This practice was recognized as a LEADing Practice by Canada Health Infoway as part of the “Knowing is Better” education campaign, in partnership with Accreditation Canada
Interconnected Health
A great contributor to the team’s success in providing quality care to their patients is the use of decision support tools and the advanced features available in their Electronic Medical Record (EMR).
Some of the most commonly used features/functions include:
• Recalls, appointment alerts and reminders to identify those patients eligible or overdue for visits, preventative screening or diagnostic tests;
• Electronic flow-sheets, customized stamps and encounter records to promote evidence-based practice and to ensure clinical documentation is standardized across providers; and
• Patient report cards to track their individualized clinical targets including self-management goals.
Laboratory results are automatically downloaded into the EMR. Reports from specialist and doctors are received by fax server and are then dropped into the patient chart. Later this year the Hospital Report Manager will be in use and all hospital reports will be available to also automatically download into the EMR. CHFHT also uses the Ontario Telemedicine Network for specialist consultations, continuing education sessions and inter-site meetings.
Advancing Professional Practice
“The use of standardized stamps and encounter forms helps us provide safe, quality care and enables us to collect data. This data is used by clinicians to conduct ongoing performance assessments that help identify areas for continued improvement. This process typically results in targeted interventions based on best practices to address the needs of our patients. It also helps us use our resources more effectively.” – Dr. Adam Stewart, Family Physician
Using their EMR, the team reviews their performance against a set of mutually agreed upon indicators including the number of diabetics receiving care in the past six months, the number of patients that have achieved clinical targets for blood pressure, hemoglobin A1c, LDL and the number of diabetics receiving routine foot assessments and eye exams.
Improving Continuity of Care
CHFHT has three clinical sites in Ontario, in Madoc, Marmora and Gilmour. All three clinics are interconnected by a Virtual Private Network giving the team access to the patient’s chart, regardless of the clinic location or the provider they see. The team also uses a standardized charting format based on the Canadian Diabetes Association guidelines which supports comprehensive documentation and patient care. The availability of shared access to patient information through the EMR during after-hours clinic visits also enables continuity of care.
Benefiting Providers and Patients
The ability to scan reports, download labs and diagnostic imaging reports directly into the patient’s chart means that care providers have up-to-date information at their fingertips, which improves workflow for staff. Decision support is enhanced through links within custom encounter forms providing instant access to evidence-based guidelines and patient resource materials at the point of care.
As a result of quality improvement interventions, CHFHT has successfully demonstrated improvements in process measures and clinical outcomes with their diabetic patient population:
• 94 percent had their A1C in the last 6 months
• 85 per cent had their LDL tested in the past 12 months
• 92 per cent had their blood pressure recorded in the past six months
• 60 per cent reached an LDL target of 2.0 mmol/L
• 67 per cent reached a BP target of 130/80 mmHg
Critical Success Factors and Lessons Learned
• Valuing the role of the program coordinator and data management;
• The full team needs to be engaged and feel ownership; and
• Success was achieved by taking one small step at a time.
For more information on Central Hastings Family Health Team‘s LEADing Practice, contact Julie Page, Program Coordinator / System Navigator at Julie.page@chfht.com or 613-473-4134 ext. 219.
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