Stewart B. Harris MD, MPH, FCFP, FACPM. 2 nd Annual Congress of the Global Diabetes Alliance (GDA) October 26-29, 2010 Cairo, Egypt

Transcription

1 SUMMIT SESSION: The challenges and applications of diabetes registries and electronic medical records (EMR's) in improving clinical care for patients with diabetes; a global perspective 2 nd Annual Congress of the Global Diabetes Alliance (GDA) October 26-29, 2010 Cairo, Egypt Stewart B. Harris MD, MPH, FCFP, FACPM

2 Presentation Overview Electronic Medical Records & Diabetes Registries Learning From Experience Case Studies Where Do We Fit In? GDA Vision for Diabetes Registries Summary

3 Electronic Medical Records & Diabetes Registries

4 Diabetes Registries: The Basics Definition Searchable list of patients diagnosed with diabetes Frequently associated with electronic medical records Links all members of the patient s health care team Provides information for patients, physicians and policy makers Types of Registries Hospital-based Regional Population-based Organization based on primary, secondary and tertiary levels of health care

5 Benefits of Diabetes Registries Timely identification of high-risk subpopulations Previous literature demonstrates that diabetes registries lead to significant benefits on clinical practice and patient outcomes through: Feedback to patients Tools for facilitators and providers Deliver and link available resources to providers and patients Surveillance, epidemiology & research McCulloch et al. Eff Clin Pract 1998;1:12-22.

6 Example of how a national registry improves care in the U.S.A. Indian Health Service (IHS) Exemplary national system established in 1955 IHS provides care to 80,000 people with diabetes in 150 facilities Annual IHS Diabetes Care and Outcomes Audit in >75% of facilities Chart review and feedback Data used in local quality improvement programs

7 Example of how a national registry improves care in the U.S.A. IHS Results

8 Importance of Diabetes Registries There is a general lack of population-based data Hospital-based data is limited and carries potential bias Registries can help to fill this gap Quantifying the diabetes burden aids in understanding the determinants of the disease from a population-based perspective Measurement is fundamental to changing the face of diabetes McCulloch et al. Eff Clin Pract 1998;1:12-22.

9 Importance of Registries as a means of Surveillance Diabetes surveillance is important in order to: Establishing a baseline from which progress can be measured Monitor trends in care processes, risk factors, indicators and complications over time Assess the public health burden of diabetes / health policy planning Identify high risk groups Develop and evaluate targeted health promotion strategies and the sustainment of these strategies Alberta Diabetes Surveillance System

10 Looking Forward: The Potential of EMRs in Diabetes Surveillance Governments in Australia, Canada, Denmark, Finland, France, New Zealand, the U.K. and the U.S.A. are implementing computer-based national healthcare infrastructures based around EMRs Benefits of EMRs in surveillance Rich source of clinical data Ability to provide reminders to health care team Efficiency of data gathering Coordination of care Vehicle to advance core research database Khan et al. Diabetes Technology & Therapeutics 2009;11(4): ; Ortiz DD.Fam Pract Manag 2006;13(4):47-48, Crosson et al. Ann Fam Med. 2007;5(3): ; Green et al. Int J Med Inform. 2006;75(12): Orzano et al. J Am Board Fam Med. 2007;20(3):

11 Example of how an EMR-based registry improves care in the U.S.A. Veterans Affairs EMR/Registry Example Populating a diabetes registry using EMR Registry refreshed on a nightly basis to update any patients meeting criteria for diabetes diagnosis Cleveland VA Center enrolled 81,227 DM patients since 2001 Frequency of patients with mean HbA1c 9% declined significantly over 5 years from 8.1% in % in patients enrolled in DM prevention program over past 4 years Kern et al. Journal of Diabetes Science and Technology. 2008;2(1):7-14.

12 Example of how an EMR-based registry improves care in the U.S.A. Veterans Affairs Kern et al. Journal of Diabetes Science and Technology. 2008;2(1):7-14.

13 Capitalizing on the registry & EMR movement Registry Movement Diabetes Registry EMR Movement Electronic Capitalize Medical on Record both resources for optimal benefit Crosson et al. Ann Fam Med. 2007;5(3): Green et al. Int J Med Inform. 2006;75(12): Orzano et al. J Am Board Fam Med. 2007;20(3):

14 Now is the time for action The International Diabetes Federation and World Health Organization identify diabetes and other noncommunicable diseases as the Next Health Tsunami On a global scale, we are losing the battle to contain diabetes The high cost of health care is not sustainable IDF. Available at: IDF. Available at:

15 Now is the time for action Engaging resources to facilitate improved information and data management is key to quantifying the chronic disease burden and understanding determinants of health both at a local and population-based level Diabetes registries have emerged as public health initiatives across the globe IDF. Available at: IDF. Available at:

16 Learning from Experience Diabetes in Ontario, Canada: A Provincial Case Study

17 ARCTIC OCEAN Ontario, Canada PACIFIC OCEAN Yukon British Columbia Alberta Canada s largest and most populous province (~12 million people) Nunavut HUDSON BAY Manitoba Saskatchewan Ontario BAFFIN SEA Newfoundland & Labrador Quebec New Brunswick ATLANTIC OCEAN Prince Edward Island Nova Scotia Most ethnically diverse Contains both rural and urban areas Healthcare plan available to all residents, government funded Lipscombe LL. Lancet

18 Funding constraints necessitate action Chronic diseases represent an estimated 55% of total direct and indirect health care costs in Ontario Economic burden on the publically funded health care system Rising chronic disease rates cannot equal rising costs Chronic Disease $$$$$$ Ministry of Health and Long-Term Care. Available at: Manuel et al. ICES; 2010.

19 Establishing a Diabetes Registry in the Province of Ontario Online registry Patients access to information and educational tools Health care provider access to check patient records, access diagnostic information and send patient alerts Registry to include tracking of: HbA1c LDL cholesterol Date of last eye exam Visit with a primary care physician

20 Establishing a Diabetes Registry in the Province of Ontario Step 1 - Identifications of patients with diabetes One-time process to identify Ontarians with diabetes Algorithm: codes AND 1 hemoglobin A1c lab value Step 2 -Validation at practice sites Primary care physicians provided list of identified patients with diabetes to confirm diagnosis (95% of diabetes managed in family practice setting) Step 3 - Population of registry across province

21 However research shows registry less successful than anticipated Registry definition missed 27% of patients when put into practice Lessons learned in Ontario Importance of having an accurate and reliable system for the identification of patients to populate a diabetes registry 27% of patients missing from a Diabetes Registry!

22 Diabetes Surveillance in High Risk Populations Case Study: First Nations in Canada

23 Data Availability Necessitates Flexibility Developing a system to accommodate different health care delivery models/geography/culture/linguistics No national surveillance system tracking diabetes in First Nations in Canada where: High rates of diabetes (3-5x s higher than general population) High rates of complications: 18% higher rates of end stage renal disease 2-3x s higher CVD rates Suboptimal care due to challenges Isolated, resource-constrained environments Numerous other illness and emergencies of higher priority (ex. Mental health) Hanley et al. Dabetes Care. 2005;28(8):2054 Harris et al. Canadian Journal of Diabetes. 2009;33(3):202 Dyck et al. CMAJ. 2010;182(3):249-56

24 Pilot of a First Nations Web-Based Sentinel Surveillance System The reality and requirements of surveillance in remote communities in Canada with intermittent care: Web-based Limited core data set Accessible Need for flexibility across health care systems, geography (remote/rural), cultural/linguistic differences

25 Where Do We Fit In? GDA Vision for Diabetes Registries

26 GDA Vision for Diabetes Registries To provide leadership in designing and establishing a multinational diabetes registry To promote international collaboration To capitalize on existing registries, or facilitate development of new registries To adopt a pragmatic and comprehensive approach to data collection To create and ensure standards and principles for registry data collection and use

27 To Summarize

28 To Summarize As healthcare data collection moves to an electronic format, there is a unique opportunity to track and measure the interactions between health professionals and patients, and to evaluate the impact of diabetes care models and interventions on patient outcomes One key step in this process is the creation of a Global Diabetes Registry The GDA is well positioned to promote the creation and maintenance of this registry

29 Questions?

30 About the Author Stewart B. Harris MD MPH FCFP FACPM Professor, Department of Family Medicine Schulich School of Medicine & Dentistry Canadian Diabetes Association Chair in Diabetes Management, Ian McWhinney Chair in Family Medicine Studies University of Western Ontario, London, Ontario, Canada

31 Stewart B. Harris Dr. Harris s major research interests focus on the application of diabetes clinical practice guidelines in primary care, as well as on type 2 diabetes in high-risk populations. Dr. Harris is currently the Canadian Diabetes Association Chair in Diabetes Management, and plays a central leadership role in the development and implementation of The National Diabetes Management Strategy a program to evaluate diabetes care in Canada. Dr. Harris was a Career Scientist with the Ontario Ministry of Health, has published over 150 peer-reviewed articles and received numerous awards for teaching, healthcare research and service including the Canadian Diabetes Association Dr. Gerald S. Wong Service Award (2007). Dr. Harris was Chair of the 2003 Canadian Diabetes Association Clinical Practice Guidelines expert committee and has served as Chair and Vice-Chair of CDA s Clinical and Scientific Section. He has sat as a board member of numerous national and provincial diabetes-related committees including the Northern Ontario Diabetes Network, the National Diabetes Surveillance System, the Ontario Ministry of Health Task Force for Diabetes Management, the Canadian Diabetes Association, and the International Diabetes Federation.

32 Disclosures Industry: Merck Frosst Canada, NovoNordisk, Bayer, Lifescan, Roche, sanofiaventis, Novartis, Pfizer, Servier, GlaxoSmithKline Government: Ontario Ministry of Health and Long-term Care, Health Canada, First Nations and Inuit Branch, Public Health Agency of Canada, Canadian Institutes for Health Research Specialty interest groups: Canadian Diabetes Association, American Diabetes Association, International Diabetes Federation Other: Great West Life, Lilly Neuroscience Trust Fund