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.

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