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CDM Registry Project
Dr. Richard LewanczukRegional Medical Director
Chronic Disease ManagementCapital Health
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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
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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
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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.
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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
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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
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Identification criteria
• HbA1c > 7.0• fbs >7.0• random glucose > 11.1
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What is it ?
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Registry - Aggregate Dashboard
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Dashboard Trend
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Dashboard Drilldown Patient List
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Dashboard Drilldown Flow
Dashboard
ViewerPatient List
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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
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Registry – Patient Viewer
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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
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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
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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.
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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
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Corollary Outcomes
• Reusable work for multiple chronic conditions
• Foundational elements help with other types of clinical system builds
• Improved support for family practice
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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
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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
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
0102030405060708090
100
%
higher lower
target
BP
LDL
Source: Capital Health Regional Diabetes Program
>130
>2.0>2.5
>140
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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
Source: Capital Health Regional Diabetes Program
Performance
0
100
200
300
400
500
600
700
800
pre
vale
nce
%
CH criteria-with Dx-without DxCH missed:
Sensitivity 87%, PPV 90%
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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
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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