He was a hard headed man....

“Life in the Fast Lane,
Surely make you lose your mind“

The Collins Street Medical Centre has developed a strategy that has been effective in changing their capacity to match their demand.

Why block up a 15 minute slot if all that is needed is a brief appointment for a script, a certificate, a referral or a normal result?

Andrew Knight has collected a number of variations on this idea in this article at our new sister site APCC Stories.

The people at Mt Barker/Balhannah Medical Clinic in South Australia were part of the second wave of the Collaborative back in 2005. They remind us that “care redesign” is one of the pillars of effective chronic care. That is you can’t keep doing the same thing and expect different results!

What did they do? Like many of the successful practices in the collaborative they created a new creature – the chronic disease coordinator.

Their story is on our new sister site at
http://stories.apcc.org.au/2009/11/the-rise-and-rise-of-the-chronic-care-coordinator/

As Ai-Vee Chua writes
“In the spirit of PDSAs, I am submitting one ’small’ step in the multitude of changes we have made (and will make) at our practice as a result of being involved in the APCC program…”

“Our waiting room is relatively small, but its walls have always been filled with many posters and signs (akin to the advertising noticeboards seen at many local shops!). Following one of the APCC workshops, we returned home and decided to create an electronic noticeboard.”

Recipe for an Electronic Noticeboard

Ingredients

1. One old laptop
2. Version of Powerpoint downloaded free from the Internet
3. PDF converter software
4. TV screen with wall bracket and cabling
5. One practice principal with an interest in IT and in being a handyman!

Method

1. Strip waiting room walls of existing posters/signs.
2. Download posters from the Internet where possible and use PDF converter software to tun these into Powerpoint slides; create versions of remaining posters/signs as Powerpoint slides; add some slides of beautiful scenery (so patients can momentarily dream that they are in South America and not in a doctors waiting room in Dubbo)
3. Mount wall bracket, mount TV screen onto wall bracket
4. Run cable from TV screen up through ceiling, across ceiling space, and down to laptop hidden in cupboard
5. Run repeated Powerpoint presentation throughout the day
6. Delegate one receptionist task of maintaining electronic noticeboard slides
7. Stick back a few posters/signs on areas of walls that require a re-touch paint job!

Thanks for that, Ai-vee.

Have you got an electronic noticeboard in your practice? Any suggestions for what works well? Have you developed a different solution? Let us know in the comments below.

But, alas, it has been usurped by the Smartpen. (http://smartpen.com.au) – A computer in a pen!

With the Smartpen , you can take notes, like an ordinary pen. (the Smartpen requires special paper, which you can print yourself)

Unlike a normal pen, the Smartpen also contains a microphone and an infrared camera. It records whatever is being written and makes an audio recording of what is being said at that same time.

At any subsequent time, you can touch your Smartpen on the particular written words on the page, and it will playback what was being said at the time.

So, in a consultation, if you make a note ‘abdominal pain’, you can later touch that word with your pen and it will replay what your patient actually said.

At a lecture, you can make brief notes, and if you later need clarification you can touch the appropriate word (or diagram) and you will hear the explanation given by the lecturer at the time you made the note.

How about that?

Furthermore, at the end of the day you plug your pen into your computer (!) All the pages you have written are automatically uploaded into the computer, and stored. No scanning required. The audio file is also uploaded, so you can still click on any word on the page (with your mouse), and hear what was happening at the time. You can also search your stored pages for particular words.

So, don’t take your laptop to a meeting – just your smartpen and the special pad.

(I’m not sure that I’ve ever gone back and looked at any notes I’ve made in a lecture. Perhaps with the smartpen I would.)

For those docs still using paper records, perhaps they could write their notes on the special paper and then automatically load them into the computer at the end of the day.

The smartpen does some other cool things that enable you to show off with style, always an important consideration with a new gadget. Draw a piano keyboard on a page, and then actually play it with your pen. Write 10 x 4, and the smartpen will come out with 40.

Can you think of a use for the Smartpen to improve your practice?

Let us know below.

How much of our capacity is lost bit by bit – chipped away in little inefficiencies? This story from Romsey Medical Centre appealed to me because it underlines a lesson it took me years learn. Here is how they tell it…

“It’s hard to choose just one from the most worthwhile collaboratives journey, however, the one that most stands out in my mind is ‘Tracking doctor starting times’, the graphing of which named (and sometimes shamed) each doctor’s performance in this area.

It basically measured how long after the 1st booked appointment the doctor actually saw the first patient and drew direct correlations between this and session times blowing out.

It was painfully obvious that those doctors who regularly started their session late, finished even later, and those who started on time fared much better. As a result, we have seen a behavioural shift in ‘promptness’ which has benefitted everybody; the doctor (not feeling so stressed by the end of a session), reception (not copping so much abuse from patients), and patients (not having to wait as long to see the doctor).

If that’s not a win/win/win, I don’t know what is!!!”

It is a tribute to the healthy team Romsey has developed that they were willing to put themselves under the microscope to improve this area of their performance. As Tony Lembke says 15 minutes late is not on time (see “Becoming a Time Lord”).

Lifestyle interventions for diabetes prevention continue to have benefits for patients 10 years down the track, according to recently published data from the Diabetes Prevention Program.

In the ‘Carve Out’ model for appointments, some appointments each day are kept reserved as ‘book on the day appointments’, for patients with acute conditions. In our practice, these are coloured green.

If ‘Demand is Finite and Predictable’, we should be able to look at our appointment history to anticipate the future acute requirements, and thereby determine how many appointments need to be carved out.

(Indeed, a few years ago we analysed the appointments over a whole year and found that the number of both acute and planned appointments was very consistent for any particular day of the week.)

Successfully carving out the right number of appointments proves to be harder than anticipated. Even if we know that we will require 54 acute appointments on a Monday, and ‘reserve’ them some weeks ahead of time, many of these reserved slots are mysteriously taken up beforehand. By the time Monday starts, there are always far less than 54 still ‘carved out’.

So in our practice we are now playing ‘Appointments Golf’.

It is way of scoring the success of the appointment system. It is also a means of ascertaining how many acute appointments you need each day, without having to tally them up.

The scorecard we use can be downloaded here.
Part of the scorecard looks like this.

At the start of each day, before the phones are switched on, the ‘early’ receptionist counts how many free appointments are available. (A – Acute at Start of Day”

At the end of the day, the ‘closing’ receptionist counts how many extras needed to be fitted in, “B – Extras at End of Day”and how many gaps there are where noone was booked “C – Gaps”. (an unnusual event). You should also tally how many people (if any) were turned away (hopefully an even more unnusual event!) “D – Unmet”

Your score for the day is
Number of Extras(B) – Number of Gaps(C) + Number Turned Away(D).

The lower the score, the better.
An eagle is zero. Birdie is between one and three. Par is four to six. Bogie is seven to nine. Double Bogie starts from ten.

And here’s the tip to improve your score!

The number of appointments you need to carve out to get zero on the same day of the week in one week’s time will be
Number of Free Appts at start of day (A) + Your Score for the Day (E)
This is the demand for acute appointments (F).

We have found that this number is amazingly consistent from Monday to Monday, Tuesday to Tuesday, etc.

Could you play Appointment Golf in your clinic? Let me know how you score.

Can you think of ways of adapting or extending Appointment Golf?

Do you think the ideal score is zero? Perhaps a few extras each day is a good thing?

Perhaps we should include a doctor and staff ‘zen score’, to determine how much zen was lost in a frazzled high scoring day.

Your questions and comments for this ‘virtual tabletop’ are very welcome below.

That’s 1001 stories to share!

Which brings us to the the ancient fable ‘Arabian Nights’.

The young bride Scheherazade appears doomed to be executed by her new husband, the king, on the morning after their wedding – a fate that had befallen a succession of his former wives. However, on their wedding night she begins a tale that is so beguiling that her husband, eager to find out how it ends, postpones her execution till the following day. The next night, having completed that tale, she begins another. Again the execution is postponed.

And so it goes, Schererazade beginning a new story for 1001 nights in a row. She eventually receives a royal pardon.

Which brings us back to the collaboratives’s ‘1001 Stories Project.’

Whenever we speak to one of our collaborative practices, it is fascinating to hear the improvements they have made – some small, some huge.
We are celebrating the 1001st practice by collecting just one improvement story from each of the 1001 participating practices.

As part of our aim of ‘making possible practice into usual practice’, we’ll collect and share these stories.

What story will your practice ‘share generously’? What one change idea can you tell us about us?

Have you changed the way you arrange practice meetings? Have you got a collaborative notice board? Are you handling your appointments differently? Do you have a system for maintaining registers of your chronic disease patients? Have you found new ways of engaging patients in self-management? Have you changed your practice team? Do you have better ways of integrating care? Have you redesigned parts of your clinic?

We need you to send us just one change you have made in your practice.

Let’s have them in to me at tony.lembke@improve.org.au

We’ll share them as ‘virtual tabletops’.

In the tradition of Scheherazade, I’ll post the first story from our clinic (’Appointment Golf’)

PS Remember, please send (at least) one change idea to tony.lembke@improve.org.au

Australians will have 90,000 heart attacks in 2009. 10,000 of us will die as a result – the majority before they reach hospital. According to a recent Access Economics report, it is projected that this will cost the economy $17.9 billion dollars!

As Dr Annete Katelaris writes in her blog

“While this is shocking, what really scares me is the response of the coalition of cardiac groups and the Heart Foundation. While they gave mention to the need for primary prevention, they seem to have almost exclusively focused on the need to improve acute care and secondary prevention.”

More ambulances, coronary angiograms and cardiologists. Stat!

But hang on – premature vascular disease is largely preventable. Appropriate intervention in high risk people can lead to a 55% risk reduction. That’s a $9 billion dollar saving!

What are your chances of having a heart attack in the next five years?

The absolute cardiovascular risk is used to weigh up the costs versus the potential benefits of a wide range of interventions, some of which (such as lipid lowering medications) use up a significant proportion of Australia’s PBS spending.

How accurately can we assess someone’s risk? And how important is it?

Last week I was in New Zealand, and caught up with Sue Wells, who “used to be a doctor but now works in an office”, according to her sons. She is the clinical co-ordinator of the University of Auckland’s PREDICT CVD-Diabetes program. This program is based on a Maori/non-Maori partnership and is supervised by Prof Rod Jackson, who pioneered the colour CVD risk charts in the 1990s. Their team of primary and secondary care clinicians and IT specialists form a national guidelines group that is producing the world’s best tools for assessing vascular risk.

The PREDICT program also demonstrates the value of a fundamental eHealth building block – one that Australia still lacks, yet New Zealand has had for 17 years! More on that later.

The Predict-CVD Program

Sue says “if a risk-based prevention approach is to work, CVD risk prediction must be accurate.”

Until now, The Framingham Study has been the basis for assessing cardiovascular risk. She asks “Did you know that the Framingham study included only around 5200 people, followed up for about 12 years? They were by and large middle-class and middle-aged and mostly male, and of mainly European ethinic background.”

New Zealand has a comprehensive approach to risk assessment, and their PREDICT program has been running since Aug 2002. As of January this year, 115000 assessments had been conducted on 74,402 individual patients by 1300 clinicians (GPs and practice nurses). 9000 of these patients have a prior history of CVD. Mean follow-up so far is 2 years.

So far, that is 20 times as many patients as were involved in the Framingham Study!

The PREDICT tool is built in to the GP software used in New Zealand. Most of the fields are ‘auto-populated’. It is also available on the Web.

Why have one thousand GPs used PREDICT? Sue would say that is because it provides both ‘evidence-in’ – to improve individual patient care – and ‘evidence-out’ – to improve practice-relevant evidence.

Evidence-In

When you do a risk-assessment on a patient using PREDICT, the program uses its database of clinical evidence to provide a number of support tools that make it easier to manage that patient. These tools include a great deal of education material targeted to that patient and their individual risk factors.

For example, Sue was concerned that young patients with a number of risk factors, such as smoking, still have a low 5 year absolute risk profile, and are falsely reassured. So the team developed ‘Your Heart Forecast’, which calculates current risk, but also ‘heart age’ and graphs a likely future profile. You can demonstrate to a patient that by modifying their risk factors they can improve their likely outcome. Even though their current risk might be low, their future may be less than rosy.

The tool is at http://www.yourheartforecast.org.nz/index.asp?pageID=2145872462

The Educational Support tools are at http://www.yourheartforecast.org.nz

Evidence-Out

The data entered into the tool is also automatically sent to the PREDICT database of patients at Auckland University, thus providing more evidence to improve the accuracy of health prediction, assess the effects of heath care, and aid in population health planning.

This improved evidence feeds back to improve the tool used in general practice, and thus completes the loop!

The NIH

We mentioned that there is a fundamental eHealth building block that enables the PREDICT system, that is not currently available in Australia. What is it?

The ‘National Health Index’ was introduced in New Zealand in 1992 (!) to be ‘the cornerstone of heath information’

From the Ministry of Health -
http://www.moh.govt.nz/moh.nsf/indexmh/sectorservices-claims-nhi

“The National Health Index number (NHI number) is a unique identifier assigned to every person who uses health and disability support services in New Zealand. A person’s NHI number is stored on the National Health Index (NHI) along with that person’s demographic details. The NHI and associated NHI numbers are used to help with the planning, co-ordination and provision of health and disability support services across New Zealand.

The NHI is associated with the Medical Warnings System (MWS), and is designed to warn healthcare providers of any known risk factors that may be important when making clinical decisions about individual patient care.”

In Australia, we can’t ‘track’ a patients care from clinic to laboratory to hospital because we do not have a way of uniquely identifying that patient (It’s almost OK if your surname is ‘Lembke’, or ‘Haikerwal, but a problem if it is ‘Jones’, or even ‘Wells’). It is in fact illegal to use the Medicare number for this purpose! This means that care can often be disjointed – health information is not readily available wherever and whenever it may be needed.

In NZ they can track what happens to every person. In the case of the PREDICT program they can do this anonymously, using the ‘encypted NHI’, or eNHI. This is the version of the NHI that has been de-identified, and is therefore used in research. The eNHI is encrypted in such a way that we can be sure it is always referring to the same person, but it cannot be linked back to that person’s name and address.

Linkage of Risk to Outcomes

The eNHI enables the PREDICT team to find out how accurate their predictions are, and then modify the weighting given to various risk factors to improve future predictions. (This sounds like a good skill set for developing a system to predict the results of horse races. If the team all retire early, we will know that they have been moonlighting)

When a GP uses the PREDICT tool to perform a cardiac risk assessment, the data (with the appropriate eNHI) is sent to the team at the University of Auckland. The eNHI is also sent to the New Zealand Health Information Service ( http://www.nzhis.govt.nz/), which collates a range of databases including hospital admissions and deaths. If at some future time that patient subsequently has a heart attack or dies, the Health Information Service feeds the outcome data for that patient back to the PREDICT team, so they can determine which of the patients in their database have in fact had a cardiac event.

Were we right?

The data is coming in. There have been 5000 events in 3200 of the 115,000 individuals tested so far. 1225 of these events have been fatal.

So far in this PREDICT cohort, 70% of the people tested have been in the low risk group, and they make up 24% of those who have had a cardiac event. 11% of those who have had an event have been of moderate risk, and 11% from the high risk group, which leaves a whopping 54% who have had a previous heart or stroke event. (this is the group we have been working with in our CHD collaborative). When a patient has a second PREDICT assessment done, the team can calculate how a change in risk factors affects outcomes.

The PREDICT program allows us to calculate which factors are most important in determining cardiovascular risk. Sue says that the Framingham figures are in fact not shaping up too badly, on average. However, they tend to overestimate the risk for most people, but underestimate the risk for some ethnic groups, including Maori and Pacific Islanders.

It was interesting for me to learn that adding ‘Family History’ into the calculations does not tend to add any further predictive value, whereas almost everyone would benefit from lowering their blood pressure. The PREDICT program remains a work that is continually improving.

In Australia

The first Australian guidelines for calculating absolute cardiac risk were published earlier this year as an initiative of the National Vascular Disease Prevention Alliance.

These guidelines continue to be based on the Framingham data. It will be interesting to revisit this discussion when the NZ PREDICT-CVD data extends out a few more years.

There is currently a discussion in Australia about the role of a Healthcare Identifier.
http://www.health.gov.au/eHealth/consultation

Hopefully we will soon introduce a unique patient identifier, only 17 years behind our Kiwi friends.

In the meantime, the work of the Predict team reminds us that cardiovascular risk assessment and management of risk factors should remain a national priority.

As Sue Wells reminds us

“We could prevent or delay 50% of the CVD events in the next five years if we assessed everyone for cardiovascular risk and managed them appropriately.”

“The real heroes for me are the 1300 GPs and nurses caring for their patients. We have only orchestrated a supportive IT program around this care that serves general practice at the time of decision making, for quality improvement activities and for improving what we need to know to care more accurately (risk prediction). From collective action which started out quite small…amazing things are possible”

Conclusions Against a background of increases in the quality of care before the pay-for-performance scheme was introduced, the scheme accelerated improvements in quality for two of three chronic conditions in the short term. However, once targets were reached, the improvement in the quality of care for patients with these conditions slowed, and the quality of care declined for two conditions that had not been linked to incentives. Continuity of care was reduced after the introduction of the scheme.