Webinar – Using EMRs for Chronic Disease Management

March 3, 2011

Funding to support this Webinar has been provided by Hewlett-Packard

Dr. Michelle Greiver

• Practice description:– Community-based family practice in Toronto– 1,300 patients– Part of interdisciplinary team (North York Family

Health Team)– 3 physicians, 1 nurse practitioner in the office– 60 physicians are members of the NYFHT

• EMR used:– Nightingale EMR, since 2006

Practice Profile

• Practice description (1092 adult patients)– 77% female– Taking part in a Quality collaborative since 2009– Part of national primary care EMR chronic

disease surveillance system (CPCSSN)

• Chronic Disease prevalence (adults)– 80 patients with diabetes (7%)– 89 COPD (8%)– 207 hypertension (19%)– 16 CHF (1%)– 27 confirmed asthma (2%)

Benefits of EMR for CDM

You cannot improve what you cannot measure• We decided to code important chronic conditions

so that we could build disease registries• We enter data consistently in the EMR so it can

be measured• We invested time and resources in

measurement and audits• All team members use the EMR• We have CDM flowsheets and templates, with

associated alerts and reminders • We use the EMR to audit and mail reminders to

patients who are overdue (diabetic, no eye exam for 2 years)

Screenshot

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Screenshot

CDM reminders for any chronic conditions this patient has: “HM button”

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Screenshot

Take Home Points

• Decide and agree: which chronic conditions you would like to focus on?

• Involve everyone in your practice• Enter your data carefully and consistently• Use the features that your EMR offers• Try small steps to improve care• Measure what you did and see if it worked,

then keep going• Use what you learned in one chronic

condition to improve other conditions

Dr. Nora Curran-Blaney

• 3 Physician Family Practice – Oakville, ON– 2 physicians work concurrently – flexible

schedule

• 30 years practice experience• EMR used: Healthscreen• Remote access version• Experience using tablet computers

Practice Profile

• 1348 rostered patients• 519 over 50 yrs• Chronic Disease prevalence

– Hypertension – (400 pts.)– Obesity – BMI over 33 (100 pts.)– Diabetes Mellitus – (30-40 pts.)– Heart failure – (10 pts.)

Benefits of EMR for CDM

• Ability to develop clinical queries• Active use of a patient profile

– Hand printed copy of profile to patient

• Used of coded data display– Requires discipline of data entry for future use

• Colour coding• eFax directly from EMR• Simplification of referrals• Cancer surveillance

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Take Home Points

• EMR usability is critical• Encourage patient self management

– Not yet using a patient portal

• Record information during the encounter• Patient feedback

– Most feel management is improved with EMR– Less chance for error or that information has

been forgotten– Worry about privacy and power outages

Michael Brand, Clinic ManagerAssociate Medical Centre, Taber, Ab.

• 12 Physician Family Medicine Clinic• Member of Chinook Primary Care Network• Using Wolf EMR since 2007

Practice Profile

• Approx. 18,000 patients in catchment area• Team based Care• Physician is team lead with mix of NP, RNs,

LPNs, Psychiatric RN, Psychologist, Dietician, Health Coach & MOAs

• Large Senior & “ESL” Populations• 19 bed Acute Care Hospital• 100 bed LTC Facility

Benefits of EMR for CDM

• All CDM Monitoring is managed through use of “Rules” within EMR

• Rules define a population and provide alert at Point of Care

• All Clinic Staff are tasked with dealing with relevant rules when in contact with a patient

• CDM Run charts are used to track performance over time

• Results are posted for all to see

Take Home Points

• Rules are constantly changing and evolving based on population and updates to CDM guidelines

• Patients appreciate the comprehensive level of care & develop trust in the team.

• Staff feel strong sense of accomplishment when they see positive results.

• Overall system costs decrease (ER Visits & Admissions) through comprehensive clinic based Chronic Disease Management

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Questions & Discussion

Webinar – Using EMRs for Chronic Disease Management

March 3, 2011

Funding to support this Webinar has been provided by Hewlett-Packard