Chronic disease management in primary health care : a demonstration of EMR data for quality and health system monitoring

Summary: Non-communicable diseases, referred to here as chronic diseases, are the leading cause of death in the world. Adults with multiple chronic diseases, or multimorbidity, tend to be high users of health care services and account for more than two-thirds of health care spending. Since the prevalence of multimorbidity increases with age, effectively managing patients with multiple chronic diseases in primary care is critical. Data on primary health care (PHC) has been identified as a major gap and has been highlighted as a priority for jurisdictions looking to measure and improve chronic disease prevention and management. While billing and survey data can provide part of the picture, a more complete picture of PHC patient encounter data is needed. Use of electronic medical records (EMRs) is increasing rapidly across Canada. Several provinces are investing in programs to encourage the use of EMRs in PHC settings. Because EMR data is designed to include lab results, height, weight, blood pressure measurements and other information used to prevent and manage chronic diseases, it has the potential to inform a wide range of questions on chronic disease management in PHC at the patient, practice and health system levels. This data could be used to inform health policy, resource and population health planning, and evaluation. This study investigates the burden of chronic disease and multimorbidity (the presence of two or more chronic diseases) using EMR data.