Using data to improve individual health, practice performance and understand social determinants

Agenda

Summary

This six-session course is all about applying a population health approach within traditional health service organizations. Students will learn about some of the common sources of data available to characterize the health of individuals, practices and local communities. Students will engage with data to identify “hotspots” and build population profiles, including the distribution of health outcomes and disease in a practice. Students will discuss innovative ways to understand the health care system at a population level through synthesizing clinical data and community data on social determinants.

Objectives

  1. Identify common sources of data that can be used to characterize the health of individuals, practices and the local community in which the practice is located.
  2. Understand basic ways of manipulating data to identify “hotspots” and describe the distribution of health outcomes and disease in a practice population.
  3. Explore innovative ways to bring a population health perspective into primary care practice, including through synthesizing clinical data and community data on social determinants.

Rationale

Two key processes are changing how primary health care operates in Canada. First, the increased used of electronic medical records (EMRs) now provides rich data over many years on individuals and entire practice populations. Such data is already being used in quality improvement efforts to target individuals for intervention. However, challenges remain in using data that is originally collected for only clinical purposes. Second, although primary care has always acknowledged it needs to address both individual and collective need, now it is 2 increasingly being seen as a resource to a geographically defined community (i.e. catchment area). Under policy changes such as “Patients First” in Ontario, providers are now being asked how they are serving local communities.

This reading course will begin with identifying common sources of data that are available to understand the health and determinants of health of individuals and a practice population. We will use such data to develop a practice report, applying a population health approach to this assessment. We will then discuss the complementary concepts of “shifting the curve” and “hot spotting”, and examine how they apply to primary care settings. We will work through a number of examples, including using data to understand the health of diabetics, patients with HIV infection and patients with multi-morbidity. It is important that leaders in primary care have some familiarity with conducting an assessment of the health of their practice population and this course aims to support such efforts.

This course will involve using Microsoft Excel only. No specific access to an electronic medical record (EMR) is required.

Textbook: none (readings as assigned)

Case studies to explore during the course

  • Case 1: Increasing cancer screening amongst "hard to reach" groups
  • Case 2: Addressing social determinants of health
  • Case 3: Linking with community social service agencies to fill the gap around "high cost users"
  • Case 4: Using data to re-allocate human resources to reduce health inequities
  • Case 5: Community asset mapping and community engagement
  • Case 6: UTOPIAN and public health surveillance

Evaluation

20%  

Attendance and active participation in class discussions
Students’ attendance will be verified at the beginning of each class, and students are expected to attend and participate. Completing the readings before class are essential and students will be graded based on the quality of the points raised, including reference to the readings.
Absences policy: Absences will be addressed on a case-by-case basis. Students should contact the instructor in advance if they will be absent to arrange alternative ways to cover the material.

20%  

Mid-term assignment: Proposal for final project

60%  

Final project: Each student will carry out a small project that aims to use clinical data and/or publicly available data to do one of the following:

  • Conduct a "hot spotting" exercise to identify patients with a specific disease condition who are considered poorly controlled (e.g. patients with diabetes with A1c >9.5%) or patients who are on inappropriate medications (e.g. seniors on benzodiazepines)
  • Develop a practice profile, i.e. an epidemiological report on patients served/rostered to a practice, with recommendations on planning primary care services
  • Develop a catchment area profile, i.e. an epidemiological report on the population served, with recommendations on planning primary care services

Prerequisites

none
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