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 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

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.

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

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 Viewer Patient 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

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

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

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

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

We need to know who the patients are (Registry)

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

Performance Sensitivity 87%, PPV 90%

Administrative vs Registry Data

Diabetes Prevalence Community Map