Partners in Care Initiative

Prince George

Northern Partners in Care (NPiC) has a number of projects underway that supports and improves the provision of care to patients in acute and community settings, and  enhances the ability of health care providers to work together to deliver cohesive care.

Cancer Survivorship
NPiC is working with the Northern Radiation Oncologists, the Family Practice Oncology Network and others within the BC Cancer Agency, Northern Health and the Prince George Division of Family Practice to improve cancer survivorship. This work includes the development of clear and actionable end of treatment notes (see Referral and Consultation project below) and methods to embed the required information in family physicians’ (FPs) electronic medical records (EMRs) in ways that support and prompt best practice care (see Electronic Care Plan and Secure Messaging projects below).

During the next phase of this project NPiC will work:

  • To complete the Referral and Consultation letter project to help inform the work of FPON/BCCA (including other oncologists), FPs, Divisions of Family Practice in Northern BC and Northern Health.
  • To embed best practices in actionable ways into FPs’ EMRS (including Electronic Care Plans) through collaboration with FPON, FPs and Northern Divisions of Family
  • To provide to AMCARE (Aggregated Metrics for Clinical Analysis, Research & Evaluation) with potential indicators to assist with assessing the quality of survivorship care, and the impact of interventions.
  • To help inform the Secure Messaging project to support confidential, timely and appropriately-coded  Consultation letters (Plans of Care) for use by FPs through effective and efficient integration of information into their EMRs.
  • To consider ways that tertiary care organizations/specialists can provide ongoing support to FPs.
  • To identify how this work can inform connectivity between tertiary care organizations and primary care and be transferable to other health concerns.

Clinical Outreach Visits
Clinical outreach visits advance the mission and vision of NPiC by supporting specialists’ travel to communities in Northern BC, to better address patient needs and to connect with FPs locally.  Non-physicians can also be involved with such visits. Clinical Outreach Visits to date have included nephrology, pediatrics and internal medicine.  

Ongoing support of these visits will

  • Address particularly challenging patient issues.
  • Improve the capability and confidence of family physicians (FPs) to manage patient issues independently.
  • Develop approaches for ongoing support of community FPs.
  • Develop and document a network of contacts responsible for organizing clinical visits in the region.
  • Complete a minimum of 10 clinical visits in eight communities, by the end of the first fiscal year (March 31, 2015)
  • Have a strong evaluation of each clinical visit that will add to a body of data to provide long term information on results.

Electronic Care Plans
The Care Plan allows family physicians (FPs) and other healthcare providers to more effectively and efficiently address the health needs of patients, particularly those with chronic and complex health issues.  It can help an individual FP, but is particularly helpful for patients who require health care from more than one provider. The Care Plan was developed with significant input from FPs, specialists (SPs), Northern Health IT, clinical staff, and the Prince George Division of Family Practice, and was guided by international best practices.  Plus, it was trialed by local FPs and other healthcare providers and is being further refined by the vendor (AIHS) for the pilot host electronic medical record (MOIS).

NPiC will continue to work with its partners to help clarify what information is most useful when SPs create consult letters (or Plans of Care) for FPs, and how such information is best presented to make it highly actionable.

Mobile Messaging
The Mobile Messaging project enables the secure transfer of clinical information from mobile devices (iPhone, iPad, android) to the clinician's electronic medical record.  It has been trialed in MOIS.

NPiC will use the next phase of this project to:

  • Gain an increased understanding of the technology’s capabilities.
  • Gain an increased understanding of how the capabilities are best deployed in practice.
  • Create a plan for deployment in practice.

Northern RACE
Northern RACE (NRACE) enables enhanced telephone access to Northern Specialists by northern family physicians (FPs), nurse practitioners, and other specialists throughout Northern BC. It has been functional since June 2012.  After the first year, and as a result of PDSA reviews, significant changes were made in how NRACE works in order to make it more useful for involved physicians. It has grown from enabling increased access to a single specialty area (Cardiology) to now enabling access to nine specialty areas. NRACE has benefited greatly from the knowledge and experience of the innovators of the Providence RACE line.

The next phase of the program will actively seek to:

  • Connect Northern FPs, nurse practitioners, and other specialists to predominantly Northern Specialists to assist with addressing non-emergent health issues in a timely manner within regular working hours.
  • Increase current call volumes across specialties.        
  • Increase the number of available specialty services on NRACE.

Referral and Consultation Letters
Written communication (referral letters) from family physicians (FPs) to specialists (SPs), and from SPs (consultation letters) is a critical enabler to the mission and vision of NPiC.  Work to date has focused on obtaining feedback regarding end of treatment (consultation) letters from Radiation Oncologists in Northern BC. This feedback will be collated with information obtained from non-oncology SPs, from other Shared Care and BC Cancer Agency projects, from FPs trialing the Care Plan (see Care Plan project) and from a literature review. This process will inform the creation of an improved end of treatment note (Plan of Care), which will be trialed and evaluated.  

Through this project NPiC will:

  • Gain an increased understanding how consultation letters (Plans of Care) can be structured to provide clear and actionable direction and convey important patient care information to FPs and ensure required documentation for SPs.
  • Trial revised consultation letters in a clinical area (radiation oncology) to see if they more effectively address FP and SP needs.
  • Consult with SPs in two additional clinical areas that are yet to be determined.
  • Develop standardized letters to make it easier to incorporate required actions into the FPs’ EMR.
  • Use learnings from the radiation oncology effort to inform adaptation of consultation letters (Plans of Care) by SPs from other clinical areas.

Secure Messaging
Northern Health and Interior Health are largely driving the Secure Messaging project. The project involves creating standards and capability for the secure exchange of relatively granular elements of clinical information between different electronic platforms.

The next phase of this project will work:

  • To enable physicians to securely exchange clinical data (referral and consultation letters, discharge summaries, emergency department reports, etc.) within and across information technology platforms.
  • To enable elements of the exchanged information to be electronically recognizable and importable as discrete data elements into the appropriate fields within the receiving platform [i.e., Plans of Care from specialists (SPs) into Care Plans of family physicians (FPs)].  
  • To build on agreed upon international and provincial standards for clinical data exchange.

Videoconferencing
By providing a visual and verbal link between family physicians (FPs) in larger centers with FPs in the small communities throughout Northern BC, videoconferencing assists NPiC with achieving its mission and vision.  The advent of more flexible technology that can securely connect between PCs, laptops, notepads, etc. opens a wide range of new approaches to using such technology. NPiC is supporting changes in practice that enhance existing lines of communication. New lines of communication are supported if they add value to patient care, and they do not negatively impact required physician-patient relationships.

NPiC’s project will:

  • Determine hardware/software options for use of flexible videoconferencing technology in practice.
  • Support physician innovation to determine the best ways to utilize this technology to improve access to quality patient care.
  • Spread the use of such technology to other clinical areas and geographical sites.

Click here for more information and a short video update on the projects above.