Transcript Capital Health DM Registry_Lewanczuk

CDM Registry Project
Dr. Richard Lewanczuk
Regional Medical Director
Chronic Disease Management
Capital Health
www.capitalhealth.ca
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
Patient List
Viewer
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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
•
Co-morbidities / Complication
•
Markers of Disease Progression
•
Screening for Further Complications
•
Health Status and Management Against Goals
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-Medications
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
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% of Capital Health diabetic patients at
HbA1c targets
70
all
community
RDP
60
50
40
% 30
20
10
0
6-7
7-8
8-9
9-10
10-11
11-12
>12
BP Control in Regional Diabetes
Program
100
% at target
80
<90
<140
60
<80
<130
40
20
0
DBP
Source: Capital Health Regional Diabetes Program
SBP
LDL and HbA1c Control in Regional
Diabetes Program
70
% at target
60
<8.4
50
40
<2.5
30
<7.0
20
10
<2.0
0
LDL
Source: Capital Health Regional Diabetes Program
HbA1c
proportion of hypertensive and dyslipidemics on
pharmacotherapy in Regional Diabetes Program
100
90
80
70
60
% 50
40
30
20
10
0
>140
BP
LDL
>130
>2.5
>2.0
higher
lower
target
Source: Capital Health Regional Diabetes Program
How do family doctors compare to
specialists in diabetes management in CH ?
Patients initially uncontrolled (HbA1c >8.4%)
After 6 months:
40
PCNs
35
specialists
30
25
% 20
15
10
5
0
controlled
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sub-optimal
uncontrolled
We need to know who the patients are
(Registry)
Population incidence
Population prevalence
8000
7000
6000
80000
70000
60000
50000
40000
30000
20000
10000
0
admin data
local data
5000
4000
3000
2000
1000
0
prevalence %
Age/Sex Standardized Prevalence by
Source
9
8
7
6
5
4
3
2
1
0
all
male
CCHS 05/06
Source: Capital Health Regional Diabetes Program
ADSS 06
female
CH
Performance
prevalence %
800
700
600
500
400
300
200
100
0
Sensitivity 87%, PPV 90%
CH criteria
-with Dx
-without Dx
CH missed:
0
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LREP Female
LREP Male
ADSS Female
ADSS Male
85+ yrs.
80-84 yrs.
75-79 yrs.
70-74 yrs.
65-69 yrs.
60-64 yrs.
55-59 yrs.
50-54 yrs.
45-49 yrs.
40-44 yrs.
35-39 yrs.
30-34 yrs.
25-29 yrs.
20-24 yrs.
15-19 yrs.
10-14 yrs.
5-9 yrs.
1-4 yrs.
% Criteria Met
Administrative vs Registry Data
40
35
30
25
20
15
10
5
Diabetes Prevalence Community Map
14
2007 Unique Patients Diabetes
per 100 Sept 2007 CH A/G Adj Pop
9 or Greater
8 to < 9
7 to < 8
6 to < 7
(4)
(5)
(4)
(2)
15
06
01
02
03
05
04
11
07
08
13
09
10
12
0
15
30
kilometers
Projection, Nevada 2701, Easter Zone (1983 metres)
Capital Health Finance: Funding & Methodologies: af/xdx_WtdPop_Diabetes.wor
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Jan 22, 2008