Diabetes Management

Diabetes is a serious chronic disease and growing health problem. It is the sixth leading cause of death in Ontario a leading cause of cardiovascular disease, amputation, blindness and end-stage renal failure leading to dialysis.

An estimated 1.1 million people in Ontario have type 1 or type 2 diabetes, representing approximately 8.3 per cent of the population. The number is expected to increase by another 734,000 over the next decade reaching 1.9 million by 2020.

The Ontario government seeks to enhance patient care and reduce annual costs to the health care system through the prevention, management and treatment of chronic disease, and has declared diabetes a major health care priority.

The Ministry of Health and Long-Term Care’s (MOHLTC) Ontario Diabetes Strategy (ODS) is addressing this health care priority. In support of ODS, eHealth Ontario is implementing a Diabetes Registry and Portal, built upon a chronic disease management system. It will focus on diabetes and identify patients with the disease and assist primary care providers in offering best practices in diabetes care.

Initial work on identifying the diabetes testing gap

The ODS Baseline Diabetes Dataset Initiative (BDDI) is matching patients with diabetes to primary care providers across Ontario. BDDI gives them their own Diabetes Patient Lists and Diabetes Testing Reports with the most recent dates for the three key tests for diabetes (blood glucose, cholesterol and retinal eye exam) and indicates the percentage of patients whose tests were within recommended guidelines.

BDDI supports physicians in providing better care to patients by identifying their practice testing gaps. Local Health Integration Networks (LHINs) will also have access to information about the diabetes testing gap in their areas in coming months.

The Diabetes Registry will provide a more robust identification of this testing gap and provide trending capabilities for one or multiple test indicators. It will replace the BDDI reports over time.

Diabetes Registry and Portal

The Diabetes Registry will be an interactive, real-time information system designed to support better management of diabetes patient care according to recommended guidelines. Using existing provincial databases, the Diabetes Registry will support evidence-based decision making by capturing and trending lab results and dates for kidney function (albumin to creatinine ratio), cholesterol (low-density lipoprotein) and blood sugar levels (glycated hemoglobin / HbA1c). It will also capture the date of the last retinal screening and diabetes check-up.

Primary care providers can also enter additional information (e.g. blood pressure). The Diabetes Registry will be available to the patient’s care team, ensuring a common understanding of the clinical information that informs the treatment plan. In the future, the Diabetes Registry will also provide patients with self-management guidance and tools.

By integrating with other provincial systems such as the Ontario Laboratories Information System (OLIS) and the Ontario Claims Database, the Diabetes Registry will continually capture lab results and dates and identify newly diagnosed patients with diabetes. It will generate alerts to the appropriate care team members for out-of-range lab results and reminders for overdue or upcoming examinations.

Patient benefits:

• Reduces the need to repeat diabetes information to each member of the care team; the team has access to complete, current and accurate information electronically.
• Enables patients to participate more in their own care plans and set personal targets.
  Allows more time for discussion during the patient visit by giving providers the ability to proactively
   prepare for it.
• Providers can print the patient’s customized care plan for the patient.
• Facilitates the connection of patients without a primary care provider to an available provider
  through Health Care Connect.

Diabetes care provider benefits:

• Ability to view patient health information and monitor compliance with evidence-based interventions.
  
• Improves communication and coordination between care team members, internal and external to the practice.
• Ability to be more proactive in setting patient care plan goals, view progress against targets and receive alerts when best practices are not being followed.
• More time to focus care on higher risk patients.
  
• Supports proactive scheduling of follow-ups and recalls through electronic generation of patient letters that are automatically included in the patient’s record.

Health system benefits:

• Emergency room wait times and use will be reduced.
• Lessons learned will be used for addressing other chronic disease management areas in a more systematic way.
• New patients with diabetes will continue to be identified and information on critical diabetes indicators will be consolidated and updated.
• Provider and patient reminders, alerts and reports on critical diabetes indicators will reduce the gap between evidence-based guidelines and the care Ontarians receive.

Progress to date

• A stringent procurement process led to the selection of a Diabetes Registry and Portal solution with proven success in supporting the management of chronic diseases, including diabetes.
• The successful vendor was chosen in August 2010.
• eHealth Ontario is currently working with the vendor and MOHLTC to tailor the solution to Ontario’s specific needs.

Next steps

A preliminary release to a limited number of sites is planned. It will be followed by a wider provincial rollout.