Let’s Talk Informatics More than a Registry: Making Life Easier…Improving Data Quality…Effecting Practice Change Peggy Dunbar & Robin Read June 28, 2018 Bethune Ballroom, Halifax, Nova Scotia

One Person One Record project. Please be advised that we are currently in a controlled vendor environment for the One Person One Record project. Please refrain from questions or discussion related to the

Informatics… utilizes health information and health care technology to enable patients to receive best treatment and best outcome possible.

Clinical Informatics… is the application of informatics and information technology to deliver health care. AMIA. (2017, January 13). Retrieved from https://www.amia.org/applications- infomatics/clinical-informatics

Objectives At the conclusion of this activity, participants will be able to… Identify what knowledge and skills health care providers will need to use information now and in the future. Prepare health care providers by introducing them to concepts and local experiences in Informatics. Acquire knowledge to remain current with new trends, terminology, studies, data and breaking news. Cooperate with a network of colleagues establishing connections and leaders that will provide assistance and advice for business issues, as well as for best-practice and knowledge sharing.

Objectives At the conclusion of this session, participants will be able to… Discuss how the Diabetes Care Program of Nova Scotia (DCPNS) Registry evolved to meet the needs of front-line staff Describe the rule-based approach to Registry design and its impact on data capture, data quality, and user acceptance Explain the reporting functionality that supports communication with referring providers, and the identification of patient groups for targeted interventions/initiatives Explain the current project aimed at “optimizing use” by care providers in 38 Diabetes Centres across the province (It will be E.P.I.I.C!)

Conflict of Interest Declaration We (Robin and Peggy) do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device, health care informatics organization, or other for-profit funder of this program. Speakers are to update the Conflict of Interest Declaration as it applied to them.

Starting with common language… Diabetes Care Program of Nova Scotia (1991) A former DHW Provincial Program now in the NSHA Mission: to improve the health of Nova Scotians living with, affected by, or at risk of developing diabetes. Activities: Act in an advisory capacity; recommend service delivery models Works across NSHA and the IWK Establish standards and guidelines Specialty populations; complications prevention/management; recommended processes & structures; Diabetes Surveillance and Monitoring: Surveillance cycle—collect, analyze, interpret, disseminate… to effect change Disease burden, provincial/zone trends Uptake of approved standards and system outcomes …build relationships, level the playing field, grow potential, celebrate/share innovation, balance urban and rural perspectives… https://authors.elsevier.com/a/1X7mT5KvDJyq6I

Starting with common language… (cont’d) Diabetes Centres (multi/inter-disciplinary teams) Are located province-wide (38+) Operated/funded by the NSHA and IWK Support Primary and Specialty Care Physicians Conduct individual assessments and provide individual/group education/supports Determine appropriate treatment plan, and assist with implementation Monitor for Diabetes complications development and progression Promote and support self-care

DIABETES CENTRES IN NOVA SCOTIA

Starting with common language… (cont’d) DCPNS Registry/Information Management System “an authoritative list of one kind of information” “organized system for collection, organization, storage, and communication of information…programmed to produce regular reports” more than 1 application (2014—added NSIPP) More than a Registry…Database(s) and Application(s)

DCPNS Registry (as a Database) < age 19 data since 1992 All referrals to Diabetes Centres since 1994 On-site application since 2002 (decentralized) Provincial and local reporting To March 31, 2017: ~ 107,000 individuals (all types DM & PreDM) Add ~ 3,500 new cases per year Over 45,000 visits per year 160+ users

For over 25 years, the DCPNS has focused its work on quality improvement “The enhancements to local level reporting are the direct result of engagement with our stakeholders (front line diabetes educators, specialist and generalist physicians, and program managers), learning from others, and wanting to actively build capacity and “value in data” in our Registry users.” The Program has actively supported the capacity to generate, interpret, and act on local data…

DCPNS Registry (Information Management System)

Registry Objectives: To… help determine the magnitude of Diabetes (DM) in NS improve the quality, consistency, & completeness of the data collected, enhance local capacity to collect, analyze, interpret, and use data to influence program practices, allow the collection of comparative data across Centres/zones (and hopefully, provinces) generate evidence in support of best/promising practice approaches, and reduce documentation efforts through the use of standard and custom reports.

DCPNS Registry Evolution 1992 1998 2001 2004 2006 2008 2013 2014 2016 FoxPro application Centralised entry at DCPNS 1992 dBase IOC component (stand alone) pilot sites (testing) 1998 DCPNS Registry (2 components together) Client installation P2P network use 2001 Windows 2003 Terminal Server 3 DCs use 1 installation of the DCPNS Registry in DHA 3 2004 •Interface with Meditech (Phase I: demographic and visit data) 2006 DCPNS Server (35 DCs on one server) Interface with Meditech (Phase II: lab data) 2008 Interface with STAR (Phase I: demog/visits) Interface with IWK Meditech (Phase I: demog/visits data) 2013 •DCPNS Registry migration to CAISIS platform. • Added NSIPP module 2014 •Interface with Cerner Lab (Phase II for Central Zone) •HL7 futures? 2016

Registry Overview (current state) Housed & Supported by NSHA Infrastructure Active Directory credentials MSI validation: Date of death Date of birth HC# Built and maintained by DCPNS staff CAISIS platform (open source) Web based (user friendly access) Centralized database (share data on common patients) Interfaces (Registration and Lab systems) Auditable (meets PHIA requirements)

REGISTRY DEMO Rule-based approach to design Provider/patient-friendly Registry features Reporting functionality impact on practice change

Registry Features Provider/patient-friendly Features Dashboard features (quick access, visualization of patient info) Graphing capabilities (sharing/engaging patients) Lab/visit sorting Alerts & reminders Halos Reports & labels Rule-based Approach to Design: VT (Visit Type) rules, e.g: Type of diabetes Visit type Gender Carry forward Effected by Visit Type selection. 37 data points from the current and previous visit are used to carry forward data improving DQ and lessening charting effort. Break here for demo

REGISTRY DEMO Reporting functionality impact on practice change Using local data to drive quality improvement (practice change)

Demo-Durian Wasabi-NS100233-20/03/2016 Let’s use the current visit to show some provider/patient- friendly features within a visit…

these are all auto-calculated reducing users effort .

Clinical Practice Guidelines based Decision Support Tool

Demo-Durian Wasabi-NS100233-20/09/2016 Now let’s add the new visit to demonstrate the carry forward

Auto calcs of BP avg, weight, goal weight, BMI

If > 1 year this too would be flagged as per CPG’s

Using Registry Data Locally: Provincially: DCPNS Grants DC--since 2006/07 (35+ to date—usually 3-4/year) Custom Reports--Responding to the “asks” Blood Pressure & Foot assessments (quarterly) Foot assessments—labels A1Cs (pre and post), visits/DM type Activity/exercise (quarterly) Smoking status+labels Active/inactive patient list by Dr. Making “Custom” Reports “Standard” Reports—to run locally Provincially: Annual provincial, zone, DC-specific encounter/clinical indicator reports Special Reports: Linkages with other data sources (administrative data, provincial programs, and CCDSS). Example, Diabetes and Lower Extremity Amputations in Nova Scotia, 2017 Research

Registry (as an Application): Sample Registry Reports—Local Use Data Quality Reports: Exception reports, active/inactive reports, etc. Monthly statistics Provider Reports: Physician/Nurse Practitioner Report Report sent following a DC visit Family MD/NP-Patient List Produced in confidence—supports relationship building, shared care Advanced Clinical Indicator Report (local selection of indicator(s) and time frame) Used for benchmarking and quality initiatives; group medical visits

Supporting Primary Health Care Partnerships and Group Medical Visits Improving Patient Care/Outcomes Facilitating Shared Care

Advanced Clinical Indicator Report Understanding your population By age, diabetes type, treatment Benchmarking Targeting your interventions, e.g. Transitioning youth Elderly, over managed Type 1, child-bearing years Type 2, high risk foot assessments

Putting It All Together DCPNS Annual Population Report--Blood Pressure DC Runs Quality Indicator Report Criteria: BP > 130/80 mmHg DCPNS DC Grant • Quality Improvement DC #1 Compares Population Figures Initiates 9 mos Intervention: • Produce Family Physician Patient List--q 3 months • Letter to all MDs • Implement patient BP card (allows comparison between--Dr. and DC) • Use alert letter from DC • Pre-post analysis

Looking to the Future: Optimizing Use of the DCPNS Registry

What is the Optimization Project? Optimizing “use” means: Making use of the full reporting capabilities Entering complete and accurate data/information Target audience: Diabetes teams (diabetes educators, clerical/support staff, and managers) across NS Purpose: To facilitate improved diabetes care delivery and outcomes

E.P.I.I.C! DCPNS Registry Optimization will be E.P.I.I.C! Educate Populate Illustrate Innovate Celebrate…doing things differently!

Project Bulletin, produced every 2 months: 1st issue: June 2018

In summary We have talked about and demonstrated, The evolutionary role of the DCPNS Registry The rule-based approach to Registry design and its impact (on capture/quality/acceptance) The provider/patient-friendly features The reporting functionality, including examples of impact on practice change Future plans for optimizing use of the Registry through our E.P.I.I.C work We would like to thank you for your interest and welcome any comments or questions you might have

If you would like to find out more about us (DCPNS), or learn more about the Registry, please contact: Robin Read: robin.read@dcpns.nshealth.ca Peggy Dunbar: peggy.dunbar@dcpns.nshealth.ca Website: http://diabetescare.nshealth.ca Recent publication: “Diabetes Care Program of Nova Scotia – Celebrating Twenty Five Years of Improving Diabetes Care in Nova Scotia" https://authors.elsevier.com/a/1X7mT5KvDJyq6I

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