Www.capitalhealth.ca CDM Registry Project Dr. Richard Lewanczuk Regional Medical Director Chronic Disease Management Capital Health.

www.capitalhealth.ca

CDM Registry Project

Dr. Richard LewanczukRegional Medical Director

Chronic Disease ManagementCapital Health


CDM Registry Project- Purposes

• Create population-based registry and dashboard to monitor and improve care

• Deploy the registry in AB Netcare Portal environment

• Facilitate linkage to primary care physicians and enrolment into regional programs

• Enable care coordination between primary care and specialty services within and across regions

• Provide decision support tools


The Value Proposition

For RHAs and AHW

• Assist clinicians in delivery of Chronic Disease patient care.

• Data populated and used by Primary Care clinicians.

• System-wide dashboard to monitor performance of delivery

models.

• Metrics to support appropriate allocation of funding and

resources.

• Clinical data linked to system-wide financial data for

economic analysis



For Patients

• Enhanced health outcomes and quality of life through early and accurate delivery of appropriate medical services.

• Timely access to appropriate medical services and facilities.



For Primary Care

• A single comprehensive Chronic Disease patient registry integrated with clinic registry and system processes.

• Automated tools to improve health outcomes for managed vs. unmanaged patients

• Improved linkage between regional services and primary care

• Improved efficiency


How did we get here?

• Each region had

• Business processes to identify patients, supported by IT

• Established programs and services to support CDM patients

• Executive support to create a shared patient profile viewer and dashboard system

• Established a clinical advisory group (primary care and regional service providers) who

• Identified critical data elements

• Validated business processes, reporting requirements

• Participated in User Acceptance Testing


Identification criteria

• HbA1c > 7.0• fbs >7.0• random glucose > 11.1


What is it ?


Registry - Aggregate Dashboard


Dashboard Trend


Dashboard Drilldown Patient List


Dashboard Drilldown Flow

Dashboard

ViewerPatient List


Patient Profile Viewer

• Primarily used by providers without access to registry

• Contains a summary of clinical information including

• Care Co-ordination -Medications

• Co-morbidities / Complication

• Markers of Disease Progression

• Screening for Further Complications

• Health Status and Management Against Goals


Registry – Patient Viewer


How did we support primary care clinicians to identify patients?

Capital Health:

• Used existing platform to facilitate identification, management and early intervention

• Extracted aggregate lists of patients from the Lab Repository

• Validated patient lists and diagnoses against physician clinic records

• Registered patients

• Provided standard reports

• Provided on-going support and training


What are expected outcomes ?

Care Impacts

• Improved understanding of patient populations

• More focused intervention on the highest risk group

• Improved identification of “at risk” group

• Ability to identify patients whose health status has changed


Outcomes expected (cont’d)

System Impacts

• Improved ability to identify unattached patients

• Better understanding of supports that are needed both technology and service related

• Improved communication between providers

• Data captured in a common method to enable economic analysis.


Outcomes realized to date

• Common data definitions, messaging standards, and dashboard indicators identified

• Set up for system to system communication

• Clinicians are on board with a vision


Corollary Outcomes

• Reusable work for multiple chronic conditions

• Foundational elements help with other types of clinical system builds

• Improved support for family practice


Where do we go from here?

• Expand the deployment to additional primary care physicians

• Expand the deployment across additional disease conditions

• Integrate the registry with existing EMRs

• Expand deployment across the province


Fun with data

% of Capital Health diabetic patients at HbA1c targets

0

10

20

30

40

50

60

70

%

6-7 7-8 8-9 9-10 10-11 11-12 >12

allcommunityRDP

BP Control in Regional Diabetes Program

0

20

40

60

80

100

% a

t ta

rget

DBP SBP

Source: Capital Health Regional Diabetes Program

<140

<130<80

<90

LDL and HbA1c Control in Regional Diabetes Program

0

10

20

30

40

50

60

70

% a

t ta

rget

LDL HbA1c


<7.0

<8.4

<2.5

<2.0

proportion of hypertensive and dyslipidemics on pharmacotherapy in Regional Diabetes Program

0102030405060708090

100

%

higher lower

target

BP

LDL


>130

>2.0>2.5

>140


How do family doctors compare to specialists in diabetes management in CH ?

0

5

10

15

20

25

30

35

40

%

controlled sub-optimal uncontrolled

PCNs

specialists

Patients initially uncontrolled (HbA1c >8.4%)After 6 months:

We need to know who the patients are(Registry)

0

10000

20000

30000

40000

50000

60000

70000

80000

Population prevalence

admin datalocal data

0

1000

2000

3000

4000

5000

6000

7000

8000

Population incidence

Age/Sex Standardized Prevalence by Source

0123456789

pre

vale

nce %

all male female

CCHS 05/06 ADSS 06 CH


Performance

0

100

200

300

400

500

600

700

800

pre

vale

nce

%

CH criteria-with Dx-without DxCH missed:

Sensitivity 87%, PPV 90%


0

5

10

15

20

25

30

35

401-

4 yr

s.

5-9

yrs.

10-1

4 yr

s.

15-1

9 yr

s.

20-2

4 yr

s.

25-2

9 yr

s.

30-3

4 yr

s.

35-3

9 yr

s.

40-4

4 yr

s.

45-4

9 yr

s.

50-5

4 yr

s.

55-5

9 yr

s.

60-6

4 yr

s.

65-6

9 yr

s.

70-7

4 yr

s.

75-7

9 yr

s.

80-8

4 yr

s.

85+

yrs

.

% C

rite

ria

Me

t

LREP Female LREP Male ADSS Female ADSS Male

Administrative vs Registry Data


0

kilometers

3015

11

12

13

15

1009

03

08

02

07

04

0106

05

142007 Unique Patients Diabetes

per 100 Sept 2007 CH A/G Adj Pop

9 or Greater (4)8 to < 9 (5)7 to < 8 (4)6 to < 7 (2)

Capital Health Finance: Funding & Methodologies: af/xdx_WtdPop_Diabetes.wor Jan 22, 2008

Projection, Nevada 2701, Easter Zone (1983 metres)

Diabetes Prevalence Community Map

Www.capitalhealth.ca CDM Registry Project Dr. Richard Lewanczuk Regional Medical Director Chronic Disease Management Capital Health.

Documents

registry slide

data slide

vision slide

province slide

training slide

registry patient viewer

dashboard trend slide

economic analysis slide