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BeyondDataCapturetoPracticeChange MargaretJDunbar1,LisaDeMolitor2,andRobinORead1
1DiabetesCareProgramofNovaScotia(DCPNS),Halifax,NS,Canada2ValleyRegionalHospital,DiabetesCentre,Kentville,NS,Canada
Acknowledgements:We would like to recognize and thank the Registry users from across Nova Scotia for their support, engagement and responsiveness to “all things Registry-related.”
DCPNS (www.diabetescareprogram.ns.ca) Once a DHW Provincial Program (1991), the DCPNS is now nested (since 2016) within the Nova Scotia Health Authority, Primary Health Care.
DCPNS mission: To improve, through leadership and partnerships, the health of Nova Scotians living with, affected by, or at risk of developing diabetes
“The DCPNS Registry has been essential in getting our Group Medical Visits up and running. The information has been useful in planning logistics and program
content”
We use the DCPNS Registry’s “Advanced Clinical Indicator
Report” to help inform our program planning and evaluation. It helps us target patient needs and make the
changes necessary to provide the best care for our patients.
Diabetes Canada 21st Professional Conference and Annual Meetings October 10-13, 2018 Halifax, Nova Scotia
Background:The DCPNS Registry (Clinical Information System):
• Age < 19 years, since 1992 • All referrals (all ages, all DM types) to Diabetes Centres
since 1994 • Used in all 38 Diabetes Centres (NSHA and IWK • Over 160 users
Total Registry Capture (to March 31, 2018): • 110,000 individual cases of diabetes/prediabetes • Adds ~ 3,500 new cases and ~45,000 visits per year
ClinicalInformationSystems(CIS)are considered key enablers in supporting optimal care delivery. Systems that embed practice guidelines, offer decision support, and mirror recommended practice approaches provide the basis for a quality culture in support of patient/family-centered care.
This poster profiles the real real-time application of a Provincial Diabetes Registry by front-line providers.
Sample reports show how data becomes valued information to: • Enhance communication, build relationships, and provide added
service to referring providers • Foster shared/focused care • Support program/practice change to improve outcomes
DiabetesCareProgramofNovaScotia
RegistryOverview:• Built and maintained by DCPNS Staff • CAISIS platform (open source) • Web based (user friendly access) • Centralized data base (share data on
common patients) • Interfaces with Registration and Lab
systems • Auditable (meets PHIA requirements)
RegistryFeatures:• Visit Type (VT) rules, e.g., type of
diabetes, type of visit, gender • Carry forward:
§ Effected by visit type; 37 data points • Provider/patient friendly-features
§ Dashboard, visualization of visit/patient information
§ Graphing capabilities § Alerts/reminders
• Locally-generated reports and mailing labels
ApplicationtoPractice:• Sent following a patient visit/
appointment
• Allows staff to succinctly convey pertinent details re: a patient’s progress and care plan
ApplicationtoPractice:• Sent in confidence (with an
explanatory letter) annually or as requested by the referring provider
• Provides a list of individual provider patients seen during a specified time period along with the most recently recorded clinical and assessment measures
• Used with referring providers to discuss shared care or case management, review practice approaches, and goals of care
Physician/NursePractitioner(NP)Report
Weight BMI Acceptable BMI Range (20 -25) Blood Pressure mmHg Blood Pressure Goal
90kg (198.41lb) 38.75 46.45 kg - 58.06 kg (102.40lb - 128.00lb)
155/90 145/85
Patient: STRAWBERRY DULSEfirst last
HCN : XXXX XXX XXX Gender : M DOB : 30/Nov/1972 HUN: XXXXXXX
DM Type / Present Treatment
Nutrition Plan Last Foot Assessment - Risk
T2 / OA General, Low Sodium, Low Fat (CFG)
21/03/2018 - Moderate - Done by: DC
Smoking Status Last Eye Exam Last Annual Flu Shot
Yes 3/2018 Patient Declined
Date of Visit Type of Visit Previous Visit
21/Mar/2018 Follow up 02/Jan/2018
Areas requiring reinforcement/action:
Glycemia Blood Pressure Lipids Kidney function Other WEIGHT GAIN
Comments: Lorem ipsum dolor sit amet, cum at probo eirmod, usu natum accusam explicari ut. Errem electram moderatius quo ei. Te mea ferri petentium dissentiunt, pro liber paulo aliquip te, ex cum modo dico laoreet. Pri saperet similique mediocritatem cu, admodum splendide vix at. Quo dicunt sanctus ad.Please call with any questions.Yours truly,
Lab values attached, if test conducted.
TO:
Please fold the paper here for a window envelope
Next Appointment (dd/mm/yyyy): 07/08/2018 Requisition given for routine blood work prior to appointment: Yes
PHYSICIAN NAME
PHYSICIAN/NURSE PRACTITIONER REPORTFROM: IA E ES CEN E NAME
Page 1 of 2 Report generated by The The Diabetes Care Program of Nova Scotia Registry System Print Date:28/Sep/2018
This report can be used in support of the "Chronic Disease Management Incentive Program"
°lipid targets may vary depending on risk factors.*Alerts have been applied to specific metabolic parameters as a way to increase awareness of diabetes specific issues.Individual interpretation is required.** As of June 27, 2016, Estimated Glomerular Filtration Rate (eGFR) is calculated by the CKD-EPI formula. Modification of Diet in Renal Disease (MDRD) formula is reflected on earlier dates. eGFR should not be used when creatinine is changing rapidly, in pregnancy, age less than 18, or for drug dosing, and should be interpreted with caution in extremes of body habitus (both high and low BMI), amputation, or in the elderly.*Multiply by 1.159 if African Canadian.**Measurement for eGFR-CKD-EPI/eGFR-MDRD = mL/min/1.73m²
TEST COMPLETED 20/Mar/2018 02/Jan/2018 11/Dec/2017 23/Nov/2017
LAB DATA Target Results Alert* Results Alert* Results Alert* Results Alert*Fasting Capillary 6.0 mmol/L Fasting Venous 4-7 5.4 mmol/L 12.5 mmol/L YES
Fasting meter lab Comp
<20 11.11 %
2 Hour Capillary
2 Hour Venous 5-10 2 Hour meter lab Comp
<20
Other Capillary
Other Venous 14.3 mmol/L 21.8 mmol/LOther meter lab Comp <20 TC° 5.87 mmol/L 5.89 mmol/L
HDL° 0.98 mmol/L TNPNon-HDL TC:HDL ratio° <4.0 5.99 YES
LDL° <=2.0 TNP mmol/L TNP mmol/LTriglyceride° <1.5 5.73 mmol/L YES 15.98 mmol/L YESHbA1C <7 6.0 % 9.0 % YES 11.0 % YES
Creatinine Serum 80 µmol/L 67 µmol/L eGFR-CKD-EPI** >= 90 >= 90 eGFR-MDRD**
TSH Protein Urine Negative g/LAlbumin Urine
U ACR < 2.8 TNP mg/mmol/L
21/Mar/2018 DM Treatment Medication Dose Frequency
APO-GLICLAZIDE MR 30MG TAB 60 mg o.d.
RE: STRAWBERRY DULSE DOB : 30/Nov/1972 HUN: CB00140605
Page 2 of 2 Report generated by The The Diabetes Care Program of Nova Scotia Registry System Print Date:28/Sep/2018
This report can be used in support of the "Chronic Disease Management Incentive Program"
Physician/NPPatientList
PATIENT LIST
PATIENT INFORMATION VISIT INFORMATION
Last Name, First Name DOB Age LastVisit
Type Treat BMI Blood Pressure
A1C TC HDL TC:HDL LDL TRIG UACR
Foot Exam Eye Exam
FluShot
Disch.Date
D/M/Y D/M/Y Target <130/80
Optimal < 7%
DateD/M/Y
Value M/Y M/Y D/M/Y
05/10/1957 60 18/05/2017 T2 OA 8.6* 3.48* 1.06* 3.28* 1.67* 1.65* 0.67* 2/2016 11/2012
22/03/1952 66 04/01/2017 T2 IN 8/2016
30/04/1948 70 28/06/2017 T2 INO 34.4 130/70 6.3* 3.20* 1.35* 2.37* 1.29* 1.24* 0.73* 28/06/2017 2 1/2016 11/2016
17/03/1940 78 08/06/2017 T2 OA 140/70 6.9* 4.72* 1.67* 2.83* 2.56* 1.09* TNP* 08/06/2017 2 10/2015 10/2016
22/07/1946 72 13/03/2017 T2 L 28.35 126/70 6.6* 3.43* 1.25* 2.74* 1.27* 2.02* 13/03/2017 2 10/2015 11/2014
25/04/1945 73 13/03/2017 T2 L 28.7 114/62 6.7* 3.86* 1.04* 3.71* 1.93* 1.97* 8.20* 13/03/2017 2 2/2017 11/2016
11/09/1950 68 12/04/2017 T2 IN 140/70 9.0* 6.58* 8.65* 12/04/2017 2 1/2016 11/2017
05/07/1955 63 09/05/2017 T2 INO 26.17 104/60 6.8* 3.44* 1.09* 3.16* 2.02* 0.74* 1.12* 09/05/2017 2 2/2017 11/2016
16/12/1943 74 28/02/2017 T2 OA 24.34 125/70 6.6* 3.07* 1.22* 2.52* 1.37* 1.07* 4.11* 28/02/2017 2 1/2016 11/2016
01/08/1964 54 25/05/2017 T1 IN 21.42 120/70 8.4* 5.00* 1.82* 2.75* 2.56* 1.37* 3.88* 5/2016 11/2016
30/09/1951 66 26/04/2017 T2 L 30.06 122/60 7.2* 2.56* 1.00* 2.56* 0.92* 1.42* 0.82* 26/04/2017 2 8/2016 11/2016
11/08/1963 55 03/04/2017 IGT L 40.07 148/78 11/2016
03/11/1954 63 08/03/2017 T2 L 45.64 130/70 6.0* 4.72* 1.85* 2.55* 2.17* 1.55* 1.09* 08/03/2017 2 10/2015 Declined
21/11/1959 58 03/01/2017 T2 L 31.71 120/80 03/01/2017 2 3/2015 Declined
Total Patients in Reporting Period:14 Averages: 31.09 127/69 7.19 4.01 1.34 2.85 1.78 2.07
Page 1 of 1 Report generated by The Diabetes Care Program of Nova Scotia Registry System 27 September, 2018
DIABETES TYPE
TREATMENTL - LifestyleOA - Oral Antihyperlycemic Agent + LifestyleIN - Insulin + LifestyleIJ - Injectable + LifestyleINO - Insulin + OAA + LifestyleOAIJ - OAA + Injectable + LifestyleIJIN - Injectable + Insulin + LifestyleOAIJIN - OAA + Injectable + Insulin
FOOT EXAM1 - High 2 - Moderate3 - Low 5 - Seen at Foot Clinic6 - Reported as completed by Family Physician/ Nurse Practioner/Family Practice Nurse7 - Patient Declined
This report can be used in support of the "Chronic Disease Management Incentive Program"
* completed within 6 months of last visit ƒ completed ≥ 12 months from last visit.
T1 - Type 1T2 - Type 2IGT - Impaired Glucose ToleranceIFG - Impaired Fasting GlucoseIFIG - IFG & IGTO - Other
PT1 - Pregnant Type 1PT2 - Pregnant Type 2GDM - Gestational
DIABETES CENTRE
PHYSICIAN / NURSE PRACTITIONER - PATIENT LIST (CLINICAL INDICATORS)DIABETES CENTRE NAME
Report period from: 01 Jan 2017 to: 30 Jun 2017Physican / Nurse Practitioner
NAME AND ADRESS
Privacy & ConfidentialityPersonal health information (PHI) in this report is confidential. Access, use, and disclosure must be in compliance with the NS Personal Health Information Act. PHI contained within this report cannot be used for research without prior approval from the DCPNS and the appropriate Research Ethics Board.This report is produced in confidence. This report includes information on patients under the care of this provider who attended the Diabetes Centre during the time specified (see Report period dates). • Diabetes type, treatment, and age are associated with the Last Visit (most recent) to the DC. • The lab values as displayed are the most recent (current) within this period of time. • Specific dates (as recorded on the most recent visit) are provided for foot, eye, flu shot, and discharge, if applicable.
Province HCN Patient Name (Last, first)
DOB Age (Yrs)
Sex DM Type
Visit Type
Family Physician
Blood PressureValue | D/M/Y
A1CValue | D/M/Y
eGFR-CKD-EPI
Value | D/M/Y
NS20776 ASPARAGUS, ELDERBERRY 25/Oct/1939 78 M T2 FUV GODDARD,
PETER 145/82 25/04/2017 9.6 06/03/2017 50 06/03/2017
NS51303 DULSE, HONEYDEW 17/Jan/1926 91 F T2 FUV MCMILLAN,
MERLE K 201/82 11/12/2017 8.9 04/12/2017 33 19/12/2017
NS96082 FIDDLEHEAD, GRAPE 03/May/1936 81 M T2 FUV NUNN, DAVID J 135/85 04/12/2017 8.8 17/11/2017 44 17/11/2017
NS23825 KALE, GRAPE 18/Apr/1950 67 M T2 FUV GRANDY, ELWOOD C 133/85 21/11/2017 10.4 17/11/2017 34 17/11/2017
NS66588 LETTUCE, JUJUBE 15/Apr/1951 66 F T2 FUV PENNELL,
MARK L 142/87 28/03/2017 11 19/09/2017 60 19/09/2017
NS25264 MUSHROOM, LEMON 11/Mar/1956 61 F T2 FUV NUNN, DAVID J 133/82 01/12/2017 10.7 19/10/2017 47 19/10/2017
NS65568 MUSHROOM, RASPBERRY 26/Dec/1969 48 M T2 FUV MACNAUGHTO
N, JANET E 159/90 16/06/2017 8.8 16/11/2017 47 16/11/2017
NS73050 MUSHROOM, STRAWBERRY 13/Oct/1951 66 F T2 FUV HARVEY,
JACINTA M 136/82 06/09/2017 8.2 30/10/2017 41 30/10/2017
NS15724 OKRA, BANANA 07/Jul/1942 75 F T2 FUV MACINNIS, BRIAN L 154/85 20/09/2017 8.5 24/03/2017 59 24/03/2017
NS24396 SQUASH, WATERMELON 29/Dec/1948 69 M T2 FUV KING, YVONNE 162/83 11/08/2017 11.5 04/08/2017 46 04/08/2017
Page 1 of 1 Print Date: 04/10/2018Report generated by The Diabetes Care Program of Nova Scotia Registry System
Time PeriodPatient Characteristics: Age (at end of period) Sex: DM Type:Visit Type:Indicators:
ADVANCED CLINICAL INDICATOR REPORT
Statsa) Total number of individuals seen in the specified time period: 1542b) Of the individuals in (a), the total number who had the specified patient characteristics (age, sex, DM type) and Visit Type: 1277c) Of the individuals in (b), the total number who had at least one value for each of the selected indicator(s): 715d) Of the individuals in (c), the total number whose last recorded value for each of the selected indicator(s) was in the specified range: 10
(*refer to User Guide for full reference)
VALLEY REGIONAL HOSPITAL
01/January/2017 to 31/December/2017
GREATER THAN OR EQUAL TO 19 YEARSAll T1|T2 FUV(BP Systolic > 130 AND BP Diastolic > 80) AND A1C > 8 AND eGFR-CKD-EPI [] 30-60
Privacy & ConfidentialityPersonal health information (PHI) in this report is confidential. Access, use, and disclosure must be in compliance with the NS Personal Health Information Act. PHI contained within this report cannot be used for research without prior approval from the DCPNS and the appropriate Research Ethics Board.
DCPNSREGISITRYSAMPLEREPORTS
ApplicationtoPractice:• Run as required for internal program
use (within the circle of care)
• Assists with quality improvement and helps to understand the local patient population
• Users select a specific period of time (up to the current date); define the population to be reviewed by visit type, age or age range, sex, and diabetes type; and then select up to 4 key indicators with specific values or range of values (e.g., eGFR, 30-60mL/min; A1C, <7%; BP, >140/90; etc.)
• Generates a list of cases that meet both the selected population characteristics and all the required indicators.
DiabetesCareProgramofNovaScotia(DCPNS)DiabetesRegistry
AdvancedClinicalIndicatorReport
1.SELECTYOURDATERANGE
2.SELECTVISITTYPE
3.SELECTAGE,SEX,ANDDIABETESTYPE
4.SELECTCLINICALINDICATOR(S)–UPTO4