Made-in-Vancouver innovation for a complex patient population

Despite the best intentions of health care providers, patients who reside in Vancouver's Downtown Eastside often fall through the cracks in the health system. Many patients have multiple chronic health conditions, substance use and mental health issues, and often live on the street. As medical director of Vancouver Community Substance Use Services, Vancouver Coastal Health Research Institute scientist Dr. Ronald Joe sees these challenges firsthand. “We’ve been trying very hard for many years to provide the best treatment possible for this complex population. The solutions are not going to be simple.” 

One of the key problems, Joe says, is that marginalized patients have a hard time keeping track of medical appointments and follow-up care. There is a wide range of sites that provide care and counselling in the Downtown Eastside, and patients often access multiple clinics and outreach services. These various clinics and services do not always communicate with each other, which makes it difficult for providers to trace a client’s journey through the health system—finding out where they have been and determining what their next step is. Vancouver Coastal Health (VCH) has responded to this problem by establishing integrated health teams to coordinate care, as part of its Second Generation Strategy. However, Joe says there are still many gaps to fill. 

To address this complex problem, Joe and his colleague, Gabriela Sincraian, a project manager in strategy development for VCH, came up with an innovative software solution to help track patients’ interactions with the health care system. “We were tasked with developing clinical indicators—things like how many people get diabetes care—for the Downtown Eastside strategy,” says Sincraian. “We quickly realized there wasn’t any analytic tool capable of doing that, so we built the Vancouver Community Analytics Tool, or VCAT.” 

The VCAT tool creates a 'virtual patient record' by gathering information from the various health care sites in Vancouver—from detox centres to ERs—and building a comprehensive list of all the services and supports a person has accessed. Sincraian says what separates the VCAT from other software is a focus on the patient.

“Before, we focussed on each centre. Now we are following individuals as they access acute care and community services—even services that are not provided by VCH—to find the gaps and see where improvements can be made," says Joe.

Better data for better outcomes

Joe says the other important feature of VCAT is that it looks beyond simple numerical data, such as how many people access an ER in a day.

“With this tool, we can also look at health outcomes. The numbers of visits to an ER doesn’t tell you much about how those people do afterwards. VCAT allows us to use individual-level information to guide best practice for specific groups.” 

VCAT can also generate a list of checkpoints that clinicians and other providers can use for better follow-up and after care. For example, a patient cannot be released before the next step on a best practice checklist is in place – whether that be the scheduling of the next appointment or a referral to another program.

Joe says VCAT goes to the heart of the problem of inefficiencies and care gaps by tracking all the stops along a patient’s journey through the health system. “It’s not prudent to try to reduce ER costs and wait-times by only looking at numbers. That’s a service-centred model. This client-centred software allows us to see if individuals who frequent the ER are connected to other services. If they’re not, that could be why they use the ER so much. Knowing that, we can step in and redirect them to more appropriate services.”

Sincraian adds, “We need to get a better picture of where someone goes after their ER visit, and we need to reinforce better connections between all the possible service sites. Right now, ER providers only focus on their specific service.”

Joe and Sincraian say the VCAT will bolster the integration efforts already underway, as well as allow for better coordination with emergency services.

"The tool pulls all the data into one place, for one client, regardless of which service they use. It makes it easier to provide the right services to each client," says Joe.

For now, VCAT only reflects a client’s journey through the system, providing a record to be reviewed by researchers and care providers to discover where gaps exist. In the future, Joe hopes to implement real-time management and intervention using VCAT, allowing providers to step in and help patients as soon as they begin to stray from their prescribed journey.