1
Please take a copy of the instructions below to complete our brief on-line survey. We value and appreciate your feedback. Beyond Data Capture to Practice Change Margaret J Dunbar 1 , Lisa DeMolitor 2 , and Robin O Read 1 1 Diabetes Care Program of Nova Scotia (DCPNS), Halifax, NS, Canada 2 Valley Regional Hospital, Diabetes Centre, 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 21 st 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 Clinical Information Systems (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 Diabetes Care Program of Nova Scotia Registry Overview: • 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) Registry Features: • 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 Application to Practice: • Sent following a patient visit/ appointment • Allows staff to succinctly convey pertinent details re: a patient’s progress and care plan Application to Practice: • 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/Nurse Practitioner (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 DULSE first 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 $''5(66 PHYSICIAN/NURSE PRACTITIONER REPORT FROM: 'IA%E7ES CEN75E 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/L Other meter lab Comp <20 TC° 5.87 mmol/L 5.89 mmol/L HDL° 0.98 mmol/L TNP Non-HDL TC:HDL ratio° <4.0 5.99 YES LDL° <=2.0 TNP mmol/L TNP mmol/L Triglyceride° <1.5 5.73 mmol/L YES 15.98 mmol/L YES HbA1C <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/L Albumin 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/NP Patient List PATIENT LIST PATIENT INFORMATION VISIT INFORMATION Last Name, First Name DOB Age Last Visit Type Treat BMI Blood Pressure A1C TC HDL TC:HDL LDL TRIG U ACR Foot Exam Eye Exam Flu Shot Disch. Date D/M/Y D/M/Y Target <130/80 Optimal < 7% Date D/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 TREATMENT L - Lifestyle OA - Oral Antihyperlycemic Agent + Lifestyle IN - Insulin + Lifestyle IJ - Injectable + Lifestyle INO - Insulin + OAA + Lifestyle OAIJ - OAA + Injectable + Lifestyle IJIN - Injectable + Insulin + Lifestyle OAIJIN - OAA + Injectable + Insulin FOOT EXAM 1 - High 2 - Moderate 3 - Low 5 - Seen at Foot Clinic 6 - Reported as completed by Family Physician/ Nurse Practioner/Family Practice Nurse 7 - 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 1 T2 - Type 2 IGT - Impaired Glucose Tolerance IFG - Impaired Fasting Glucose IFIG - IFG & IGT O - Other PT1 - Pregnant Type 1 PT2 - Pregnant Type 2 GDM - Gestational DIABETES CENTRE PHYSICIAN / NURSE PRACTITIONER - PATIENT LIST (CLINICAL INDICATORS) DIABETES CENTRE NAME Report period from: 01 Jan 2017 to: 30 Jun 2017 Physican / Nurse Practitioner NAME AND ADRESS Privacy & Confidentiality Personal 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 Pressure Value | D/M/Y A1C Value | 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: 04/10/2018 Report generated by The Diabetes Care Program of Nova Scotia Registry System Time Period Patient Characteristics: Age (at end of period) Sex: DM Type: Visit Type: Indicators: ADVANCED CLINICAL INDICATOR REPORT Stats a) Total number of individuals seen in the specified time period: 1542 b) Of the individuals in (a), the total number who had the specified patient characteristics (age, sex, DM type) and Visit Type: 1277 c) Of the individuals in (b), the total number who had at least one value for each of the selected indicator(s): 715 d) 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 YEARS All T1|T2 FUV (BP Systolic > 130 AND BP Diastolic > 80) AND A1C > 8 AND eGFR-CKD-EPI [] 30-60 Privacy & Confidentiality Personal 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. DCPNS REGISITRY SAMPLE REPORTS Application to Practice: • 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. Diabetes Care Program of Nova Scotia (DCPNS) Diabetes Registry Advanced Clinical Indicator Report 1. SELECT YOUR DATE RANGE 2. SELECT VISIT TYPE 3. SELECT AGE, SEX, AND DIABETES TYPE 4. SELECT CLINICAL INDICATOR (S) – UP TO 4
