Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0

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1 pic Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0 Business View Primary Health Care

2 Who We Are Established in 1994, CIHI is an independent, not-for-profit corporation that provides essential information on Canada s health system and the health of Canadians. Funded by federal, provincial and territorial governments, we are guided by a Board of Directors made up of health leaders across the country. Our Vision To help improve Canada s health system and the well-being of Canadians by being a leading source of unbiased, credible and comparable information that will enable health leaders to make better-informed decisions.

3 Table of Contents Acknowledgements iii About the Canadian Institute for Health Information viii Executive Summary viii Introduction Background Scope Benefits to Patient Care and the Health System Approach Business Context Use Case Category 1: PHC Clinic Visits and Program Management Use Case Category 2: Referral to a Specialist and Wait Times Management Use Case Category 3: Patient Self-Reporting and Chronic Disease Prevention and Management s Adoption, Maintenance and Governance Next Steps Contact Information and Links Appendix A: Draft Conceptual Model Appendix B: Matrix Appendix C: Pan-Canadian Primary Health Care Indicators Appendix D: Glossary of Terms References

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5 Acknowledgements The Canadian Institute for Health Information (CIHI) would like to acknowledge and thank the many individuals and organizations that contributed to the development of this product. In particular, CIHI would like to acknowledge and express its appreciation to the members of the Jurisdictional Advisory Group (JAG) and the Content Standards Working Group (CSWG), who provided invaluable guidance in developing the core content for the Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard. As of September 1, 2010, these groups consisted of the following members: Jurisdictional Advisory Group Members Mr. Jeff Aitken Director, First Nations ehealth, BC Ministry of Health Services (December 2009 September 2010) Mr. Thomas P. Alteen Project Manager, Newfoundland and Labrador Centre for Health Information (December 2009 September 2010) Ms. Pat Booth Manager of Information Management Unit, Information Services Division, Department of Health and Social Services, Government of the Northwest Territories (February 2010 June 2010) Ms. Claire Bernatchez Senior Program Manager, Federal Healthcare Partnership (December 2009 September 2010) Ms. Sandra Cascadden Chief Information Officer, Nova Scotia Department of Health (December 2009 September 2010) Mr. Neil Gardner Chief Information Officer, Saskatchewan Health (December 2009 September 2010) Mr. Dennis Giokas Chief Technology Officer, Canada Health Infoway (December 2009 September 2010) Ms. Cheryl Hansen Executive Director, Innovation, New Brunswick Department of Health (December 2009 September 2010) Mr. Richard Johnstone Senior Delivery Manager, Shared Health Network, Alberta Health and Wellness (December 2009 June 2010) Mr. Martin Joy Acting Director, Nunavut Department of Health and Social Services (December 2009 September 2010) iii

6 Ms. Heather E. N. Cooper Health Information Standards Coordinator, Alberta Health and Wellness (June 2010 September 2010) Mr. Tom Fogg (Co-Chair) Director of Strategy and Planning, Manitoba ehealth (December 2009 September 2010) Mr. Randy Francis Director, Program Management, Prince Edward Island Department of Health (December 2009 September 2010) Mr. John McKinley Assistant Deputy Minister, Ontario Ministry of Health and Long-Term Care (December 2009 July 2010) Ms. Janet Nyberg Chief Information Officer, Yukon Department of Health (December 2009 September 2010) Mr. Greg Webster (Co-Chair) Director, Primary Health Care Information, Canadian Institute for Health Information (December 2009 September 2010) Content Standards Working Group Members Mr. Jeff Aitken Director, First Nations Health, British Columbia Ministry of Health Services (February 2010 September 2010) Mr. Thomas P. Alteen Project Manager, EHR Projects, Health Information Network, Newfoundland and Labrador Centre for Health Information (February 2010 September 2010) Ms. Claire Bernatchez Senior Program Manager, Federal Healthcare Partnership (February 2010 September 2010) Dr. Richard Birtwhistle Director of Centre for Studies in Primary Care, Queen s University and Principal Investigator, Canadian Primary Care Sentinel Surveillance Network (February 2010 April 2010) Ms. Mary Ann Juurlink ehealth Standards, Lead, ehealth Ontario (February 2010 September 2010) Ms. Beverly Knight Terminology Services Manager, Canada Health Infoway (February 2010 September 2010) Ms. Jan Labovich Manager, Information Architecture, Manitoba ehealth (February 2010 September 2010) Dr. Marion Lyver President, Healthy Futures Inc.; Associate Clinical Professor, McMaster University Faculty of Medicine (February 2010 September 2010) iv

7 Ms. Pat Booth Manager of Information Management Unit, Information Services Division, Department of Health and Social Services, Government of the Northwest Territories (February 2010 June 2010) Dr. Denise Campbell-Scherer Associate Professor, Department of Family Medicine, University of Alberta (February 2010 September 2010) Ms. Heather E. N. Cooper Health Information Standards Coordinator, Alberta Health and Wellness (February 2010 September 2010) Dr. Sisira De Silva Electronic Health Record Standards Specialist, Newfoundland and Labrador Centre for Health Information (February 2010 September 2010) Mr. Finnie Flores Senior Standards Analyst, ehealth Ontario (April 2010 September 2010) Ms. Irene A. K. Gillis Health Information Specialist, Prince Edward Island Department of Health (February 2010 September 2010) Ms. Beverly Greene Primary Health Care Consultant, New Brunswick Department of Health (February 2010 September 2010) Ms. Michelina Mancuso Executive Director of Performance Management, New Brunswick Health Council (February 2010 September 2010) Mr. Ken Martin Senior Manager, CPCSSN Project, Queen s University (April 2010 September 2010) Ms. Patti McManus Nurse Practitioner, Federal Healthcare Partnership and First Nations and Inuit (April 2010 September 2010) Ms. Lynn Miller Nurse Practitioner, Cumberland North Rural Practice Network (April 2010 September 2010) Ms. Lisa Napier PHIM Program Manager, Nova Scotia Department of Health (February 2010 September 2010) Dr. Ray Simkus Physician, Brookswood Family Practice Biomedical Informatics, British Columbia (February 2010 September 2010) Ms. Karen Oldford PHC Nurse Practitioner, Labrador Grenfell Health (April 2010 September 2010) Mr. Pavel Platonov Senior EMR Technical Specialist, Manitoba ehealth (February 2010 September 2010) Dr. Morgan Price University of British Columbia, Department of Family Practice (February 2010 September 2010) v

8 Dr. Roger Hamilton Physician, Nova Scotia (February 2010 September 2010) Ms. Cindy Hollister Clinical Leader, Clinical Adoption, Canada Health Infoway (February 2010 September 2010) Dr. R. Liisa Jaakkimainen Family Physician; Scientist, Institute for Clinical Evaluative Sciences, Ontario (February 2010 September 2010) Ms. Brenda Jackman Clinical Business Analyst, Primary Health Care, Health Information Solutions, Saskatchewan Ministry of Health (February 2010 September 2010) Ms. Donna Shanley Physician ehealth Program, ehealth Ontario (February 2010 September 2010) Ms. Cynthia Smith Senior Manager, Primary Health Care Unit, Alberta Health and Wellness (February 2010 September 2010) Ms. Patricia Sullivan-Taylor (Chair) Manager, Primary Health Care Information, Canadian Institute for Health Information (February 2010 September 2010) Ms. Valerie Ross Acting Manager, Information Management, Department of Health and Social Services, Northwest Territories (June 2010 September 2010) vi

9 Canada Health Infoway CIHI would like to thank Canada Health Infoway (Infoway) for its collaboration on this project, with special thanks to Sukhi Burgen, Linda Dentay, Shari Dworkin, Dennis Giokas, Beverly Knight, Alex Mair, Julie Richards and Lynne Zucker. CIHI would also like to thank members of the Infoway Standards Collaborative Strategic and Coordinating Committees and Working Groups 2, 3 and 9 for their input and contributions to various phases of the project. CIHI Project Team The core CIHI project team responsible for developing the Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0 included Mr. Louis Barré, Vice President, Strategy, Planning and Outreach Mr. Ted Harrison, Project Lead, Primary Health Care Information Mr. Scott Murray, Vice President and Chief Technology Officer, Information Technology and Services Ms. Patricia Sullivan-Taylor, Manager, Primary Health Care Information Mr. Gavin Tong, Project Manager, Primary Health Care Information Mr. Greg Webster, Director, Primary Health Care Information Significant project contributions were also made by Zee Hua Cheung, Tanya Flanagan, Azra Kulenovic, Shaheena Mukhi, Marco Neri, Dawn Nicholson, Christine Proietti, Michael Terner, Christina Tomsa, Jennifer Trebell and Vicky Walker. This product could not have been completed without the generous support and assistance of many other CIHI staff members, including classifications, information technology and services, CIHI standards working group, layout and design, translation, communications and distribution, who provided ongoing support to the core team. vii

10 About the Canadian Institute for Health Information The Canadian Institute for Health Information (CIHI) collects and analyzes information on health and health care in Canada and makes it publicly available. Canada s federal, provincial and territorial governments created CIHI as a not-for-profit, independent organization dedicated to forging a common approach to Canadian health information. CIHI s goal: to provide timely, accurate and comparable information. CIHI s data and reports inform health policies, support the effective delivery of health services and raise awareness among Canadians of the factors that contribute to good health. For more information, visit our website at Executive Summary Primary health care (PHC) is the most common type of health care experienced by Canadians. Efforts to improve PHC hold the greatest potential to positively impact the health of Canadians and the sustainability of the health care system. Stakeholders across Canada are facing increased demands to improve primary health care (PHC) and to demonstrate fiscal responsibility. However, there is relatively little high-quality information available with which to guide efforts to prevent chronic diseases and to improve the quality, efficiency and accessibility of PHC. Across Canada, jurisdictions and clinicians are increasingly using Electronic Medical Records (EMRs) to support improvements in PHC. Interoperable EMRs will play a key role in ensuring that PHC clinicians have the information they need to deliver, coordinate and administer care. Using EMR information to support clinicians at the point of service is generally considered its primary use. However, the information generated at the point of service can also be used to support quality improvement initiatives, such as clinical program management, research, and monitoring the health of the population, as well as to improve the efficiency of the health care system overall. The use of information for these purposes is often referred to as health system use. The availability of high-quality information to support PHC improvements can be achieved only if a subset of priority, standardized data is present in PHC EMRs. With increased funds going toward the adoption of EMRs, it has become imperative that standardized data capture is occurring in order to support the priority information needs now and into the future. At present, most EMRs support free text data capture, with little regard for aligning viii

11 with common content standards. This approach limits the EMR s ability to provide point of care benefits, such as patient safety reminders and alerts for patients who require close monitoring. The absence of standardized PHC data compromises the quality and comparability of all forms of information that can be created an issue that affects all stakeholders, regardless of type (for example, clinician or health system planner) and regardless of their intended use of that information. To support the EMR adoption initiatives, stakeholders identified the need for a pan-canadian PHC EMR content standard that would define a common approach to capturing a priority set of data elements in a structured manner that supports both primary and health system uses of the data. Supporting a single pan-canadian standard was seen by stakeholders as a way to maximize the value and efficiency associated with development, implementation and maintenance. In collaboration with stakeholders from across the country, the Canadian Institute for Health Information (CIHI) led the project to establish the Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0 (PHC EMR CS). The PHC EMR CS is composed of 106 data elements that are commonly captured in EMRs and that support both primary uses of EMR data, such as reminders and alerts for patients with chronic conditions, and health system uses, such as a jurisdictional diabetes management registry. These data elements are required to support the many facets of PHC, including treatment of illnesses, as well as health promotion and disease prevention. The creation of the PHC EMR CS marks a key milestone on the path to improving PHC in Canada. The next step along this path is to ensure that the PHC EMR CS is properly and widely implemented in EMRs. Two future steps involve ensuring that implementation of the PHC EMR CS supports care delivery and PHC system improvements in a privacy-sensitive manner; and ensuring that PHC EMR data is privacy-protected when employed for health system uses. CIHI will continue to work with stakeholders to establish additional products and services to facilitate the adoption and implementation of the PHC EMR CS. In parallel, strategies and plans for the longer-term governance and maintenance of the PHC EMR CS will be established to ensure it remains clinically and technically relevant to meet evolving stakeholder needs in the years to come. ix

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13 Introduction The Challenge Primary health care (PHC) is the most common type of health care experienced by Canadians. Efforts to improve PHC hold the greatest potential to positively impact the health of Canadians and the sustainability of the health care system. 1 As health care costs continue to rise, all stakeholders are increasingly accountable to demonstrate value for health care spending while improving the quality and outcomes of care. Accountabilities in this area are far-reaching and extend to jurisdictions, i PHC clinicians and electronic medical records (EMR) vendors. At the same time that stakeholders are experiencing a greater demand to demonstrate improvements in health care delivery and fiscal responsibility, information on PHC remains limited. Currently, there is limited evidence-based information to inform better practice and health system management on how to improve the quality, effectiveness and efficiency of patient care. Across Canada, the increased use of EMRs has been promoted to support improvements in PHC quality and efficiency. However, in the absence of a pan-canadian PHC EMR content standard, multiple EMR standards have been developed to support jurisdictional needs. The lack of a pan-canadian approach to EMR standards to date has resulted in Increased costs to the system associated with developing, implementing and maintaining multiple standards; Fewer benefits realized from EMRs, including limited information to support clinical decision-making at the point of care; and Limited comparable information to support health system evaluation and management across the country. i. The term jurisdiction broadly refers to the provincial and territorial ministries of health, as well as the Federal Healthcare Partnership, which comprises Citizenship and Immigration Canada, Correctional Service Canada, Department of National Defence, Health Canada, Public Health Agency of Canada, Royal Canadian Mounted Police and Veterans Affairs Canada. 1

14 The Solution Stakeholders from across the country developed a set of priority data elements to ensure that the necessary subset of standardized information is available to improve access, quality, outcomes and chronic disease prevention and management across Canada. These priority data elements formed the core content of the Draft Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 2.0, henceforth referred to as the PHC EMR CS. The PHC EMR CS is composed of 106 data elements that are commonly captured in EMRs and support primary uses, such as reminders and alerts for patients with chronic conditions and health system uses of EMR data, such as a jurisdictional diabetes management registry. These data elements are required to support the many facets of PHC, which include not only treatment of illnesses but also include health promotion and disease prevention activities. About This Document This document is intended for clinicians and decision-makers from public and private sector organizations with an interest in effective PHC EMRs, with a goal of aiding these stakeholders in understanding the purpose and development process of the PHC EMR CS. To this end, the document has been written from a business perspective as opposed to a technical one. ii ii. Technical information that is of interest to implementers and standards experts is available on CIHI s Primary Health Care Information Program website at 2

15 Background Primary Health Care Indicators to Support Measurement for Improvement Primary health care (PHC) has been called the foundation of Canada s health system and is the most common type of health care that Canadians experience. 2 Currently, we know little about the way services are delivered, the results that these services yield or how our PHC system is evolving. Broadly, PHC indicators and the data required to report on these indicators contribute to the measurement and management of PHC in Canada. Measuring PHC in Canada will require harnessing and enhancing data sources at the local, regional, provincial/territorial and pan-canadian levels. In 2005, the Canadian Institute for Health Information (CIHI) received funding from the Primary Health Care Transition Fund and partnered with a broad range of PHC experts across Canada to develop an agreed-upon set of pan-canadian indicators that could be used to measure PHC at multiple levels within jurisdictions across Canada. The resulting 105 indicators were published in the two-volume report Pan-Canadian Primary Health Care Indicators in A companion report recommended options for enhancing the infrastructure required to collect the data associated with the PHC indicators. CIHI built on this work in 2007 by exploring the feasibility of various options to improve PHC data sources, including data on quality and outcomes from clinical sources. CIHI PHC Indicators EMR Content Standards, Version 1.1 to Support Quality Measurement and Improvement In 2007, CIHI conducted an environmental scan to assess the feasibility of collecting data on these 105 PHC indicators from a variety of sources, including electronic medical records (EMRs), existing CIHI databases and other administrative databases, as well as patient, provider and organizational surveys. The environmental scan found that data for the PHC quality indicators representing approximately one-third of the 105 could potentially be collected from EMRs plus diagnostic imaging, prescription drug and lab data sources. However, the scan also highlighted the need to establish EMR content standards in order to standardize data collection across PHC settings. In response to provincial, territorial and federal needs, CIHI led the PHC Indicators EMR Content Standards Project, which included pan-canadian collaboration with PHC clinicians, researchers, standards experts and health system managers to identify the priority data elements for the preliminary 3

16 standard (Version 1.1). The focus of the project was to establish a new pan- Canadian data stream for populating and reporting on a subset of the PHC quality indicators in order to improve the understanding of PHC across the country and inform health policy and decision-making at various levels. In early 2009, CIHI issued Version 1.1 of the PHC Indicators EMR Content Standards to facilitate the standardized capture of a priority subset of EMR data associated with 12 quality PHC indicators. Over the past year, pilot testing in PHC settings informed the need for a subsequent iteration of the standard. Draft Pan-Canadian PHC EMR Content Standard, Version 2.0 to Support Primary and Health System Use In the fall of 2009, stakeholders identified the need to expand the scope of Version 1.1 to include both primary and health system uses of EMR data and to improve alignment of the data elements with the pan-canadian Electronic Health Record (EHR) Messaging and Terminology Standards, as well as with Infoway s Physician Office System Requirements. 3 In response to the needs of the jurisdictions promoting the use of PHC EMRs, CIHI launched a project to work with stakeholders to develop Version 2. Two Types of Use Primary use The data are currently and commonly required to support the delivery and/or administration of primary health care. Health system use The data are commonly required to support PHC clinical program management, health system management, research and monitoring the health of the population. To achieve this goal, a jurisdictional advisory group (JAG) with representation from the jurisdictions, Infoway and CIHI was established to help set the strategic direction for the project. The JAG was supported by a pan-canadian Content Standards Working Group (CSWG), which provided input and advice on the data elements to ensure that they were clinically relevant, aligned with existing standards where appropriate, met the needs of stakeholders and were implementable. The JAG and CSWG were also responsible for informing strategies and plans for the longer term adoption, governance and maintenance of the PHC EMR CS. 4

17 The collaborative approach was intended to reduce duplication of effort in the development of EMR content standards at the jurisdictional level and to minimize the burden on EMR vendors who would otherwise have to incorporate and maintain multiple standards in their EMRs. The draft standard was given a slightly different name than its predecessor to reflect the fact that it is a pan-canadian standard that supports both primary and health system uses of EMR data. Content Standard Naming Convention The PHC EMR CS is considered a draft pan-canadian standard because it meets the following criteria: It is governed by a body with pan-canadian representation. Its scope is to meet pan-canadian requirements. It was developed with pan-canadian input on clinical content, jurisdictional priorities and standards expertise. It was established by a pan-canadian, consensus-based approval process. It is considered draft because it has not yet been implemented and there are areas for further refinement that require implementation experience. In this context, the term pan-canadian means across Canada ; generally, in the health field, the term often implies representation from the majority of the health jurisdictions and other stakeholder categories from across Canada. The title Draft Pan-Canadian Standard was recommended by the CSWG in order to avoid confusion with labels used by the Infoway Standards Collaborative ( Canadian Draft for Use ) and other standards bodies, such as HL7 ( Draft Standard for Trial Use ). Scope The purpose of the PHC EMR CS is to provide a minimum data set that, when implemented in PHC EMRs, will yield data that enables EMR functionality and provides information that will lead to quality improvements in patient care and the broader health care system. Once the PHC EMR CS has been implemented, PHC EMRs can make better use of EMR data to drive application functionality such as the functions described in Infoway s Physician Office System Requirements (e.g. the EMR can graph lab results over time) and to generate information. They can also extract data to support a variety of needs ranging from interoperating with a jurisdictional EHR to providing data to a chronic disease management repository. 5

18 Scope Criteria The main criterion for the inclusion of a data element in the PHC EMR CS was its ability to support both primary and health system uses of EMR data. Examples of data elements that support both primary and health system uses of EMR data are shown in Figure 1. elements that appear in the overlapping area of the two circles support both uses, and are therefore deemed to be in scope for the PHC EMR CS. Figure 1: PHC EMR CS Scope Primary Use Health System Use Patient Street Number and Patient Postal Code Patient Socio-Economic Neighbourhood Clinician Billing Number Clinician Role Type Clinician Highest Degree Obtained Number of Prescribed Medication Refills Prescribed Medication Dispensed Medication Cost In Scope 6

19 Benefits to Patient Care and the Health System The PHC EMR CS directly supports patient care improvements by enabling EMR functionality (for example, clinical decision support) and providing information that clinicians and health care system decision-makers can use to improve quality of care (for example, prevention, outcomes and access to care). Without the PHC EMR CS, it would not be possible to efficiently monitor and evaluate efforts to improve PHC across the country in a comparable way. standards allow comparisons between patients within the practice, as well as comparisons across practices, and facilitate surveillance and a population health approach to primary health care. Dr. Alan Katz Family Physician Winnipeg, Manitoba A pan-canadian approach to the PHC EMR CS mitigates duplication of effort to develop jurisdictional-specific standards, which otherwise increases costs to EMR vendors who would have to support the implementation of multiple standards in their products. By supporting both primary and health system uses of EMR data, the PHC EMR CS will reduce data collection costs by reusing data captured at the point of care for clinical program management, health system management, research, and monitoring the health of the population. Collecting information in a structured way helps manage our precious resources in the most effective way. Dr. Roger Hamilton Family Physician Wolfville, Nova Scotia While clinicians, jurisdictions and PHC EMR vendors receive the benefits described above, they also derive unique benefits from the adoption of the PHC EMR CS. These benefits can only be fully realized through incorporation into software and systems that are properly designed and used by all stakeholders. 7

20 Clinician Benefits Improve patient care and safety through the use of clinical decision support functions in their PHC EMR. Examples of clinical decision support functions include, but are not limited to, drug-to-drug interaction alerts, reminders for follow-up care and suggested treatment plans for specific conditions. Facilitate patient care coordination through electronic communications with other clinicians via interoperable systems, such as electronic referrals, and ordering of lab tests using standardized, comparable and clinicianfriendly terms. Improve the quality of care and efficiency in their PHC practice by examining reports on their patient population and quality of care indicators over time. Understanding trends in patient demographics, quality of care, patient-centred care and disease prevalence can help clinicians plan for quality improvement and optimize resource allocation in their practice. Standardized data in the EMR helps those of us working in primary health care to work more collaboratively as a team. The easy retrieval of information in the EMR also gives me more time to deal with issues that my patients have. Denise Moss Registered Nurse and Certified Diabetes Educator Algoma Diabetes Education and Care Program Sault Ste. Marie, Ontario Jurisdiction Benefits Improve availability of comparable, standardized data in order to Evaluate and monitor chronic disease prevention and management (CDPM) initiatives. Improvements to CDPM will not only improve the lives of patients but also decrease costs to the jurisdictional health care system. Analyze PHC delivery and administration to identify areas to improve quality, outcomes, safety and efficiency and to ensure that patients have optimal access to care. Monitor the health of the population to identify, prevent and contain outbreaks of disease. 8

21 This standard enables the consistent capture of information in EMRs that will help inform efforts to better manage the health system. Tom Fogg Director of Strategy and Planning, Manitoba ehealth Co-chair of the Pan-Canadian EMR Content Standard Jurisdictional Advisory Group PHC EMR Vendor Benefits Lower the implementation and maintenance costs of EMRs through support of a single standard. Otherwise, vendors must consume considerable resources in evaluating jurisdictional requirements that conform to different standards. The vendors then have to expend resources to maintain each of these standards in their products and support mapping between these standards. Improve product offerings by providing innovative features and functionality that rely on the underlying standardized data (clinical decision-support tools, quality indicator reporting). Increase the speed at which products can be brought to the market by decreasing development and conformance-testing efforts. When properly implemented, the PHC EMR CS offers numerous benefits to stakeholders, such as ensuring that PHC clinicians have the information they need to deliver, coordinate and administer optimal care, and providing the information required to manage the PHC system in an efficient and effective manner. I want to know how I can get good data out of my EMR without disrupting the work flow. Pan-Canadian standardized data allows you to identify work flow issues and patients needs and gives you an opportunity to compare models of care not only within your own province, but models operating across Canada. Dr. Lewis O Brien Family Physician Sault Ste. Marie, Ontario 9

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