘Less by More GPs’. Our ‘Generous’ GPs
- 53. Consequences and conclusions. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 The first group, the ‘More by less Gps’, the ‘excellent’ professionals, shows a 350% better cost- effectiveness than the rest of their colleagues. 350% A B C D
- 54. Consequences and conclusions. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 Essential knowledge, usually unknown by doctors and managers who are guided by the inertial information record, which is unable to recognize the excellence. Consequently, we won't be able to identify them, to emulate them or to pay them properly. A B C D Logical & fighters Excellent & Invisible Inaccessible “Generous”
- 55. Consequences and conclusions. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 We achieved to built a common language for professional and managers, leaned on a new case-mix classification in iso-therapeutic behavior (G.R.E./ NCC© Group Related Episodes by Need of Care Criteria, based on the ICPC) that allow to group all activity in 24 Models of Behavior and in 7 Types of Problems. . G.R.E./NCC© Group Related Episodes by Need of Care Criteria © G.R.E. DESCRIPTION A PROBLEMS OF COLLECTIVE ORIENTATION B CONSUMTIVE OR DISABLING DISEASES B1 SANITARY PROBLEM OF SOCIAL ORIGIN C HEALTH PROBLEMS THAT TEND TO AN SPONTANEOUS RESOLUTION D SPECIFIC PROBLEMS OF INDIVIDUAL HEALTH, DEPENDANT ON TECHNICAL ABILITIES. E HEALTH PROBLEMS OF LOW FEASIBILITY, IN PRIMARY CARE P HEALTH NEEDS WITH EFFECTIVE PREVENTION
- 56. Consequences and conclusions. angelruiztellez@cymap.es +0034 637532359 www.cymap.es WONCA Istanbul 2015 This allowed us to measure the effectiveness and efficiency of the 100% of the Episodes of Attention and the 100% of manageable health costs, implemented in a Software named ISIS Manager© and in the Centers Transition Project©. G.R.E./NCC© Group Related Episodes by Need of Care Criteria © G.R.E. DESCRIPTION A PROBLEMS OF COLLECTIVE ORIENTATION B CONSUMTIVE OR DISABLING DISEASES B1 SANITARY PROBLEM OF SOCIAL ORIGIN C HEALTH PROBLEMS THAT TEND TO AN SPONTANEOUS RESOLUTION D SPECIFIC PROBLEMS OF INDIVIDUAL HEALTH, DEPENDANT ON TECHNICAL ABILITIES. E HEALTH PROBLEMS OF LOW FEASIBILITY, IN PRIMARY CARE P HEALTH NEEDS WITH EFFECTIVE PREVENTION
- 57. How does coding support the key tasks of the GP and improve patient care? Ángel Ruiz Téllez Fernando A. Alonso López October 2015 Concept & Methodology in Primary Care (Ltd.) Technological semFYC Partner CYMAP Director. Spain semFYC (Spanish society of community and family practice). Spain
Editor's Notes
- The crisis in Spain has failed to reverse the growth in drug costs, hospital referrals and the hospital-centered model. The central and regional governments’ management has been based only on economic cuts. Despite this, the professionals have continued during the crisis without any reduction in their inertial inflationary behavior.
- However, implementing a different Primary Care project, named Transition Centers© we have reversed, in a population of 100.000 inhabitants, the inertial inflationary trend of health spending, increasing paradoxically, the activity and quality in two years. The key to change was the modification of professionals’ behavior based on knowledge. We needed to do it , fulfilling five critical conditions.
- It was possible through a valuable, sensitive and reliable information system that the professionals and managers demanded us 18 years ago at the start of the project, as a condition for becoming their common communication language in order to overcome their usual divorce.
- Firstly, the need for coding the activity in ‘Episodes of Attention’, and, definitely giving up the ‘encounter’ or the appointment as a unit of activity, because both are units of costs, and because there is not any direct proportional relation among them and the volume of Episodes treated
- Another reason for this was the impossibility of measuring the real Productivity, which is the rate of Number of Episodes Attended divided by Costs, and not the accounting of resources used over the years, as our Managers usually think.
- The second condition was the need of evaluating (not only recording) the whole activity and costs, already feasible thanks to the EHR- Electronic Health Records. The evaluation in particular of the 100% of Episodes of Attention as activity, growing in ordinates at the picture, and the 100% of manageable health costs like drug prescription, medical leave days and referrals to hospital, mainly represented in abscissas. The image represents the cloud of cost-activity of professionals, and we can see the paradoxical distribution, away from the model of ‘higher activity - higher cost’.
- There is a first reason for this requirement, because the cost-activity and the Cost-Effectiveness does not usually behave on a direct proportional way, increasing the cost when the activity increases. On the contrary, it usually works in the opposite sense for standardized populations. If we look at the graphic we can see the dot ‘A’ representing a kind of professional that shows a high activity and a low cost,
- while the professional ‘BC’ displays the inverse pattern with lower activity and higher costs, with same population.
- Two professionals, and the same population. Dr.C replaces Dr A. Dr A High activity , low cost. Dr C Low activity , high cost. The difference of productivity was more or less 170%. We abandon de ACG, because it do not recognize the real key of differences : the professional, not the population.
- The second reason for the need to analyze the whole activity and costs, appears because our usual set of indicators of activity in Primary Care, our Quality Outcome Frame, hardly ever represents (at least in Spain) no more than the 15% of the whole morbidity treated. Moreover, it is a defective sample of the universe of activity, distorting professional behavior.
- We can see the low representation of reality with the classical set of quality or activity indicators. This slide shows us the absence of correlation between the official evaluations based in the official set of indicators and the whole activity, when they are matched.
- Remember : Sensitive able to discriminate differences in clinical practice
- I would like to point out the huge importance of evaluation, remembering Goldratt’s quote: “Tell me how you measure me, and I will tell you how I will behave”
- In the third place, the professionals needed to work facing their own local universe of epidemiological needs,
- in order to change their way of thinking. Without that reference every professional would think
- that those problems attended by him in his surgery are the whole health needs in their area.
- This happens until he realizes about the distance to his epidemiological goal.
- Initially this surprises them, since they realize that the activity is
- a rate of numbers of Episodes treated divided by the total number of Episodes Expected in their population: The real Supply Rate. The professional is wrong thinking that his Supply is a whole number.
- It is actually a rate.
- Before to start his job in the health center the professional can check the real size of his morbidity, according to his population pyramid.
- And, so, at the end of every month will be able to know the real outcomes.
- There are big professional differences in standardized populations,
- and the professionals can check the significant differences among them,
- modifying their own perception and behavior. This forces them to select, choose, prioritize, reject the ‘non-diseases’ and accelerate the different steps of the care process.
- This knowledge encourages motivation, because it touches the core, the essence of medical profession: To treat the existing social health needs and not only those which have been expressed or demanded.
- Remember : Valuable based on the medical essence: Try to solve the 100% of health population needs
- In the fourth place, the condition to measure, on one hand, the weight or complexity of care and, on the other hand, the capability to solve problems or Episodes of Attention in the 100% of problems, not only in those related with classic indicators of quality outcome. This would contribute to increase the confidence in the professional records comparison.
- It is not the same to treat 100 colds that 100 Diabetes. And neither to achieve an excellent 5% of retinopathy in such patients with Diabetes…..
- ……………
- ….or a worrying 50%.
- But also in the 100% of problems, not only the classical, also in respiratory, locomotor, digestive, etc.
- Remember : Sensitive able to discriminate differences in clinical practice.
- In the last place, the highest confidence in information records, as I said before, is the key to cause the change of professionals’ behavior.
- In addition to the above, we built a model of Certification of the reliability of data records, with more than 100 checks for comparison and standardization. "I trust it", they say now.
- Remember: Reliable High confidence on figures and reports.
- All these steps have allowed us to find four professional behavior profiles. Every dot at the image represents a GP.
- We can see then, at the left upper quadrant, those who make more activity for less cost. The ‘More by less GPs’. Our excellent professionals.
- At the right upper quadrant, we find those who make more activity for more cost. The ‘More by More Gps’,. Our ‘Dr Houses’ or internists-like in Primary Care, the ones who worse manage the uncertainty.
- At the lower left quadrant, we have those who make less activity for less cost. The ‘Less by Less GPs’, those that are more carefree around the health needs of their patients
- And finally, those who make less activity for more cost. The ‘Less by More GPs’. Our ‘generous GPs’ who jumping on the bandwagon of the inflation.
- The first group, the ‘More by less Gps’, the ‘excellent’ professionals, shows a 350% better cost-effectiveness than the rest of their colleagues for standardized populations.
- Essential knowledge, usually unknown by doctors and managers who are guided by the inertial information record, which is unable to recognize the excellence. Consequently, we won't be able to identify them, to emulate them or to pay them properly.
- We achieved to built a common language for professional and managers, leaned on a new case-mix classification in iso-therapeutic behavior (G.R.E./ NCC© Group Related Episodes by Need of Care Criteria, based on the ICPC) that allow to group all activity in 24 Models of Behavior and in 7 Types of Problems. .
- This allowed to measure the effectiveness and efficiency of the 100% of the Episodes of Attention and the 100% of manageable health costs, implemented in a Software named ISIS Manager© and in the Centers Transition Project©.