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LEADing
Practice:
Achieving a High Performing
Health System in Primary Care
The Centre for Family Medicine (CFFM) is an interdisciplinary family health team located in
Kitchener Ontario providing care to over 24,000 patients and has demonstrated leadership at
the provincial and national level for primary care. The CFFM eHealth Centre of Excellence
(eCE), established in 2014, was founded on a vision of creating a collaborative space to share
knowledge, develop best practices and to enable technology to support improved clinical care.
The eCE team provides support to clinicians wishing to integrate electronic tools into their
practice.
Advancing Professional Practice
CFFM worked with the eCE team to leverage the full capabilities of the EMR and support improved patient care by coding 18 chronic conditions using SNOMED CT and ICD-9 in all patient records. This has
enabled the integration of alerts and reminders into the workflow that encourage clinicians to implement
best practices for patients with diabetes and heart failure which can be actioned by multiple members of
the care team. In addition, quick and flexible reports to better inform clinicians and the organization of
the needs of their patients, and which patients with chronic conditions require follow-up care, have also
been made possible.
Improving Continuity of Care
Standardized data and optimized use of the EMR resulted in better identification of patients allowing the
full inter-professional team to better care for complex patients. In addition, through this in-depth chronic
disease coding, patients in need of referral can be more efficiently identified.
Organization:
The Centre for Family
Medicine
Location: Kitchener, Ontario
Sector: Primary Care
Publication Date:
April 13, 2015
Impacting Patients and Providers Building on data standardization efforts, the following clinical decision support tools were able to be
implemented and are being used by clinicians to Enable a High Performing Health System:

ICES EMRALD reporting tool, which provides a practice profile, practice vs. clinic profile, clinic
profile and comparison against other provincial contributors for several care indicators

Medidash Reporting Tool, created by East Wellington Family Health Team, which allows physicians to clearly and quickly identify patients who are not receiving specific best practice care for
diabetes.
Next steps for CFFM & eCE include spreading quality improvement supports, chronic disease management best practices and information management techniques to other primary care organizations within Waterloo Wellington through the Quality Based Improvements in Care (QBIC) Project. CFFM & eCE
also continue to undertake benefits evaluation to better understand the impact of this work.
Critical Success Factors

Change management coaching was deployed to help clinicians incorporate the standardization of
data into their existing workflow; by offering choice on how to code new diagnoses, clinicians are
able to select the method that is most sustainable for them. For example, a simple template was
implemented to allow easy “point and click” coding.

Development of an Implementation Model which can be adopted by other primary care organizations looking to optimize their EMR in order to better understand and manage their chronic disease patient populations.

Establishing a Clinical Best Practice Committee which provides a governance framework for the
implementation of clinic wide best practice guidelines and the development of enabling technologies to support these workflows.
For more information on this LEADing practice, contact: Dr. Mohamed Alarakhia, Family Physician & Director or Ted Alexander, Research Associate info@ehealthce.ca