1. Canada Primary Care Sentinel Surveillance Network Working toward an Ottawa Regional Network

2. Data
De-identified data is extracted from practice EMRs and collected at the regional networks.
Monitors 8 chronic diseases:
Data collected:
Basic demographics
Co-morbid conditions
Medications
Lab results
Risk Factors
Referrals and procedures
COPD
Depression
Diabetes
Hypertension
Osteoarthritis
Epilepsy
Dementia
Parkinson’s

3. Process Data Extraction
Map free EMR text to standardized terms (SNOMED CT)
Standardized coding across vendor
Secure process to re-identify patients within circle of care for tracking/follow-up

4. Adoption 10 PBRNs across Canada British Columbia Alberta Manitoba
- BCPCReN, Vancouver - Wolf, OSCAR (1)
Alberta
- SAPCReN, Calgary - Med Access, Wolf
- NAPCReN, Edmonton - Med Access, Wolf
Manitoba
- MaPCReN, Winnipeg - JonokeMed
Ontario
- DELPHI, London - Optimed-Accuro, OSCAR
- UTOPIAN, Toronto - Nightingale,
Practice Solutions, Bell EMR
- EON, Kingston - P&P (4), OSCAR, Bell EMR,
Practice Solutions (1), Nightingale (1)
Québec
- RRSPUM, Montréal - Da Vinci, Purkinje (2)
Nova Scotia/New Brunswick
- MaRNet, Halifax - Nightingale, Purkinje (3)
Newfoundland
- APBRN, St. John's - Wolf, Nightingale
(1) = recruited but not yet operational
(2) = nearly operational
(3) = available
(4) = supported as legacy
10 PBRNs across Canada

5. Opportunities Quality Improvement Research
Regional PC performance monitoring
Practice level monitoring
Practice level queries for specific QI initiatives
Research
Epidemiological research
Informs research direction
Can substitute for manual chart extraction
Is being linked to ICES
Standardized Quality Dashboard for front line providers
Improved data quality at the practice level
Secure process to re-identify patients within circle of care for tracking/follow-up
Scalable processes to enable use of data for QI projects

7. State very clearly that these are physician reports for the pcp to get

8. Customized reports through DPT
Data Presentation Tool (DPT)
Customized reports through DPT
Standardized Quality Dashboard for front line providers - interactive software
Programmed (cleaned, coded) by CPCSSN
Accessible to Primary Care Practices
Standardized CPCSSN data to provide customized reports/information on:
Medications
Co-morbidities
Care provision
Other queries

9. Data Presentation Tool (Data Overview)

10. Data Presentation Tool (Search Screen)

11. Feedback Reports (Sample)

12. Data Presentation Tool (Data trending)

13. CHAP-EMR: A pilot study
S Dahrouge, D Rolfe, L Muldoon, J Kaczorowski, L Dolovich, L Chambers, R Birtwhistle, C Liddy, MH Chomienne, M Greiver, D Barber, J Kotecha
Thank you for the invitation to present our results from the CHAP study that we proposed at the last CCPN meeting in 2014.

14. Collaboration with CPCSSN for Research
CHAP-EMR project assessed the feasibility of:
Partnering with the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) to:
Extract relevant EMR data for participant selection (patients ≥65 yrs)
Generate CVD and diabetes risk scores for CHAP participants using CHAP and EMR data (without the large costs)
Assess the reach of the CHAP by comparing participants and non- participants using EMR data
We decided to pilot the CHAP in our region to assess whether the program would be feasible and acceptable in urban primary care practices with a diverse patient population.
We also wanted to trial a partnership with the Canadian Primary Care Sentinel Surveillance Network (or CPCSSN) to extract and utilize electronic medical record (or EMR) data to select eligible participants and to enable detailed data analyses about participants.

15. Generate CVD and diabetes risk scores for CHAP participants using CHAP and EMR data
Male Participants
Female Participants
High risk
High risk
3. By combining data collected at CHAP sessions with relevant EMR data, it is feasible to generate global cardiovascular and diabetes risk scores to identify individuals at risk of CVD and diabetes.
NOTES:
In cases where lipid values were not available in the EMR, we used BMI as a proxy. During our analysis we found that there were more cases of females than males with missing lipids in EMR (25% females missing lipids; 10.7% males).
Significant impact of age, sex on CVD risk scores
Acknowledge FRS overestimation of CVD risk, particularly among males
Framingham (CVD risk)

16. CANRISK (diabetes risk)
Generate CVD and diabetes risk scores for CHAP participants using CHAP and EMR data
Without Diabetes
With Diabetes
High risk
High risk
This information may help guide follow-up care from primary care providers.
NOTES: Some diabetics are doing well in terms of self-management
CANRISK (diabetes risk)

17. Non Participant Participant
Assess the reach of the CHAP by comparing participants and non-participants using EMR data
Profile
Non Participant
Participant
Female
59%
Diabetes dx
23%
13%
Hypertension dx
40%
34%
COPD 9% 4%
Depression
21%
17%
Discussed diet
35%
39%
Discussed alcohol
27%
Discussed psychosocial 1% 0%
Discussed obesity
10%
Identified as smoker
79%
73%
Despite the fact that we offered CHAP sessions during the winter, we achieved a participation rate of 21% which is comparable to the large scale CHAP trial.
Using data available from CPCSSN, we were able to compare CHAP participants to non-participants to assess the reach of the CHAP.
Although CHAP participants were slightly healthier than non-participants, we feel that we were able to reach a substantial portion of the population that could benefit from heart health promotion programs and resources.
NOTES:
Typo? 79% vs. 73% of non-participants and participants were identified as “non” smokers

18. For more information

19. CPCSSN Funders & Stakeholders
HSU Demonstration Project – Strategic Investor:
Funding for this publication was provided by the Public Health Agency of Canada The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada.
Cette publication a été réalisée grâce au financement de l'Agence de la santé publique du Canada. Les opinions exprimées ici ne reflètent pas nécessairement celles de l'Agence de la santé publique du Canada.