Use EMR data to inform and plan proactive patient care

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Quality information about a patient panel is an essential tool for having a family practice. It helps GPs identify and solve problems, do their job well to support patients, and manage their practice more efficiently.

What is panel management

Panel management is a process of proactively managing a defined population of patients, using EMR data to identify and respond to patients’ chronic and preventative care needs. It is a key step toward transitioning to a patient medical home.

Panel management enables family doctors to understand both the patients they are taking care of, and what those patients need. The concept is simple: better information about patients leads to better care for patients.

By using EMR data to proactively manage patient panels, doctors and their practice teams can:

  • Organize services and team members appropriately to best serve patients.
  • Provide proactive and preventative care for all patients they see, including those who have not actively engaged the family practice through recent visits.
  • Plan and streamline care and supports for prevalent health conditions among patients.
  • Increase access to information to help with patient care such as referral call-backs, reports, and accurate resources.
  • Advocate for appropriate resources to meet patients’ needs, such as allied care providers and community services for vulnerable patients.
  • Keep track of patient activities to bill effectively for the work they are doing. In some practices, this improvement has helped to pay for team members in the practice.
  • Along with other physicians, use aggregated data to plan patient supports and services in the community as a whole.

The big picture

GPs can make informed decisions about the kind of clinical and team supports they need in the practice to effectively care for patients. They can also use their data with other doctors to determine what kind of patient and team-based supports would be most beneficial to the community, to inform the work of divisions and health authorities in creating primary care networks.

For patients

Panel management has been shown to increase continuity of care, meaning that the patient’s experience of care is more coherent, consistent, and connected. This process is associated with improved patient-provider relationships, and long-term, coordinated care. Seeing the same provider consistently also increases the knowledge of the patient, such as preferences, social context, and values. Overall, patients within a well-managed panel receive more consistent care as well as more preventative and proactive care.

For doctors

Using high quality data from a managed panel, doctors can:

  • Make the most of their time and resources.
  • Improve preventative and proactive care for their patients.
  • Organize team members to best serve patients and take pressure off themselves.
  • Do the best job they can with patients.

Get involved

To help doctors and their teams implement and sustain panel management, the GPSC has developed the Phases of Panel Management. The Phases of Panel Management is a framework that helps practice teams introduce and implement tools and clinic processes that enable the use of EMR data to proactively identify and respond to patients’ chronic and preventative care needs.

The three phases are:

  1. Empanelment: Develop an accurate list of active patients by confirming the patient-provider relationship and most responsible provider. (Estimated time to complete: 1 month*)
  2. Panel Clean-up: Improve data entry procedures and develop accurate and up-to-date clinical registries. (Estimated time to complete: 1-2 months*)
  3. Panel Optimization: Use the EMR to proactively manage clinical registries by responding to patients’ chronic and preventative care needs. (Estimated time to complete: 4-9 months*)

*Time frames may vary depending on EMR, identified support needs of the clinic, or additional educational activities, however it is estimated that this work will take up to 12 months with 25 hours of dedicated time.

For more information about the Phases of Panel Management, please contact the GPSC’s Practice Support Program.

Supports

  • Panel Management Manual and Workbook*
    Guides doctors and their teams through the Phases of Panel Management step-by-step and is intended to serve as a clinic manual for team members outlining your practice’s panel management practices.

    Receive three Mainpro + credits per hour for up to 25 hours for completing the GPSC Panel Management Manual and Workbook, which has been certified by the College of Family Physicians of Canada for up to 75 Mainpro+ credits.

    *Before entering data into the workbook, please save the PDF workbook to your computer. Editing the workbook in a web browser may result in loss of data. Your computer may need Adobe Acrobat Reader.

  • In-Practice Coaching 
    Provides coaching sessions through the Phases of Panel Management including action planning and EMR Optimization. Get started by contacting your PSP Regional Support Team.
  • Panel Development Incentive ($6,000) 
    Compensates eligible family doctors for completing phase one, two, and three of the Phases of Panel Management and documenting work in the GPSC Panel Management Manual and Workbook. 
  • EMR-based Panel Management Tools
    Simplify the process of updating patient information and developing disease registries. Get started by contacting your PSP Regional Support Team.