Optimizing the delivery of Chronic Disease Management-Quality Improvement (CDM-QIP) in Saskatchewan


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The CDM-QIP session relates directly to both Better Care and Better Health and will focus on how the program helps clinicians across Saskatchewan to manage chronic conditions in their patients. The current chronic conditions included in the program are Diabetes and Coronary Artery Disease and will be expanding to include COPD and congestive heart failure. The presentation will include a demonstration CDM-QIP, an overview of its delivery and information regarding participation for those who want to sign up. A clinician will discuss how they have used CDM-QIP in their practice to benefit their patients. Early results generated by the program will be shared.

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  • Chronic Disease is a critical issue in Canada and Saskatchewan is not unique. The costs of treating and living with chronic diseases to Saskatchewan is staggering and when they are calculated they often do not include the cost of pain and suffering. The cost of chronic diseases to Saskatchewan is estimated to be $240M annually due to illnesses and disability. (College of Family Physicians of Canada 2012 Pre-budget Submission to the Standing Committee on Finance).
    Government, providers and patients all know that we have to do better.
  • A Partnership was created between the Ministry, and eHS the objective of improving care for patients with chronic disease by providing better supports to the healthcare providers for those patients. A Clinical Services Expert Group was created to help drive this work.
    The Ministry brought resources, knowledge and a connection to the pan-Canadian efforts to a address CDM challenges
    The SMA brought the voice of some our brightest family physicians to the table
    eHealth brought its expertise in supporting electronic healthcare solutions as well as one of its flagship products – the eHR Viewer
    CSEG brought a wide selection of health care providers, subject matter experts and administrators
    Members include:
    Physician subject matter experts (EMR and Paper) - 9
    Nurse Practitioner
    Regional Health Authority (Saskatoon and Sun Country)
    Saskatchewan Medical Association
    PHC and Saskatchewan EMR Programs
    Health Quality Council
    Ministry and eHealth Saskatchewan Project Team
  • Improve the continuity and quality of care for people living with chronic conditions
    Encourage and support physicians and other health care providers to implement best practices (flow sheets and clinical practice guidelines) and be provided with state of the art supports (clinical information notes, patient profile reports, recommended care reports)
    - Supporting team based and collaborative care
    - Leverage our health information systems assets
    The program launched in August 2014 and after our successful pilot at nine sites across Saskatchewan, it is now available to both EMR and paper physician clinics across the province
    An extensive collection of program and vendor supports have designed and built for CDM-QIP
    Currently, we have ___ physicians, ___ nurse practitioners and ___ delegates who are able to enter data on behalf of participating providers
  • Options for both EMR and Paper practices
    Optimal care flow sheets – standardized, evidenced based and a commitment to keep them regularly updated
    State of the art supports – smart templates with clinical notes and hyperlinks to regularly updated best practice guidelines and relevant patient information
    Standardized reporting to support quality improvement featuring:
    Patient Profile Report which display patient profiles for patients with chronic disease over time
    Observation History Report which summarizes the chronic disease observations that have been associated with patients over time
    Recommended Care Report which displays recommended care for patients with Diabetes and/or CAD
    Targeted Payments
    Early Adopter Payment when chronic disease process indicators are submitted for a new patient with a chronic condition. Available until March31, 2015
    Quality Improvement Payment for the ongoing submission of chronic disease process indicators over the course of a 12 mo.
  • Pilot and anecdotal feedback suggests:
    The program is easy to navigate and use
    The program is well- supported by wat of training, provider and patient supports.
    Most importantly, the program enhances the ability to manage and support patients with chronic disease
  • Optimizing the delivery of Chronic Disease Management-Quality Improvement (CDM-QIP) in Saskatchewan

    1. 1. Optimizing Chronic Disease Care in Saskatchewan Introducing CDM-QIP Dr. Tessa Laubscher, Family Physician – Saskatoon Glen Paskiw, a/Director Transition Services – eHealth Saskatchewan
    2. 2. Clinical Services Expert Group
    3. 3. Faster • Safer • Better • SecureOne Patient: One Record CDM Taking A New Direction Watch Closely!
    4. 4. Faster • Safer • Better • SecureOne Patient: One Record CDM - QIP Optimal Care Flow Sheets Clinical & Patient Supports Targeted Payments
    5. 5. Faster • Safer • Better • Secure Early Feedback
    6. 6. Faster • Safer • Better • Secure
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    8. 8. Faster • Safer • Better • Secure
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    12. 12. Faster • Safer • Better • Secure
    13. 13. Faster • Safer • Better • Secure
    14. 14. Faster • Safer • Better • Secure CAD Lantus Insulin Humalog
    15. 15. Faster • Safer • Better • Secure CAD
    16. 16. Faster • Safer • Better • Secure
    17. 17. Faster • Safer • Better • Secure
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    25. 25. Faster • Safer • Better • Secure
    26. 26. Faster • Safer • Better • Secure Questions?
    27. 27. Faster • Safer • Better • Secure Interested in Participating? Speak with the fine folks at the eHealth Saskatchewan booth here at the Quality Summit!