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CDM Registry Project

CDM Registry Project. Dr. Richard Lewanczuk Regional Medical Director Chronic Disease Management Capital Health. CDM Registry Project- Purposes. Create population-based registry and dashboard to monitor and improve care Deploy the registry in AB Netcare Portal environment

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CDM Registry Project

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  1. CDM Registry Project Dr. Richard Lewanczuk Regional Medical Director Chronic Disease Management Capital Health

  2. 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

  3. 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

  4. The Value Proposition 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.

  5. The Value Proposition 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

  6. 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

  7. Identification criteria • HbA1c > 7.0 • fbs >7.0 • random glucose > 11.1

  8. What is it ?

  9. Registry - Aggregate Dashboard

  10. Dashboard Trend

  11. Dashboard Drilldown Patient List

  12. Dashboard Drilldown Flow Dashboard Patient List Viewer

  13. 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

  14. Registry – Patient Viewer

  15. 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

  16. 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

  17. 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.

  18. 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

  19. Corollary Outcomes • Reusable work for multiple chronic conditions • Foundational elements help with other types of clinical system builds • Improved support for family practice

  20. 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

  21. Fun with data

  22. % of Capital Health diabetic patients at HbA1c targets

  23. BP Control in Regional Diabetes Program <90 <140 <80 <130 Source: Capital Health Regional Diabetes Program

  24. LDL and HbA1c Control in Regional Diabetes Program <8.4 <2.5 <7.0 <2.0 Source: Capital Health Regional Diabetes Program

  25. proportion of hypertensive and dyslipidemics on pharmacotherapy in Regional Diabetes Program >140 >130 >2.5 >2.0 Source: Capital Health Regional Diabetes Program

  26. How do family doctors compare to specialists in diabetes management in CH ? Patients initially uncontrolled (HbA1c >8.4%) After 6 months:

  27. We need to know who the patients are(Registry)

  28. Age/Sex Standardized Prevalence by Source Source: Capital Health Regional Diabetes Program

  29. Performance Sensitivity 87%, PPV 90%

  30. Administrative vs Registry Data

  31. Diabetes Prevalence Community Map

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