FastTrack

At Qualsa, we know that providers are key partners in our quest to manage the health of medical scheme members. We believe it is essential that we work closely with them in this challenging task. In this edition of Fasttrack, we look at an exciting new project currently in development - the creation of a provider hub on the Qualsa website. We also meet Professor Manie de Klerk - Director of Clinical Services at Qualsa and instrumental in creating the programmes and treatment guidelines necessary to ensure members at the different risk levels receive appropriate care. In addition, we provide a brief update on the ground-breaking work Professor Praneet Valodia is busy with in the area of Health Outcomes Measurement.

As facilitator of the Qualsa Disease Management Forum, Manie de Klerk plays a key role in developing new disease management programmes and revamping existing ones. Diseases currently on his radar include diabetes and asthma, as well as cardiovascular, psychiatric and respiratory diseases - to name but a few. Another forum he facilitates is the Health Technology and Guidelines Forum - the focus being on the development of guidelines when it comes to new technology, new tests, procedures, drugs and new equipment.

An integrated approach to care management and the role of the GP

Manie's approach is one of integration. He believes optimal health risk management and the best possible health outcomes result when there is integration of all health management interventions. And central to this process is the general practitioner (GP), who plays a key role as the coordinator of care. The international trend is that general practitioners are starting to play a far more dominant central role in patient care, as their hospital privileges, previously the domain of the specialist, are slowly returned.

The guidelines and protocols that Manie's teams develop support this trend. In fact, guidelines and protocols are often co-developed with doctor groups and ensure that the GP plays an important role in the management of diseases. A recent example has been the development of psychiatry programmes in cooperation with the SA Society of Psychiatrists.

The management guidelines will also recognise "up-skilled" GPs (e.g. those who have specialist qualifications in certain areas) and are designed to allow them to prescribe drugs that were previously reserved for specialists.

Leading the way in Health Outcomes Management

Working closely with Manie and his team is Professor Praneet Valodia who heads the Research and Development Department. While medical schemes and employers are increasingly requesting meaningful data on health outcomes, measurement in this area has been particularly challenging. This is largely due to ICD-10 or diagnosis coding only being introduced as compulsory on all claims in 2005 - making it possible to start reporting on diagnosis. However, data from this period is not entirely up to standard, and it is only now in 2007, that more accurate measurement in this area is becoming possible.

According to Praneet, health outcomes measurement is far more than simply reporting on health data. Described in very basic terms, the process starts with measuring reliable baseline data. A specific intervention

in turn leads to post-intervention data. This data is then analysed to produce health outcomes information that determines the value of the intervention.

The visual below provides an overview of the Health Outcomes Project that Praneet and his team are working on. They are continuously busy designing and testing methods that will provide Qualsa with the ability to report on health outcomes. The unique models they are busy developing will also enable the prediction of health outcomes. Praneet believes these models will be unique in the local (and even international) healthcare industry.

Future editions of Fasttrack will provide examples of Qualsa's Health Outcomes reports.

Recognising fundamental flaws in the fragmented US healthcare systems, not unlike the South African healthcare system, and the potential of an integrative, generalist approach, the leadership of 7 national family medicine organisations initiated the Future of Family Medicine (FFM) project in 2002. The goal of the project was to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing healthcare environment. An extensive national research study was conducted by independent research firms.

RESULTS:
The project identified core values, a New Model of practice, and a process for development, research, education, partnership, and change, with great potential to transform the ability of family medicine to improve the health and healthcare of the nation.

The proposed New Model of practice has the following characteristics:

a patient-centered team approach (which implies coordination of care);
elimination of barriers to access (implying that the doctor is closer to the patient);
advanced information systems, including an electronic health record;
redesigned, more functional offices;
a focus on quality and outcomes; and
enhanced practice finance.

The study also concluded that family medicine education must continue to include training in maternity care (which is essentially the "up-skilling" Manie and his team are committed to supporting in their protocol/guidelines development), the care of hospitalised patients (or return of hospital privileges to GPs), community and population health, and culturally effective and proficient care (or skills to cope in multi-cultural communities).

The study promoted a comprehensive lifelong learning programme for each family physician that will support continuous personal, professional, and clinical practice assessment and improvement.

Such changes include taking steps to ensure that every citizen has a general practitioner's practice.

Reference:

1. Pubmed. PMID: 15080220
    [PubMed - indexed for
    MEDLINE]

2. 2004 Mar-Apr;2 Suppl
    1:S3-32

This paper looks at the significant changes general practice is likely to undergo over the next few years. The new roles that are identified that the average GP will need to occupy include: the general practitioner in the community, the epidemiologist, the entrepreneur and the networker. The paper explores each of these roles in some depth, and then concludes by saying that each of these developments is rooted in the practice, but is linked by political expediency.

General practitioners need to be physicians in the community to contain the costs of the health service. They need to think like epidemiologists to see

if goals are being achieved, and then set new goals. They need to collaborate with colleagues to speak with a united voice on health policy on behalf of our patients.

They have to learn to respond to a changing society without retreating behind barbed wire or acceding to unreasonable demands. Those who have trained may have to relearn. Those planning medical education should enable tomorrow's doctors to learn co-operatively from the start, to value themselves, the colleagues they work with, and their patients.

Qualsa would like to empower its providers by giving you easy access to important information that will add value to your practice and increase efficiency in the treatment of your patients. The "provider hub" that will be launched at the beginning of November is designed especially for our providers who prefer working in an interactive online medium.

The provider hub will be a secure environment where you can access your electronic patient records and claims information, request authorisations and also find up-to-date disease information, formularies, guidelines and treatment protocols.

Some of the new exciting features that will be phased in on the hub include:

Find-a-specialist tool
You can request a specialist in a certain area and the address or contact details will be sent to you or your patient via SMS or email. This will assist with referrals.
Peer review tool
This facility will allow you to privately
review your operations, outcomes and
patient experience on a number of levels,
and also receive input on how to improve
your status level.
Online request / authorisation tool
Another feature that will be included is an online communications channel where you can request authorisations and paste photos, for example breast reduction procedures. This facility will ensure confidentiality for the patient in a secure environment.

Future editions of Fasttrack will provide an update on what is available in Qualsa's provider hub as it is rolled out. Should you have any questions or comments, please e-mail talk2me@qualsa.co.za.