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Clinician-Friendly Pick-List Guide

Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 3.0

Our VisionBetter data. Better decisions. Healthier Canadians.

Our MandateTo lead the development and maintenance of comprehensive and integrated health information that enables sound policy and effective health system management that improve health and health care.

Our ValuesRespect, Integrity, Collaboration, Excellence, Innovation

Table of Contents Acknowledgements ..................................................................................................................... 4

About the Canadian Institute for Health Information .................................................................... 6

Introduction ................................................................................................................................. 7 Background/Purpose ............................................................................................................... 7 About This Document .............................................................................................................. 7 Value to Stakeholders ............................................................................................................. 7 Stakeholder Inputs ................................................................................................................... 8

Clinician-Friendly Pick-Lists ........................................................................................................ 9 Overview ................................................................................................................................. 9 CFPL Scope ............................................................................................................................ 9 PHC EMR CS Use Case Scenario ........................................................................................ 10 CFPL Licensing ..................................................................................................................... 13

Adoption, Maintenance and Governance .................................................................................. 14 Adoption ................................................................................................................................ 14 Maintenance .......................................................................................................................... 14 Governance ........................................................................................................................... 14

Stakeholder Implementation Considerations ............................................................................. 15 PHC EMR CS Data Elements ................................................................................................ 15 Additional Data Elements ...................................................................................................... 15 Data Extraction ...................................................................................................................... 15 Other Data Sources ............................................................................................................... 16 PHC Practice Considerations ................................................................................................ 16 PHC Reference Sets ............................................................................................................. 16

Next Steps ................................................................................................................................ 17 Stakeholder Engagement ...................................................................................................... 17 EMR Demonstration .............................................................................................................. 17 CIHI Contact Information and Companion Products .............................................................. 17

Appendix A: PHC EMR CS Data Elements ............................................................................... 18

Appendix B: PHC EMR CS Priority Subset—Data Element Matrix ............................................ 19

Appendix C: CIHI’s Pan-Canadian PHC EMR–Related Indicators—Definitions ........................ 28

Appendix D: CIHI’s Pan-Canadian PHC EMR–Related Indicators—Relation to the Priority Subset of Data Elements ...................................................................................... 38

Appendix E: Glossary of Terms ................................................................................................. 45

Bibliography .............................................................................................................................. 47

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Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 3.0—Clinician-Friendly Pick-List Guide

Acknowledgements The Canadian Institute for Health Information (CIHI) would like to acknowledge and thank the many individuals and organizations that contributed to the development of this product. In particular, CIHI would like to acknowledge and express its appreciation to the members of the Jurisdictional Advisory Group (JAG) who provided invaluable guidance in developing the content for the Primary Health Care Electronic Medical Record Content Standard Priority Subset.

CIHI would also like to acknowledge the stakeholders who were engaged to validate and provide input to the Clinician-Friendly Pick-Lists (CFPLs). This included a pan-Canadian mix of primary care clinicians, nurse practitioners, decision-support specialists, jurisdictional representatives and Canada Health Infoway.

Jurisdictional Advisory Group Tom Fogg (Co-Chair) Consultant, Primary Health Care Manitoba Health

Jeff Aitken Director, Conformance and Integration Services, Health IT Strategy Branch British Columbia Ministry of Health

Tom Alteen Project Manager Newfoundland and Labrador Centre for Health Information

Claire Bernatchez Health Information Management Advisor Treasury Board Secretariat of Canada

Neil Gardner Strategic Advisor Saskatchewan Health

Christine Grimm Acting Chief Health Information Officer eHealth Nova Scotia

Caroline Heick (Co-Chair) Executive Director, Ontario, Quebec and Primary Health Care Information Canadian Institute for Health Information

Cheryl Hansen Executive Director, Innovation, eHealth New Brunswick Department of Health

Michele Herriot Chief Information Officer Northwest Territories Department of Health and Social Services

Martin Joy Director, Health Information Nunavut Department of Health and Social Services

Denise Junek Vice President, eHealth and Business Relations eHealth Saskatchewan

Janet Nyberg Manager, Information Systems Yukon Department of Health and Social Services

Sylvia Robinson Director, Primary Care British Columbia Ministry of Health

Christine Sham Manager, Strategy, Planning and Alignment eHealth Liaison Branch Ontario Ministry of Health and Long-Term Care

Sonya Stasiuk Director, Data Management Unit Alberta Health and Wellness

Liam Whitty Executive Director, Health Information Management Health PEI

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Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 3.0— Clinician-Friendly Pick-List Guide

CFPL Validation Stakeholders Dr. Tim Kolotyluk Family Physician Alberta

Dr. Leo Wong Family Physician British Columbia

Gillian Brennan Project Director Manitoba

Dr. Carol Critchley Family Physician Nova Scotia

Dr. Leslie Griffin Family Physician Nova Scotia

Dr. John Campbell Family Physician Newfoundland and Labrador

Dr. Avnish Mehta Family Physician Ontario

Sheri Ross Senior Clinical Analyst Alberta

Dr. Leslie Sank Family Physician British Columbia

Dr. Robert Oliver Family Physician Nova Scotia

Pamela Biggs Business Analyst Nova Scotia

Patsy Smith Nurse Practitioner Nova Scotia

Cindy Hollister Clinical Leader, Clinical Adoption Canada Health Infoway

Dr. Ben Chan Assistant Professor University of Toronto

Dr. Ed Hirvi Family Physician Ontario

Dr. Mohamed Alarakhia Family Physician Ontario

Dr. Jennifer Rayner Family Physician Ontario

Sara Dalo Quality Improvement Decision Support Ontario

Dr. Wayne Parsons Family Physician Ontario

Carol Quinlan Nurse Practitioner Ontario

Chelsea Good Quality Improvement Decision Support Ontario

Ibrahim Omar Nurse Practitioner Ontario

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CIHI Project Team The core CIHI project team responsible for developing the Pan-Canadian Primary Health Care Electronic Medical Record Content Standard included

• Alison Bidie, Project Lead, Primary Health Care Information Program

• Jing Howard, Senior Coordinator, Primary Health Care Information Program

• Deepak Swain, Analyst, Primary Health Care Information Program

• Mary Byrnes, Manager, Primary Health Care Information Program

• Caroline Heick, Executive Director, Ontario, Quebec and Primary Health Care Information

Significant project contributions were also made by Husam Alqatami, Finnie Flores, Andrew Goosen, Alana Lane, Shaheena Mukhi, Martin Ortuzar, Isabelle Roberge, Maria Sanchez, Ginette Therriault, Cristina Tomsa and Jennifer Trebell.

This product could not have been completed without the generous support and assistance of many other CIHI departments, including Classifications and Terminology, Information Technology and Services, Publishing and Translation, Communications, and Distribution, and the CIHI Standards Working Group, who provided ongoing support to the core team.

About the Canadian Institute for Health Information The Canadian Institute for Health Information (CIHI) collects and analyzes information on health and health care in Canada and makes it publicly available. Canada’s federal, provincial and territorial governments created CIHI in 1994 as a not-for-profit, independent organization dedicated to forging a common approach to Canadian health information. CIHI’s goal is to provide timely, accurate and comparable information. CIHI’s data and reports inform health policies, support the effective delivery of health services and raise awareness among Canadians of the factors that contribute to good health. The year 2014 marks CIHI’s 20th anniversary of operation.

For more information, visit our website at www.cihi.ca.

http://www.cihi.ca/CIHI-ext-portal/internet/EN/Home/home/cihi000001

http://www.cihi.ca/

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Introduction Background/Purpose CIHI has been leading the initiative to improve primary health care (PHC) data and information across Canada, in alignment with Canada’s federal, provincial and territorial governments and electronic medical record (EMR) programs. Data and information standards are the foundation of relevant and useful information. Standards ensure the consistent collection of data that is comparable and measurable. The Pan-Canadian Primary Health Care Electronic Medical Record Content Standard (PHC EMR CS) was thus created as a pan-Canadian solution to facilitate the capture of structured EMR data at the point of care. Environmental scans and stakeholder consultation recommended a smaller, more focused scope of priority data elements and highlighted the need for Clinician-Friendly Pick-Lists (CFPLs). In April 2014, CIHI released a PHC EMR CS Priority Subset (45 of the 106 data elements) to accelerate EMR content standards adoption across Canada. Refer to Appendix A for the data elements that are in scope. CIHI also developed CFPLs for 8 priority data elements. For more information, please refer to Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 3.0—Business View, available at www.cihi.ca/phc.

About This Document This guidance document is intended to provide jurisdictions and EMR vendors with information about the use of PHC EMR CS data elements, CFPLs and PHC reference sets (ref sets). The guide includes details about the scope and intended use of the standard, the value to stakeholders and implementation considerations. It is anticipated that the Priority Subset and associated CFPLs and ref sets will be included in EMR vendor requirements. This document does not contain technology-specific implementation guidance (e.g., how to extract data from an EMR, how to design EMR user interfaces to facilitate clinician data capture, how to load EMR data into a repository to support health system use). Over time, future EMR demonstration projects and implementation experience will inform version updates of the CS, CFPLs and associated guidance materials.

The companion products supporting the PHC EMR CS include an information sheet, the Business View v3.0, Data Models v3.0, Technical Guidance v3.0 and CFPL Spreadsheets v1.0. These products are available on CIHI’s website at www.cihi.ca/phc.

Value to Stakeholders When implemented at the point of care, it is anticipated that the Priority Subset and the associated CFPLs will increase the availability of structured, comparable EMR data to support priority information needs at the practice and health system levels. The focused scope of the CFPLs is intended to support priority PHC information needs and CIHI’s pan-Canadian PHC EMR–related indicators. For PHC clinicians, this means better EMR data to inform improvements to the quality of care, patient safety and efficiency in their practices.

https://secure.cihi.ca/free_products/PHC_EMR_Content_Standard_V3.0_Business_View_EN.pdf

https://secure.cihi.ca/free_products/PHC_EMR_Content_Standard_V3.0_Business_View_EN.pdf

http://www.cihi.ca/phc


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Similarly, structured EMR data will be an asset at the health system level and will support monitoring of chronic disease prevention and management, health outcomes, health promotion and quality of care. EMR vendors will also benefit from a single, usable pan-Canadian standard that has the potential to lower EMR implementation and maintenance costs in the longer term.

Stakeholder Inputs The Priority Subset was developed in consultation with the JAG, whose members validated the data elements with their respective stakeholders. Prince Edward Island, Nova Scotia, Ontario, Manitoba, Saskatchewan, Alberta, British Columbia and the Northwest Territories provided input. In addition, stakeholders representing federal organizationsi were engaged to provide feedback. The final 45 data elements were endorsed by the JAG in December 2013.

Stakeholder input also informed the development of the CFPLs. In March 2014, the draft clinician-friendly terms were validated by a cross-section of stakeholders, including PHC clinicians, nurse practitioners, decision-support specialists, jurisdictional representatives and Canada Health Infoway. Feedback from stakeholders informed the final CFPL scope. In May 2014, the updated CFPLs and a plan to map them to relevant code systems were also reviewed by the JAG.

i. Health Canada, Department of National Defence, Public Health Agency of Canada, Correctional Service Canada.

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Clinician-Friendly Pick-Lists Overview The CFPLs are constrained lists of clinician-validated terms commonly used in PHC settings. CFPLs were developed for 8 Priority Subset data elements: Health Concern, Clinician Assessment, Social Behaviour, Reason for Visit, Intervention, Diagnostic Imaging Test Ordered, Referral and Vaccine Administered.

The CFPLs were developed to support aggregate-level reporting and analysis; in order to facilitate this, the CFPL terms were mapped to recognized code systems. Table 1 summarizes the CFPLs and the corresponding code system maps.

Table 1: CFPL Mapping to Code Systems

CFPL Description Code System Maps Available In Health Concern ICD-10-CA and ICD-9 Clinician Assessment ICD-10-CA and ICD-9 Social Behaviour ICD-10-CA and ICD-9 Reason for Visit ICD-10-CA and ICD-9

Intervention CCI Diagnostic Imaging Test Ordered CCI Referral Service SNOMED CT Vaccine Administered SNOMED CT

Note See Appendix E for descriptions of the code systems.

CFPL Scope The CFPL terms are intended to be captured as a minimum priority subset of information to facilitate standardized data capture at the point of care. Terms were identified to support a variety of needs for aggregate information at the practice level and to support quality improvement. Consideration was also given to uses such as population health and disease surveillance. Other scope considerations, such as enabling the use of PHC priority indicators and jurisdictional PHC information needs, were taken into account. Refer to Table 2 for detailed scope information.

The CFPLs do not include terms that are typically not critical to priority information needs expressed by CIHI’s stakeholders. For example, signs and symptoms (e.g., knee pain) as well as individual problem lists were not included in the Health Concern CFPL. In addition, the scope is mostly focused on data relevant to the PHC environment. For instance, past surgical interventions are out of scope, with a few exceptions required to support a PHC priority indicator.

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Table 2: CFPL Scope

CFPL Name In Scope Out of Scope Reason for Visit High-frequency complaints, symptoms, follow-ups,

requests for referral/services/medicine renewals

Health Concern Chronic conditions, comorbidities, ambulatory care and family practice sensitive conditions, special interests of population health, major previous medical history

Signs and symptoms, suspected/ query conditions, past surgeries

Social Behaviour Negative social behaviours (e.g., tobacco use, abuse of prescription drugs)

Occupations, positive social behaviours

Clinician Assessment Diagnoses, comorbidities, chronic conditions, ambulatory care sensitive conditions

Signs and symptoms, past history

Intervention Services/procedures relevant to PHC setting (e.g., counselling, education, examinations, past surgical interventions performed outside the PHC setting but relevant to PHC care)

Activities captured discretely in other data elements (e.g., diagnostic imaging tests, medications, lab tests, vaccines)

Diagnostic Imaging Test Ordered

Diagnostic imaging tests required for priority indicators such as cancer screening (mammogram) and bone density screening (bone mineral densitometry), high-frequency and special interest diagnostic imaging tests

Referral Types of specialty services (e.g., cardiology) Specialist descriptions (e.g., cardiologist), low-frequency services (e.g., faith healer)

Vaccine Administered High-frequency and mandatory vaccines and those included by the National Advisory Committee on Immunization (NACI); supports indicators on influenza, pneumococcal and childhood immunizations

PHC EMR CS Use Case Scenario What Is a Use Case? Use cases provide scenarios that describe the electronic transmission points of a common set of data elements between an end user and another system to link knowledge and achieve a specific business goal. For example, the structured capture of patient administrative and clinical data from a PHC encounter supports the calculation of PHC priority health indicators for clinicians, health system planners and policy-makers.

A use case includes the following components:

• Narrative: A brief story about people’s interactions with specific aspects of the PHC system.

• Swim lane diagram: A picture of the people, systems and EMR data involved in specific aspects of PHC systems. Each swim lane represents the action of a person or a system. In each lane, actions are initiated by an actor and result in data inputs or outputs to the system.

• Flow of events: A sequential flow of actions, derived from the narrative, that corresponds to key points in the swim lane diagram. Each step in the sequential flow of actions is referenced in the diagram as a numbered circle.

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Use Case: Narrative

At the onset of an encounter, patient administrative details are captured in the EMR, followed by the additional clinical data captured by a nurse and then a PHC clinician. Priority data elements such as Health Concern, Social Behaviour (risk factors) and Intervention are captured in the EMR in a structured format. Other data elements are captured when applicable, such as Vaccine Administered and Diagnostic Imaging Test Ordered. The collection of these priority data elements is supported by underlying CFPLs and PHC ref sets to enable structured EMR data at the point of care.

Once captured within the EMR, the structured data is used to support improvements to quality of care and health outcomes. In a standardized format, the EMR data can be aggregated for comparable reporting to support performance measurement at the practice and health system levels. The priority data elements can also be used to directly support the calculation of priority PHC indicators for use by clinicians, health system planners and policy-makers.

Use Case: Swim Lane Diagram

Figure 1 provides an example of a swim lane diagram.

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Figure 1: Use Case: Swim Lane Diagram

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Notes * Data element with an associated CFPL. † Data element with an associated constrained PHC ref set. Please refer to Appendix C for indicator definitions.

Patient arrives at PHC clinic based on his/her appointment

(set up before)

Administrative details • Patient Identifier • Patient Date of Birth • Patient Gender • Reason for Visit* • Visit Date

Nurse assesses the patient

• Blood pressure • Height • Weight

Physician assesses the patient based on

the Reason for Visit

Social Behaviour* • Smoking • Physical inactivity • Obesity

Relevant past and present medical history followed by physical examination (both general and regional based on Reason for Visit and risk factors)

• Health Concerns* • Clinician Assessment* • Intervention* • Diagnostic Imaging

Test Ordered* • Vaccine Administered†

Electronic medical record

Administrative details recorded by receptionist/

nurse

1 2

Indicators related to monitoring population health (for policy-makers) • Breast cancer screening • Cervical cancer screening • Child immunization • Overweight and obesity rate

Indicators related to chronic disease management (for clinicians) • Blood pressure control for hypertension • Screening for modifiable risk factors in adults with hypertension • Screening for modifiable risk factors in adults with diabetes • Screening for modifiable risk factors in adults with coronary artery disease

3

4 5

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Use Case: Flow of Events

1. The patient arrives at a PHC clinic for a scheduled appointment.

2. The receptionist/nurse records administrative details and Reason for Visit of the patient.

3. The nurse assesses the patient and captures systolic blood pressure, diastolic blood pressure, height, weight, etc., in the EMR.

4. The physician reviews the nurse’s assessment information in the EMR and, based on Reason for Visit, gathers relevant past and present medical history and performs physical examination and risk factor assessment.

5. Based on Reason for Visit, medical history and clinical examination, all health concerns are listed. Finally, the most relevant health concern related to the Reason for Visit is identified as the Clinician Assessment.

6. The data captured in the EMR at different stages during an encounter is used by clinicians and health system policy-makers to aggregate information to facilitate quality improvement and analysis of health system performance.

CFPL Licensing In order to protect the integrity of the CFPL terms and associated mapping to the relevant code systems, licence agreements are required for use by stakeholders, including commercial vendors, governments, non-commercial entities and others.

These agreements provide stakeholders with access to the CFPLs and the code mappings so they can adopt and implement them. Stakeholders are required to sign and submit an annual licence agreement before gaining access to the CFPLs.

For additional information about licence agreements, send an email to [email protected].

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Adoption, Maintenance and Governance Adoption It will be critical for jurisdictions to include the Priority Subset and associated CFPLs and PHC ref sets in their EMR vendor requirements to realize the benefits of structured EMR data collection at the point of care. However, incorporating the PHC EMR CS into an EMR specification does not, on its own, translate into the collection of meaningful, structured EMR data. Other key enablers to adoption include jurisdictional and clinician leadership, clear data governance, collaborative partnerships, change management, capacity-building and policy frameworks.

CIHI’s role in supporting the PHC EMR CS is to provide usable tools and products to jurisdictional stakeholders that are aligned with their priorities. CIHI will also offer subject matter expertise and technical guidance to implementers.

It is anticipated that jurisdictions will include the PHC EMR CS and CFPLs in their EMR vendor requirements. For details on PHC EMR CS data elements, refer to Appendix B. For additional information about obtaining the CFPLs, send an email to [email protected].

Maintenance CIHI will work with jurisdictions and other key partners to inform the refinement and evolution of the PHC EMR CS and CFPLs over time. Changes to data elements and clinician-friendly terms and further mapping to code systems will be driven by jurisdictional priorities and information needs, as well as the capability and interest of clinicians to collect additional data in a structured format. A maintenance plan will be developed by CIHI. The plan will include a stakeholder change request process with input from the JAG. However, the Priority Subset and CFPLs will remain stable and unchanged until piloting of the CFPLs has been completed. Additional implementation considerations will be identified at that stage and incorporated into the next generation of PHC EMR CS products.

Canada Health Infoway will continue to retain accountability for the PHC ref sets associated with the PHC EMR CS. CIHI will continue to collaborate with Canada Health Infoway in the area of standards and other opportunities to influence the standardization of EMR data.

Governance Oversight of the PHC EMR CS and CFPLs will be the responsibility of the Primary Health Care Information program at CIHI. Governance and endorsement of these products will continue to be driven through consultation with jurisdictional stakeholders. It should be noted that the use of the PHC EMR CS and CFPLs by jurisdictions and PHC providers is on a voluntary basis. Jurisdictions may choose to endorse these products and/or mandate their use by all PHC providers or by subsets of regional/local providers; they may also choose to encourage their use through other accountability mechanisms and agreements. CIHI does not have the authority to mandate the use of these products or the collection of data using these standards.

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Stakeholder Implementation Considerations PHC EMR CS Data Elements Stakeholders are encouraged to adopt all Priority Subset data elements in their EMR vendor requirements. The Data Element Matrix in Appendix B provides a detailed view of the Priority Subset of 45 data elements, including data element definitions, data types, valid formats, examples in primary care use and applicable CFPLs or PHC ref sets.

Note that the Priority Subset of data elements supports CIHI’s pan-Canadian PHC indicators. Information about the EMR-related indicators and how the data elements relate to the specific indicators can be found in appendices C and D, respectively.

Additional Data Elements Federal, provincial and territorial stakeholders may choose to define and collect additional EMR data elements beyond the Priority Subset and/or the original 106 data elements in the PHC EMR CS. This decision will be driven and supported by individual jurisdictional program needs. In turn, CIHI will consider including these additional elements in the Priority Subset and/or PHC EMR CS in the longer term.

When jurisdictional stakeholders consider using additional data elements beyond the Priority Subset, it is recommended that the core relationships in the underlying data models be retained. This will facilitate the use of the resulting EMR data for PHC indicator calculations.

Please send an email to [email protected] or visit CIHI online at www.cihi.ca/phc for further guidance when considering the inclusion of additional data elements. For more information, please refer to Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 3.0—Technical Guide (April 2014), available at www.cihi.ca/phc.

Data Extraction CIHI’s current focus is on providing tools to facilitate the capture of structured EMR data at the point of care. As such, the previously released pan-Canadian Data Extraction Specification (DES) v2.1 has not been updated. CIHI will evaluate the need to update the DES, depending on the needs of jurisdictions choosing to implement the PHC EMR CS.

When stakeholders plan for EMR data extraction, it is important that the solution supports the data relationship as reflected in the PHC EMR Data Models, v3.0. Jurisdictions are advised to consider existing jurisdictional data transfer solutions, as well as pan-Canadian directions/trends in data interoperability.

Please contact CIHI for further guidance when considering EMR data extraction. CIHI is interested in collaborating with jurisdictions that are implementing the PHC EMR CS, including the CFPLs.


https://secure.cihi.ca/free_products/PHC_EMR_Content_Standard_V3.0_Technical_Guide_EN.pdf

https://secure.cihi.ca/free_products/PHC_EMR_Content_Standard_V3.0_Technical_Guide_EN.pdf


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Other Data Sources PHC data may also include data that is transferred into the EMR from other external sources, such as a drug information system (e.g., lab prescriptions, dispenses), a lab system (e.g., lab results), diagnostic imaging repositories (e.g., diagnostic imaging reports), provincial electronic health record (EHR) repositories (e.g., clinical documents, allergies) or other EMRs (e.g., clinical summaries, referrals). Implementers will need to consider how to transform the data transferred into the EMR from external sources to align with the supported Priority Subset and/or CFPL code system(s) (e.g., to convert free-text information to coded data).

PHC Practice Considerations Should there be existing pick-lists in a PHC practice, it is recommended that these local lists be compared with the CFPL terms for alignment. The CFPL terms are generally broad descriptions (e.g., depression, asthma) that map to high-level codes to support aggregate-level reporting at the practice level and for health system use.

In order to maintain a standard approach to data capture, terms in the CFPLs are recommended as the terms of choice that can be easily viewed in the EMR interface to facilitate standardized data capture at the point of care. For example, when Alzheimer’s disease is typically captured in a PHC practice, the standardized description for Alzheimer’s disease from the CFPL should be adopted, not the local description, to reduce duplication and potential data quality issues.

Additional terms can be implemented as required by PHC clinicians. However, it will be the responsibility of the implementer to incorporate these additional terms into the EMR and undertake associated mapping to code systems where needed. In order to align to the CFPL development process, it is recommended that additional terms remain broad, unless there is a specific need for added granularity. For example, should additional mental health diseases be included in the pick-list, include the general description as a starting point and map to a high-level code category. This approach will facilitate analysis and aggregate-level reporting. Over time, through implementation experience and stakeholder feedback, the CFPL scope will evolve, and CIHI may include more granular terms and codes where required. For additional guidance on the CFPLs, please send an email to [email protected].

PHC Reference Sets Canada Health Infoway, in collaboration with CIHI, led the development of the PHC ref sets. The ref sets are intended to support the PHC EMR CS data elements and, when implemented, will enable structured EMR data at the point of care. For example, Patient Gender, Visit Type and Patient Identifier Type all have associated ref sets. The Priority Subset data elements are supported by 15 PHC ref sets in addition to the 8 CFPLs. Refer to Appendix A for details.

In the development of CFPLs, some ref sets were constrained to support the focused scope (e.g., Vaccine Administered, Referral). For more information about the ref sets, visit Canada Health Infoway at https://infocentral.infoway-inforoute.ca/2_Standards.

https://infocentral.infoway-inforoute.ca/2_Standards

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Next Steps Stakeholder Engagement CIHI will engage jurisdictional representatives and vendors to promote the PHC EMR CS and CFPLs. In turn, jurisdictions and other primary health care stakeholders should consider the potential implementation of these products via PHC EMR programs and with jurisdictional partners.

EMR Demonstration CIHI will explore opportunities with ready jurisdictions or partners to engage in EMR demonstration projects or pilot projects where there is a commitment by the jurisdiction and/or partner to collect some structured data at the point of care. These local projects will form the basis for larger regional initiatives leading to a pan-Canadian approach. Future EMR demonstration projects will inform the evolution of the PHC EMR CS and CFPLs to ensure they continue to support health system use and priority PHC information needs for clinicians, health system planners and policy-makers. These projects will also inform CIHI’s approach and timing in considering resuming the collection of EMR data in a systematic way.

CIHI Contact Information and Companion Products For more information on the PHC EMR CS or CFPLs, or to learn more about PHC in Canada, please email the Primary Health Care Information program at [email protected] or visit CIHI’s website at www.cihi.ca/phc. The website also provides access to the following companion products: Business View (version 3.0); Technical Guide (version 3.0); Data Models (version 3.0) and an information sheet. Contact CIHI to learn how to purchase and access the Pan-Canadian Clinician-Friendly Pick-List Spreadsheets (version 1.0).


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Appendix A: PHC EMR CS Data Elements DE # Data Element Name DE # Data Element Name A1 Patient Identifier E29 Height Unit of Measure* A2 Patient Identifier Type* E30 Weight A3 Patient Identifier Assigning Authority* E31 Weight Unit of Measure* A4 Patient Date of Birth E34 Clinician Assessment A5 Patient Gender* F1 Intervention A9 Patient Status* F2 Intervention Date A14 Patient Postal/Zip Code G1 Lab Test Ordered* B4 Clinician Identifier G2 Lab Test Ordered Date B5 Clinician Identifier Type* H1 Lab Test Performed Date B6 Clinician Identifier Assigning Authority* H2 Lab Test Name* B7 Clinician Role* H3 Lab Test Result Value C1 Service Delivery Identifier H4 Lab Test Result Unit of Measure* C4 Service Delivery Postal Code I1 Diagnostic Imaging Test Ordered D1 Appointment Creation Date I2 Diagnostic Imaging Test Ordered Date D2 Reason for Visit J1 Diagnostic Imaging Test Performed Date D3 Visit Date K1 Referral* D4 Visit Type* K2 Referral Requested Date E11 Health Concern L1 Referral Occurred Date E12 Health Concern Date of Onset M1 Prescribed Medication E14 Social Behaviour M2 Prescription Date E23 Systolic Blood Pressure O1 Vaccine Administered* E24 Diastolic Blood Pressure O2 Vaccine Administered Date E28 Height

Notes * Data elements with PHC ref sets. Data elements highlighted in grey have CFPLs.

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Appendix B: PHC EMR CS Priority Subset—Data Element Matrix

Data Element Number

Data Element Common Name

Data Element Standard Name

Data Element Definition

Data Type

Valid Format

Example Values

Permissible Values Source Name

Type of Source for Permissible Values

Code System

Permissible Values Source ID

Example of Primary Care Use

A1 Patient Identifier

Client Identifier Represents a unique identifier assigned to the Client.

Identifier N/A N/A N/A N/A Used in the provision and administration of care. Can be used to associate administrative information (e.g., demographic) and health information (e.g., lab results) with the Client.

A2 Patient Identifier Type

Client Identifier Type Code

Represents the type of Client Identifier (e.g., jurisdictional health care identifier, passport).

Code N/A Jurisdictional health number

ClientIdentifierTypeCode

PHC Reference Set

SNOMED CT®

2.16.840.1. 11388.3.2.20. 3.255

Helps differentiate the type of identifier used to identify the Client. In conjunction with the Client Identifier, can be used to associate administrative information (e.g., demographic) and health information (e.g., lab results) with the Client.

A3 Patient Identifier Assigning Authority

Client Identifier Assigning Authority Code

Represents the legal entity/ organization responsible for assigning the Client Identifier.

Code N/A Ministry of Health Alberta (qualifier value)

ClientIdentifier AssigningAuthorityCode

PHC Reference Set

SNOMED CT®

2.16.840.1.113883.2.20.3.256

Helps identify the organization that issued the identifier when a Client can have multiple identifiers. In conjunction with the Client Identifier, can be used to associate administrative information (e.g., demographic) and health information (e.g., lab results) with the Client.

A4 Patient Date of Birth

Client Birth Date

Represents the Client’s date of birth.

Date YYYYMMDD 20101001 N/A N/A N/A N/A Birthdate is used to validate the identity of the Client. It is also used to ensure that the right drug and lab reference ranges are used for the Client.

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Data Element Number




Data Type Valid Format

Example Values



Code System



A5 Patient Gender

Client Administrative Gender Code

Represents the reported gender category of the Client at a given time.

Code N/A Male AdministrativeGender

PHC Reference Set

HL7 2.16.840.1.113883.2.20.3.308

Used for administrative purposes. Can be used for identification matching and confirmation.

A9 Patient Status

Client Status Code

Represents whether or not the PHC Provider considers the Client to be actively seeking PHC services through him or her.

Code N/A Patient active (finding)

ClientStatusCode

PHC Reference Set

SNOMED CT®

2.16.840.1.113883.2.20.3.191

Ensures that inappropriate reminders are not sent to Clients who have a status of inactive with the Provider.

A14 Patient Postal/Zip Code

Client Residence Postal Code

Represents the postal code of the Client’s primary residence.

String ANA NAN K0K 3R0 N/A N/A N/A N/A Provides a part of the Client’s address, which can be used to help find Service Delivery Locations that are close to the Client’s home.

B4 Clinician Identifier

Provider Identifier

Represents a unique identifier assigned to the Provider.

Identifier N/A 82356743 N/A N/A N/A N/A Can be used to link Client records and billing information to a specific Provider. Can be used to support authorization to access sensitive records.

B5 Clinician Identifier Type

Provider Identifier Type Code

Represents the type of Provider Identifier.

Code N/A Provider billing number (qualifier value)

ProviderIdentifierTypeCode

PHC Reference Set

SNOMED CT®

2.16.840.1.113883.2.20.3.257

In conjunction with the Provider Identifier, can be used to link Client records and billing information to a specific Provider. Can be used to support authorization to access sensitive records.

B6 Clinician Identifier Assigning Authority

Provider Identifier Assigning Authority Code

Represents the legal entity responsible for assigning the unique identifier to the Provider.

Code N/A Health regulatory body for physicians and surgeons (qualifier value)

ProviderIdentifierAssigningAuthorityCode

PHC Reference Set

SNOMED CT®

2.16.840.1.113883.2.20.3.252

In conjunction with the Provider Identifier, can be used to link Client records and billing information to a specific Provider. Can be used to support authorization to access sensitive records.


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Example Values



Code System



B7 Clinician Role Provider Role Type Code

Represents the role of the Provider in relation to his or her participation in a specific health care event.

Code N/A Primary care physician (occupation)

ProviderRoleCode

PHC Reference Set

SNOMED CT®

2.16.840.1.113883.2.20.3.265

Used to distinguish roles within a health care setting. Can be used to restrict access to Client data by role type.

C1 Service Delivery Identifier

Service Delivery Location Identifier

Represents the unique identifier of the practice (Service Delivery Location) where the Client received care.

Identifier N/A 897564RT N/A N/A N/A N/A Name of the Service Delivery Location is referenced on letters sent to Clients.

C4 Service Delivery Postal Code

Service Delivery Location Postal Code

Represents the postal code where the Client received the PHC service.

String ANA NAN K0K 3R0 N/A N/A N/A N/A Provides a part of the Service Delivery Location address, which helps Clients know where to go for service.

D1 Appointment Creation Date

Encounter Request Date

Represents the date on which an appointment was created for the Client by the Provider (or his or her staff).

Date YYYYMMDD 20100430 N/A N/A N/A N/A Helps identify wait times for specific Providers.

D2 Reason for Visit

Client Encounter Reason Code

Represents the reason for the encounter as conveyed by the Client.

Code N/A R51 Reason for Visit CFPL

CFPL ICD-10-CA

2.16.840.1.113883.3.1780.5.12.2.3

Can be used to give the Provider advance notice of information that may need to be addressed with the Client during the encounter. Can assist in scheduling the amount of time a Client may need with the Provider.

D3 Visit Date Encounter Date

Represents the date the Client had an encounter with the Provider.

Date YYYYMMDD 20101001 N/A N/A N/A N/A Can report on Client wait times for scheduled Clients and track the continuum of care provided to Clients.


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Code System



D4 Visit Type Encounter Mode Code

Represents the type of contact between the Provider and the Client.

Code N/A Direct Encounter Client Alone (procedure)

EncounterTypeCode

PHC Reference Set

SNOMED CT®

2.16.840.1.113883.2.20.3.207

Can be used to track services provided that may require special billing processes. Can be used to track percentage of Clients treated through various modes of visits.

E11 Health Concern

Observation Health Concern Code

Represents the Client’s relevant conditions, diagnoses and major past medical history.

Code N/A J44.9 Health Concern CFPL

CFPL ICD-10-CA

2.16.840.1.113883.3.1780.5.12.2.1

Provides a longitudinal record of health problems for a Client. Clinicians can use this information to monitor the health of their Clients, recommend treatments and assist in the formation of diagnoses.

E12 Health Concern Date of Onset

Observation Health Concern Start Date

Represents the date on which the Client’s health concern started.

Date YYYYMMDD 20100430 N/A N/A N/A N/A Provides a longitudinal record of health problems for a Client. Clinicians can use this information to monitor the health of their Clients.

E14 Social Behaviour

Observation Social Behaviour Code

Represents a type of Client social behaviour that increases the possibility of disease or injury for the Client. This can include risk factors such as tobacco use, alcohol use and abuse of illicit or prescription drugs.

Code N/A Z72.0 Social Behaviour CFPL

CFPL ICD-10-CA

2.16.840.1.113883.3.1780.5.12.2.4

Can be used to identify Client behaviours or risk factors that, if treated, could lead to improvements in the Client’s health and wellness.


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Example Values



Code System



E23 Systolic Blood Pressure

Observation Systolic Blood Pressure Number

Represents the Client’s systolic blood pressure value (in mmHg) as measured. The unit of measure (mmHg) is implied when representing the value.

Number N/A 120 N/A N/A N/A N/A A discrete value provides the ability to graph and trend values over time. The measurement supports clinical decisions.

E24 Diastolic Blood Pressure

Observation Diastolic Blood Pressure Number

Represents the Client’s diastolic blood pressure value (in mmHg) as measured. The unit of measure (mmHg) is implied when representing the value.

Number N/A 120 N/A N/A N/A N/A A discrete value provides the ability to graph and trend values over time. The measurement supports clinical decisions.

E28 Height Observation Height Number

Represents the height of the Client as measured.

Number N/A 3.25 N/A N/A N/A N/A A decrease in female height could be an early sign of osteoporosis and trigger a need for a bone mineral density test.

E29 Height Unit of Measure

Observation Height Unit of Measure Code

Represents the unit of measure used to capture the Client’s height.

Code N/A Centimetre HeightUnitofMeasureCode

PHC Reference Set

UCUM 2.16.840.1.113883.2.20.3.194

A decrease in female height could be an early sign of osteoporosis and trigger a need for a bone mineral density test.

E30 Weight Observation Weight Number

Represents the weight of the Client as measured.

Number N/A 75.6 N/A N/A N/A N/A Weight is used to calculate body mass index (BMI).

E31 Weight Unit of Measure

Observation Weight Unit of Measure Code

Represents the unit of measure used to capture the Client’s weight.

Code N/A Kilogram WeightUnitofMeasureCode

PHC Reference Set

UCUM 2.16.840.1.113883.2.20.3.195

Weight is used to calculate BMI.


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Example Values



Code System



E34 Clinician Assessment

Observation Encounter Clinical Assessment Code

Represents the Provider’s professional opinion of the most significant condition related to the Client’s current encounter following clinical assessment.

Code N/A J45.9 Clinician Assessment CFPL

CFPL ICD-10-CA

2.16.840.1.113883.3.1780.5.12.2.6

The clinical assessment of the encounter can be used to help track episodes of care. Can also support the automatic creation of billing information.

F1 Intervention (Treatment)

Intervention Code

Represents the services or activities performed for the Client within the PHC setting as well as relevant intervention history that occurred beyond the PHC setting.

Code N/A 7.SP.10.VK Intervention CFPL

CFPL CCI 2.16.840.1.113883.3.1780.5.12.2.2

Tracked interventions performed on a Client can help guide future interventions. Used to track Client’s progressive improvement on the continuum of care timeline (e.g., counselling for smoking cessation delivered in 2012).

F2 Intervention (Treatment) Date

Intervention Date

Represents the date the intervention was performed.

Date YYYYMMDD 20100430 N/A N/A N/A N/A Used in the provision of care to track the date a particular intervention was performed by the Provider.

G1 Lab Test Ordered

Laboratory Test Name Ordered Code

Represents the lab test ordered by the Provider for the Client.

Code N/A Hemoglobin A1c in Blood

ObservationOrderableLabType

PHC Reference Set

LOINC®, pCLOCD

2.16.840.1.113883.2.20.3.164

Used in the provision of care (e.g., confirmation of suspected diagnoses). The lab test name is required to know what test is being ordered.

G2 Lab Test Ordered Date

Laboratory Test Order Date

Represents the date the lab test was ordered by the Provider.

Date YYYYMMDD 20100430 N/A N/A N/A N/A Supports scheduling of future appointments based on the tracked turnaround time of lab tests.


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Example Values



Code System



H1 Lab Test Performed Date

Laboratory Test Performed Date

Represents the date the lab test was performed.

Date YYYYMMDD 20100430 N/A N/A N/A N/A Schedule future appointments based on the tracked turnaround time of lab tests.

H2 Lab Test Name

Laboratory Test Result Name Code

Represents the lab test performed.

Code N/A Hemoglobin (Mass/ Volume) in Blood

ObservationResultableLabType

PHC Reference Set

LOINC®, pCLOCD

2.16.840.1.113883.2.20.3.105

Used to ensure that the name of the test performed is understood by the Provider, researcher, etc.

H3 Lab Test Result Value

Laboratory Test Result Value Text (Number, Code)

Represents the result of the lab test.

String (Number, Text)

N/A Sickle cell trait

N/A N/A N/A N/A Used in the provision of care (e.g., confirmation of suspected diagnoses). For instance, blood sugar monitoring (Accu-Chek) values are tracked over time and compared with yearly HbA1c test results at a central lab.

H4 Lab Test Result Unit of Measure

Laboratory Test Result Value Unit of Measure Code

Represents the unit of measure of the lab result for the lab test performed.

Code N/A mg/mmol (milligram per millimole)

LaboratoryObservationUnitOfMeasureCode

PHC Reference Set

UCUM 2.16.840.1.113883.2.20.3.152

Ensures that the unit of measure associated with the value is provided.

I1 Diagnostic Imaging Test Ordered

Diagnostic Imaging Test Ordered Code

Represents the type of diagnostic imaging test ordered by the Provider for the Client.

Code N/A 3.GY.10 Diagnostic Imaging Test Ordered CFPL

CFPL CCI 2.16.840.1.113883.3.1780.5.12.2.5

Diagnostic images can be used to assist in the confirmation of suspected diagnoses.

I2 Diagnostic Imaging Test Ordered Date

Diagnostic Imaging Test Ordered Date

Represents the date the diagnostic imaging test was ordered by the Provider.

Date YYYYMMDD 20100430 N/A N/A N/A N/A Schedule future appointments based on the tracked turnaround time of diagnostic imaging tests.

J1 DI Test Performed Date

Diagnostic Imaging Test Performed Date

Represents the date the diagnostic imaging test was performed.

Date YYYYMMDD 20100430 N/A N/A N/A N/A Schedule future appointments based on the tracked turnaround time of diagnostic imaging tests.


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Example Values



Code System



K1 Referral Service Code

Referral Represents the type of service required for the Client.

Code N/A 310063007 ReferralServiceCode

PHC Reference Set

SNOMED CT®

2.16.840.1.113883.2.20.3.197

Identifies the general type of care or category of referral services requested.

K2 Referral Requested Date

Referral Requested Date

Represents the date the referral request was created by the PHC Provider.

Date YYYYMMDD 20100430 N/A N/A N/A N/A Assists Providers in tracking when a request to obtain a consult was first requested.

L1 Referral Occurred Date

Referral Occurred Date

Represents the actual date the Client had the encounter with the referred-to Provider.

Date YYYYMMDD 20100430 N/A N/A N/A N/A Assists Providers in understanding which referral services have longer wait times.

M1 Prescribed Medication

Medication Prescribed Name Code

Represents the medications prescribed to the Client.

Code N/A Amoxicillin N/A N/A TBD N/A Can be used to create a longitudinal medication record to support the provision of care.

M2 Prescription Date

Medication Prescribed Date

Represents the date the prescription for the medication was created for the Client.

Date YYYYMMDD 20100430 N/A N/A N/A N/A Can be used to create a longitudinal medication record to support the provision of care.


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Example Values



Code System



O1 Vaccine Administered

Vaccine Administered Name Code

Represents the vaccine administered to the Client within and beyond the PHC setting, including current and past vaccination history.

N/A Influenza virus vaccine (product)

VaccineAdministeredNameCode: • VaccineAdministeredTradeNameCode • VaccineHistoricalNameCode • PassiveAdministeredImmunizingAgentCode • PassiveHistoricalImmunizingAgentCode

PHC Reference Set

SNOMED CT®

• 2.16.840.1.113883.2.20.3.281 • 2.16.840.1.113883.2.20.3.282 • 2.16.840.1.113883.2.20.3.279 • 2.16.840.1.113883.2.20.3.262

Can be used to create reminders about vaccines to be administered and track past history of vaccinations.

O2 Vaccine Administered Date

Vaccine Administered Date

Represents the date the vaccine was administered to the Client.

Date YYYYMMDD 20100430 N/A N/A N/A N/A Can be used to support vaccine reminders to relevant Clients or to flag that a vaccine has already been given and is not required until a future date.

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Appendix C: CIHI’s Pan-Canadian PHC EMR–Related Indicators—Definitions This information comes from the Pan-Canadian Primary Health Care Indicator Update Report, which is available from www.cihi.ca/phc. The following is a subset of EMR-related indicators.

Indicator Name Indicator Definition Numerator Denominator Child Immunization Percentage of patient population,

currently age 7, who have received recommended childhood immunizations.

Number of individuals in the denominator who have received childhood immunizations in accordance with the recommended schedule.

Inclusions • Individual is in the denominator • Individual has received all immunizations listed

in the National Advisory Committee on Immunizations (NACI) recommended schedule, or had a contraindication for immunizations that were not received

Exclusions None

Number of primary health care (PHC) clients/patients currently age 7.

Inclusions • PHC client/patient • Age of individual is 7 years

Exclusions None

Colon Cancer Screening Percentage of patient population, age 50 to 74, who had a screening test ordered for colon cancer.

Number of individuals in the denominator who had a screening test for colon cancer ordered within an appropriate time frame.

Inclusions • Individual is in the denominator • Individual who had at least one of the following

screening tests ordered: − Fecal occult blood test (FOBT) within the past

24 months − Sigmoidoscopy within the past 5 years − Colonoscopy within the past 10 years

Exclusions None

Number of primary health care (PHC) clients/patients, age 50 to 74.

Inclusions • PHC client/patient • Age of individual is between 50 and

74 years

Exclusions None



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Indicator Name Indicator Definition Numerator Denominator Breast Cancer Screening Percentage of female population,

age 50 to 74, who reported having had a mammogram.

Number of individuals in the denominator who had a mammogram ordered within the past 36 months.

Inclusions • Individual is in the denominator • Individual had a mammogram ordered within

the past 36 months

Exclusions None

Number of female primary health care (PHC) clients/patients age 50 to 74.

Inclusions • PHC client/patient • Sex of individual is female • Age of individual is between 50 and

74 years

Exclusions • Individual has had a bilateral

mastectomy

Cervical Cancer Screening Percentage of female patient population, age 18 to 69, who had a Papanicolaou test.

Number of individuals in the denominator who had a Papanicolaou test within the past 36 months.

Inclusions • Individual is in the denominator • Individual had a Papanicolaou test within the

past 36 months

Exclusions None

Number of female primary health care (PHC) clients/patients, age 18 to 69.

Inclusions • PHC client/patient • Sex of individual is female • Age of individual is between 18 and

69 years

Exclusions • Individual had a hysterectomy

Smoking Cessation Advice in PHC

Percentage of patient population who are smokers, age 12 and older, who were offered specific help or information to quit smoking.

Number of individuals in the denominator who were offered specific help or information to quit smoking within the past 15 months.

Inclusions • Individual is in the denominator • Individual was offered smoking cessation

education within the past 15 months

Exclusions None

Number of primary health care (PHC) clients/patients, age 12 and older, who are smokers.

Inclusions • PHC client/patient • Age of individual is at least 12 years • Individual is a smoker • Individual visited his or her PHC

provider within the past 15 months

Exclusions • Individual uses tobacco only for a

purpose other than smoking


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Indicator Name Indicator Definition Numerator Denominator Influenza Immunization, 65+ Percentage of patient population,

age 65 and older, who received an influenza immunization.

Number of individuals in the denominator who received an influenza immunization within the past 12 months.

Inclusions • Individual is in the denominator • Individual received an influenza immunization

within the past 12 months

Exclusions None

Number of primary health care (PHC) clients/patients, age 65 and older.

Inclusions • PHC client/patient • Age of individual is at least 65 years

Exclusions None

Well Baby Screening Percentage of patient population, currently age 3, who received screenings for congenital hip displacement, eye and hearing problems.

Number of individuals in the denominator who received screening for congenital hip displacement, eye and hearing problems.

Inclusions • Individual is in the denominator • Individual received screening for congenital

hip displacement • Individual received screening for eye problems • Individual received screening for

hearing problems

Exclusions None

Number of primary health care (PHC) clients/patients, currently age 3.

Inclusions • PHC client/patient • Age of individual is 3 years

Exclusions None

Blood Pressure Testing Percentage of patient population, age 18 and older, who have had their blood pressure measured by their primary health care (PHC) provider.

Number of individuals in the denominator who had their blood pressure measured by their PHC provider in the past 15 months.

Inclusions • Individual is in the denominator • Individual had a blood pressure measurement

taken by his or her PHC provider within the past 15 months

Exclusions None

Number of PHC clients/patients, age 18 and older.


Exclusions None


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Indicator Name Indicator Definition Numerator Denominator Screening for Modifiable Risk Factors in Adults With Coronary Artery Disease

Percentage of patient population, age 18 and older, with coronary artery disease (CAD) who received testing for all of the following: • Full fasting lipid profile screening; • Blood pressure measurement; and • Obesity/overweight screening.

Number of primary health care (PHC) clients/patients who received testing within the past 12 months for all of the following: • Full fasting lipid profile screening; • Blood pressure measurement; and • Obesity/overweight screening.

Inclusions • Individual is in the denominator • Individual had a lipid profile screening

performed within the past 12 months • Individual had a blood pressure measurement

taken by his or her PHC provider within the past 12 months

• Individual had at least one of the following: − Weight measured by his or her PHC provider

within the past 12 months − Waist circumference measured by his or her

PHC provider within the past 12 months

Exclusions None

Number of PHC clients/patients, age 18 and older, with CAD.

Inclusions • PHC client/patient • Age of individual is at least 18 years • Individual has a diagnosis of CAD

Exclusions None


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Indicator Name Indicator Definition Numerator Denominator Screening in Adults With Diabetes

Percentage of patient population, age 18 and older, with diabetes mellitus who received testing for all of the following: • Hemoglobin A1c (HbA1c); • Full fasting lipid profile screening; • Nephropathy screening

(e.g., albumin/creatinine ratio, microalbuminuria);

• Foot examination; • Blood pressure measurement; and • Obesity/overweight screening.

Number of individuals in the denominator who received testing for all of the following: • At least two HbA1c tests within the past

12 months; • Full fasting lipid profile screening within the

past 36 months; • Nephropathy screening (e.g., albumin/

creatinine ratio, microalbuminuria) within the past 12 months;

• Foot examination within the past 12 months; • Blood pressure measurement within the past

12 months; and • Obesity/overweight screening within the past

12 months.

Inclusions • Individual is in the denominator • Individual had at least two HbA1c tests within

the past 12 months • Individual had a lipid profile screening within

the past 36 months • Individual had a nephropathy screening test

within the past 12 months • Individual had a foot examination from his or

her primary health care (PHC) provider within the past 12 months

• Individual had a blood pressure measurement taken by his or her PHC provider within the past 12 months



PHC provider within the past 12 months

Exclusions None

Number of PHC clients/patients, age 18 and older, with diabetes mellitus

Inclusions • PHC client/patient • Age of individual is at least 18 years • Individual has a diagnosis of

diabetes mellitus

Exclusions None


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Indicator Name Indicator Definition Numerator Denominator Screening for Modifiable Risk Factors in Adults With Hypertension

Percentage of patient population, age 18 and older, with hypertension who received testing for all of the following: • Fasting blood sugar; • Blood pressure measurement; and • Obesity/overweight screening.

Number of individuals in the denominator who received testing, within the past 12 months, for all of the following: • Fasting blood sugar; • Blood pressure measurement; and • Obesity/overweight screening.


taken by his or her primary health care (PHC) provider within the past 12 months



PHC provider within the past 12 months • Individual had at least one of the following:

− A blood sugar test within the past 12 months − A diagnosis of diabetes mellitus

Exclusions None

Number of PHC clients/patients, age 18 and older with hypertension


hypertension

Exclusions • Individual is pregnant

Treatment of Dyslipidemia Percentage of patient population, age 18 and older, with established coronary artery disease (CAD) and elevated low-density lipoprotein cholesterol (LDL-C) who were offered lifestyle advice and lipid-lowering medication.

Number of individuals in the denominator who were offered lifestyle advice and lipid-lowering medication within the past 12 months.

Inclusions • Individual is in the denominator • Individual was offered lifestyle advice within the

past 12 months • Individuals who have one or both of

the following: − Individual was prescribed lipid-lowering

medication within the past 12 months − Individual has a documented contraindication

to lipid-lowering medication

Exclusions None

Number of primary health care (PHC) clients/patients, age 18 and older, with established CAD and elevated LDL-C (i.e., greater than 2.0 mmol/L).


coronary artery disease • Individual has an LDL-C value

greater than 2.0 mmol/L

Exclusions None


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Indicator Name Indicator Definition Numerator Denominator Treatment of Acute Myocardial Infarction

Percentage of patient population who have had an acute myocardial infarction (AMI) and are currently prescribed a beta-blocking drug.

Number of individuals in the denominator who are currently prescribed a beta-blocking drug.

Inclusions • Individual is in the denominator • Individuals who had one or both of

the following: − Individual was prescribed a beta-blocking

drug within the past 12 months − Individual has a contraindication to beta-

blocking drugs

Exclusions None

Number of primary health care (PHC) clients/patients who had an AMI between 12 and 24 months ago.

Inclusions • PHC client/patient • Individual had an AMI between 12

and 24 months ago

Exclusions None

Treatment of Anxiety Percentage of patient population, age 18 and older, with a diagnosis of panic disorder or generalized anxiety disorder who were offered treatment or referral to a mental health provider.

Number of individuals in the denominator who were offered treatment or referral to a mental health provider within the past 12 months.

Inclusions • Individual is in the denominator • Individual received at least one of the following

from his or her primary health care (PHC) provider within the past 12 months: − A prescription for anti-anxiety medication − A referral to a mental health provider − An offer for non-pharmacological treatment

(psychological interventions: individual non-facilitated self-help, individual guided self-help and psychoeducational groups)

Exclusions None

Number of PHC clients/patients, age 18 and older, with a diagnosis of panic disorder or generalized anxiety disorder.

Inclusions • PHC client/patient • Age of individual is at least 18 years • Individual has a diagnosis of at least

one of the following conditions: − Panic disorder − Generalized anxiety disorder

Exclusions None


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Indicator Name Indicator Definition Numerator Denominator Blood Pressure Control for Hypertension

Percentage of patient population, age 18 and older, with hypertension for a duration of at least 12 months, who have blood pressure measurement control.

Number of individuals in the denominator who have had blood pressure measurement control within the past 12 months.


taken by his or her primary health care (PHC) provider within the past 12 months

• If patient does not have a diagnosis of diabetes mellitus: − The latest blood pressure reading is less

than 140/90 • If patient does have a diagnosis of

diabetes mellitus: − The latest blood pressure reading is less

than 130/80

Exclusions None

Number of PHC clients/patients, age 18 and older, with hypertension for duration of at least 12 months.

Inclusions • PHC client/patient • Age of individual is at least 18 years • Individual has had a diagnosis of

hypertension for at least 12 months

Exclusions • Individual is currently pregnant

Overweight and Obesity Rate Percentage of patient population, age 2 and older, who are currently overweight or obese.

Number of individuals in the denominator who have a height and weight corresponding to a body mass index (BMI) in the overweight or obese range.

Inclusions • Individual is in the denominator • Individual has a height and weight

corresponding to a BMI in the overweight or obese range

Exclusions None

Number of primary health care (PHC) clients/patients age 2 and older.


Exclusions • Individual is currently pregnant • Individuals who are

− Age 18 and older; and − Shorter than 0.914 metres

• Individuals who are − Age 18 and older; and − Taller than 2.108 metres


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Indicator Name Indicator Definition Numerator Denominator Complications of Diabetes Percentage of population, age

50 to 74, with established diabetes mellitus who had an acute myocardial infarction, had an above- or below-knee amputation or began chronic dialysis.

Number of individuals, age 50 to 74, with diabetes mellitus who had an acute myocardial infarction, had an above- or below-knee amputation or began chronic dialysis within the past 12 months.

Inclusions • Age of individual is between 50 and 74 years • Individual has a diagnosis of diabetes mellitus • Individual had one or more of the following

within the past 12 months: − Acute myocardial infarction − Amputation above or below the knee − Initiation of chronic dialysis

Exclusions None

Number of individuals, age 50 to 74, with diabetes mellitus who had an acute myocardial infarction, had an above- or below-knee amputation or began chronic dialysis within the past 12 months.

Inclusions • Age of individual is between 50 and

74 years • Individual has a diagnosis of

diabetes mellitus • Individual had one or more of the

following within the past 12 months: − Acute myocardial infarction − Amputation above or below

the knee − Initiation of chronic dialysis

Exclusions None

Health Risk Screening in PHC Percentage of PHC clients/patients, age 12 and older, who were screened by their PHC provider for the following common health risks over the past 12 months: • Tobacco use; • Unhealthy eating habits; • Problem drug use; • Physical inactivity; • Overweight status; • Problem alcohol drinking; • Unintentional injuries (home

risk factors); • Unsafe sexual practices; and • Unmanaged psychosocial stress

and/or depression.

Number of PHC clients/patients who report being screened by their PHC provider for common health risks over the past 12 months

Total number of PHC clients/patients, 12 years and over


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Indicator Name Indicator Definition Numerator Denominator Glycemic Control for Diabetes Percentage of PHC clients/patients,

age 18 and older, with diabetes mellitus in whom the last HbA1c was 7.0% or less (or equivalent test/reference range depending on local laboratory) in the last 15 months.

Number of PHC clients/patients with diabetes mellitus in whom the last HbA1c was 7.0% or less (or equivalent test/reference range depending on local laboratory) in the past 15 months

Total number of PHC clients/patients, 18 years and over with diabetes mellitus within the past 15 months

Dyslipidemia Screening for Women

Percentage of PHC women clients/patients, age 55 and older, who had a full fasting lipid profile measured within the past 24 months.

Number of PHC women clients/patients who had a full fasting lipid profile measured within the past 24 months

Total number of PHC women clients/patients, age 55 years and older, within the past 24 months

Dyslipidemia Screening for Men

Percentage of PHC men clients/ patients, age 40 and older, who had a full fasting lipid profile measured within the past 24 months.

Number of PHC men clients/patients who had a fasting lipid profile measured within the past 24 months

Total number of PHC men clients/ patients age 40 years and older

Screening for Visual Impairment in Adults With Diabetes

Percentage of PHC clients/patients, age 18 to 75, with diabetes mellitus who saw an optometrist or ophthalmologist within the past 24 months.

Number of PHC clients/patients with diabetes mellitus who saw an optometrist or ophthalmologist within the past 24 months

Total number of PHC clients/patients, age 18 to 75 years, with diabetes mellitus within the past 24 months

Bone Density Screening Percentage of women PHC clients/patients, age 65 and older, who received screening for low bone mineral density at least once.

Number of women PHC clients/patients who received screening for low bone mineral density at least once

Total number of women PHC clients/ patients age 65 years and older

Pneumococcal Immunization, 65+

Percentage of PHC clients/patients, age 65 and older, who have received a pneumococcal immunization.

Number of PHC clients/patients who received a pneumococcal immunization

Total number of PHC clients/patients age 65 years and older

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Appendix D: CIHI’s Pan-Canadian PHC EMR–Related Indicators—Relation to the Priority Subset of Data Elements

DE #

PHC Indicator Data Element Name

Health Status

Appropriateness

Effectiveness

Other Quality Measures

Immunization Screening Treatment and

Education Wait

Times Referral O

verw

eigh

t and

Obe

sity

Rat

e

Influ

enza

Imm

uniz

atio

n, 6

5+

Chi

ld Im

mun

izat

ion

Pne

umoc

occa

l Im

mun

izat

ion,

65+

Hea

lth R

isk

Scre

enin

g in

PH

C

Wel

l Bab

y Sc

reen

ing

Blo

od P

ress

ure

Test

ing

Col

on C

ance

r Scr

eeni

ng

Cer

vica

l Can

cer S

cree

ning

Bre

ast C

ance

r Scr

eeni

ng

Dys

lipid

emia

Scr

eeni

ng (M

en a

nd W

omen

)

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

C

oron

ary

Arte

ry D

isea

se

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

H

yper

tens

ion

Scr

eeni

ng in

Adu

lts W

ith D

iabe

tes

Scr

eeni

ng fo

r Vis

ual I

mpa

irmen

t in

Adu

lts W

ith D

iabe

tes

Bon

e D

ensi

ty S

cree

ning

Trea

tmen

t of D

yslip

idem

ia

Trea

tmen

t of A

nxie

ty

Trea

tmen

t of A

cute

Myo

card

ial I

nfar

ctio

n

Sm

okin

g C

essa

tion

Adv

ice

in P

HC

Blo

od P

ress

ure

Con

trol f

or H

yper

tens

ion

Com

plic

atio

ns o

f Dia

bete

s

Gly

cem

ic C

ontro

l for

Dia

bete

s

Wai

t Tim

es fo

r PH

C P

rovi

der

Wai

t Tim

es fo

r Spe

cial

ist R

efer

ral

Ref

erra

ls fo

r Pat

ient

s W

ith C

hron

ic C

ondi

tions

A1 Patient Identifier X X X X X X X X X X X X X X X X X X X X X X X X X X

A4 Patient Date of Birth

X X X X X X X X X X X X X X X X X X X X X X X

A5 Patient Gender X X X X

A9 Patient Status X X X X X X X X X X X X X X X X X X X X X X X X X

D1 Appointment Creation Date

X

D3 Visit Date X X X X X X X X X X X X X X


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DE #


Health Status

Appropriateness

Effectiveness



Education Wait

Times Referral

Ove

rwei

ght a

nd O

besi

ty R

ate

Influ

enza

Imm

uniz

atio

n, 6

5+

Chi

ld Im

mun

izat

ion

Pne

umoc

occa

l Im

mun

izat

ion,

65+

Hea

lth R

isk

Scre

enin

g in

PH

C

Wel

l Bab

y Sc

reen

ing

Blo

od P

ress

ure

Test

ing

Col

on C

ance

r Scr

eeni

ng

Cer

vica

l Can

cer S

cree

ning

Bre

ast C

ance

r Scr

eeni

ng

Dys

lipid

emia

Scr

eeni

ng (M

en a

nd W

omen

)

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

C

oron

ary

Arte

ry D

isea

se

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

H

yper

tens

ion

Scr

eeni

ng in

Adu

lts W

ith D

iabe

tes

Scr

eeni

ng fo

r Vis

ual I

mpa

irmen

t in

Adu

lts W

ith D

iabe

tes

Bon

e D

ensi

ty S

cree

ning

Trea

tmen

t of D

yslip

idem

ia

Trea

tmen

t of A

nxie

ty

Trea

tmen

t of A

cute

Myo

card

ial I

nfar

ctio

n

Sm

okin

g C

essa

tion

Adv

ice

in P

HC

Blo

od P

ress

ure

Con

trol f

or H

yper

tens

ion

Com

plic

atio

ns o

f Dia

bete

s

Gly

cem

ic C

ontro

l for

Dia

bete

s

Wai

t Tim

es fo

r PH

C P

rovi

der

Wai

t Tim

es fo

r Spe

cial

ist R

efer

ral

Ref

erra

ls fo

r Pat

ient

s W

ith C

hron

ic C

ondi

tions

E11 Health Concern X X X X X X X X X X X X X

E12 Health Concern Date of Onset

X X X X X

E14 Social Behaviour

X X

E23 Systolic Blood Pressure

X X X X X

E24 Diastolic Blood Pressure

X X X X X

E28 Height X X

E29 Height Unit of Measure

X X

E30 Weight X X X X X


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DE #


Health Status

Appropriateness

Effectiveness



Education Wait

Times Referral

Ove

rwei

ght a

nd O

besi

ty R

ate

Influ

enza

Imm

uniz

atio

n, 6

5+

Chi

ld Im

mun

izat

ion

Pne

umoc

occa

l Im

mun

izat

ion,

65+

Hea

lth R

isk

Scre

enin

g in

PH

C

Wel

l Bab

y Sc

reen

ing

Blo

od P

ress

ure

Test

ing

Col

on C

ance

r Scr

eeni

ng

Cer

vica

l Can

cer S

cree

ning

Bre

ast C

ance

r Scr

eeni

ng

Dys

lipid

emia

Scr

eeni

ng (M

en a

nd W

omen

)

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

C

oron

ary

Arte

ry D

isea

se

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

H

yper

tens

ion

Scr

eeni

ng in

Adu

lts W

ith D

iabe

tes

Scr

eeni

ng fo

r Vis

ual I

mpa

irmen

t in

Adu

lts W

ith D

iabe

tes

Bon

e D

ensi

ty S

cree

ning

Trea

tmen

t of D

yslip

idem

ia

Trea

tmen

t of A

nxie

ty

Trea

tmen

t of A

cute

Myo

card

ial I

nfar

ctio

n

Sm

okin

g C

essa

tion

Adv

ice

in P

HC

Blo

od P

ress

ure

Con

trol f

or H

yper

tens

ion

Com

plic

atio

ns o

f Dia

bete

s

Gly

cem

ic C

ontro

l for

Dia

bete

s

Wai

t Tim

es fo

r PH

C P

rovi

der

Wai

t Tim

es fo

r Spe

cial

ist R

efer

ral

Ref

erra

ls fo

r Pat

ient

s W

ith C

hron

ic C

ondi

tions

E31 Weight Unit of Measure

X X X X X

E34 Clinician Assessment

X X X X X X X X X X X X X

F1 Intervention X X X X X X X X X

F2 Intervention (Treatment) Date

X X X X X X X X X

G1 Lab Test Ordered

X

G2 Lab Test Ordered Date

X

H1 Lab Test Performed Date

X X X X X X

H2 Lab Test Name X X X X X X


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DE #


Health Status

Appropriateness

Effectiveness



Education Wait

Times Referral

Ove

rwei

ght a

nd O

besi

ty R

ate

Influ

enza

Imm

uniz

atio

n, 6

5+

Chi

ld Im

mun

izat

ion

Pne

umoc

occa

l Im

mun

izat

ion,

65+

Hea

lth R

isk

Scre

enin

g in

PH

C

Wel

l Bab

y Sc

reen

ing

Blo

od P

ress

ure

Test

ing

Col

on C

ance

r Scr

eeni

ng

Cer

vica

l Can

cer S

cree

ning

Bre

ast C

ance

r Scr

eeni

ng

Dys

lipid

emia

Scr

eeni

ng (M

en a

nd W

omen

)

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

C

oron

ary

Arte

ry D

isea

se

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

H

yper

tens

ion

Scr

eeni

ng in

Adu

lts W

ith D

iabe

tes

Scr

eeni

ng fo

r Vis

ual I

mpa

irmen

t in

Adu

lts W

ith D

iabe

tes

Bon

e D

ensi

ty S

cree

ning

Trea

tmen

t of D

yslip

idem

ia

Trea

tmen

t of A

nxie

ty

Trea

tmen

t of A

cute

Myo

card

ial I

nfar

ctio

n

Sm

okin

g C

essa

tion

Adv

ice

in P

HC

Blo

od P

ress

ure

Con

trol f

or H

yper

tens

ion

Com

plic

atio

ns o

f Dia

bete

s

Gly

cem

ic C

ontro

l for

Dia

bete

s

Wai

t Tim

es fo

r PH

C P

rovi

der

Wai

t Tim

es fo

r Spe

cial

ist R

efer

ral

Ref

erra

ls fo

r Pat

ient

s W

ith C

hron

ic C

ondi

tions

H3 Lab Test Result Value

X X

H4 Lab Test Result Unit of Measure

X X

I1 Diagnostic Imaging Test Ordered

X X

I2 Diagnostic Imaging Test Ordered Date

X

K1 Referral X X X

K2 Referral Requested Date

X X X

L1 Referral Occurred Date

X X


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DE #


Health Status

Appropriateness

Effectiveness



Education Wait

Times Referral

Ove

rwei

ght a

nd O

besi

ty R

ate

Influ

enza

Imm

uniz

atio

n, 6

5+

Chi

ld Im

mun

izat

ion

Pne

umoc

occa

l Im

mun

izat

ion,

65+

Hea

lth R

isk

Scre

enin

g in

PH

C

Wel

l Bab

y Sc

reen

ing

Blo

od P

ress

ure

Test

ing

Col

on C

ance

r Scr

eeni

ng

Cer

vica

l Can

cer S

cree

ning

Bre

ast C

ance

r Scr

eeni

ng

Dys

lipid

emia

Scr

eeni

ng (M

en a

nd W

omen

)

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

C

oron

ary

Arte

ry D

isea

se

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

H

yper

tens

ion

Scr

eeni

ng in

Adu

lts W

ith D

iabe

tes

Scr

eeni

ng fo

r Vis

ual I

mpa

irmen

t in

Adu

lts W

ith D

iabe

tes

Bon

e D

ensi

ty S

cree

ning

Trea

tmen

t of D

yslip

idem

ia

Trea

tmen

t of A

nxie

ty

Trea

tmen

t of A

cute

Myo

card

ial I

nfar

ctio

n

Sm

okin

g C

essa

tion

Adv

ice

in P

HC

Blo

od P

ress

ure

Con

trol f

or H

yper

tens

ion

Com

plic

atio

ns o

f Dia

bete

s

Gly

cem

ic C

ontro

l for

Dia

bete

s

Wai

t Tim

es fo

r PH

C P

rovi

der

Wai

t Tim

es fo

r Spe

cial

ist R

efer

ral

Ref

erra

ls fo

r Pat

ient

s W

ith C

hron

ic C

ondi

tions

M1 Prescribed Medication

X X X

M2 Prescription Date

X X X

O1 Vaccine Administered

X X X

O2 Vaccine Administered Date

X X X

A2 Patient Identifier Type

Used for administrative purposes

A3 Patient Identifier Assigning Authority


A14 Patient Postal/ Zip Code

Used to distinguish urban and rural patient populations or to stratify quality indicators by geographic region; can also be used to calculate travel distance to PHC clinic to inform equity of care


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anadian Prim

ary Health C

are Electronic M

edical Record C

ontent Standard, V

ersion 3.0—


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DE #


Health Status

Appropriateness

Effectiveness



Education Wait

Times Referral

Ove

rwei

ght a

nd O

besi

ty R

ate

Influ

enza

Imm

uniz

atio

n, 6

5+

Chi

ld Im

mun

izat

ion

Pne

umoc

occa

l Im

mun

izat

ion,

65+

Hea

lth R

isk

Scre

enin

g in

PH

C

Wel

l Bab

y Sc

reen

ing

Blo

od P

ress

ure

Test

ing

Col

on C

ance

r Scr

eeni

ng

Cer

vica

l Can

cer S

cree

ning

Bre

ast C

ance

r Scr

eeni

ng

Dys

lipid

emia

Scr

eeni

ng (M

en a

nd W

omen

)

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

C

oron

ary

Arte

ry D

isea

se

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

H

yper

tens

ion

Scr

eeni

ng in

Adu

lts W

ith D

iabe

tes

Scr

eeni

ng fo

r Vis

ual I

mpa

irmen

t in

Adu

lts W

ith D

iabe

tes

Bon

e D

ensi

ty S

cree

ning

Trea

tmen

t of D

yslip

idem

ia

Trea

tmen

t of A

nxie

ty

Trea

tmen

t of A

cute

Myo

card

ial I

nfar

ctio

n

Sm

okin

g C

essa

tion

Adv

ice

in P

HC

Blo

od P

ress

ure

Con

trol f

or H

yper

tens

ion

Com

plic

atio

ns o

f Dia

bete

s

Gly

cem

ic C

ontro

l for

Dia

bete

s

Wai

t Tim

es fo

r PH

C P

rovi

der

Wai

t Tim

es fo

r Spe

cial

ist R

efer

ral

Ref

erra

ls fo

r Pat

ient

s W

ith C

hron

ic C

ondi

tions

B4 Clinician Identifier

For Provider-level analysis and reporting; required to calculate which patients will be aggregated into which provider’s report

B5 Clinician Identifier Type


B6 Clinician Identifier Assigning Authority


B7 Clinician Role Used to restrict indicator calculations to appropriate provider types (e.g., access information on a specific type of PHC provider); can also inform coordination of care within a PHC setting

C1 Service Delivery Identifier

For practice-level analysis and reporting; required to identify the PHC practice where the patient received care in order to generate practice-level statistics

C4 Service Delivery Postal Code

Used to distinguish urban and rural clinics; paired with A14 to calculate travel distance to clinic to inform equity of care

D2 Reason for Visit Used to inform how often patients come to PHC clinic for a specific chronic health condition


Pan-C

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ersion 3.0—


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DE #


Health Status

Appropriateness

Effectiveness



Education Wait

Times Referral

Ove

rwei

ght a

nd O

besi

ty R

ate

Influ

enza

Imm

uniz

atio

n, 6

5+

Chi

ld Im

mun

izat

ion

Pne

umoc

occa

l Im

mun

izat

ion,

65+

Hea

lth R

isk

Scre

enin

g in

PH

C

Wel

l Bab

y Sc

reen

ing

Blo

od P

ress

ure

Test

ing

Col

on C

ance

r Scr

eeni

ng

Cer

vica

l Can

cer S

cree

ning

Bre

ast C

ance

r Scr

eeni

ng

Dys

lipid

emia

Scr

eeni

ng (M

en a

nd W

omen

)

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

C

oron

ary

Arte

ry D

isea

se

Scr

eeni

ng fo

r Mod

ifiab

le R

isk

Fact

ors

in A

dults

With

H

yper

tens

ion

Scr

eeni

ng in

Adu

lts W

ith D

iabe

tes

Scr

eeni

ng fo

r Vis

ual I

mpa

irmen

t in

Adu

lts W

ith D

iabe

tes

Bon

e D

ensi

ty S

cree

ning

Trea

tmen

t of D

yslip

idem

ia

Trea

tmen

t of A

nxie

ty

Trea

tmen

t of A

cute

Myo

card

ial I

nfar

ctio

n

Sm

okin

g C

essa

tion

Adv

ice

in P

HC

Blo

od P

ress

ure

Con

trol f

or H

yper

tens

ion

Com

plic

atio

ns o

f Dia

bete

s

Gly

cem

ic C

ontro

l for

Dia

bete

s

Wai

t Tim

es fo

r PH

C P

rovi

der

Wai

t Tim

es fo

r Spe

cial

ist R

efer

ral

Ref

erra

ls fo

r Pat

ient

s W

ith C

hron

ic C

ondi

tions

D4 Visit Type Used for administrative purposes

J1 DI Test Performed Date

Used to calculate diagnostic imaging wait times

45

Pan-Canadian Primary Health Care Electronic Medical Record Content Standard, Version 3.0—Clinician Friendly Pick List Guide

Appendix E: Glossary of Terms

Term Acronym (if Applicable) Description

Canadian Classification of Health Interventions

CCI The Canadian Classification of Health Interventions (CCI) is the new Canadian national standard for classifying health care procedures. CCI is the companion classification system to ICD-10-CA. CCI replaces the Canadian Classification of Diagnostic, Therapeutic and Surgical Procedures (CCP) and the intervention portion of ICD-9-CM in Canada. It is designed to be provider and location neutral so that it may be used across the continuum of health care settings in Canada.

Canadian Institute for Health Information

CIHI CIHI is an independent, not-for-profit organization that provides essential data and analysis on Canada’s health system and the health of Canadians.

Clinician-Friendly Pick-Lists

CFPLs The CFPLs are constrained lists of clinician-friendly terms mapped to 1 appropriate code system, aimed at supporting adoption of the PHC EMR CS Priority Subset. The scope of the CFPLs is focused on supporting PHC indicators for clinicians and jurisdictions.

Content Standard Working Group

CSWG The CSWG provides input and expert advice on the adoption, implementation and maintenance of the PHC EMR CS to ensure that it remains clinically and technically relevant and aligned with existing standards, where applicable. The group includes jurisdictional standards experts, PHC providers, researchers and Canada Health Infoway.

Electronic Medical Record

EMR An EMR is a computer-based patient medical record used by physicians, nurses and administrative staff. EMRs contain patient information that authorized health professionals can access electronically rather than through a traditional paper chart.

Health System Use HSU HSU of information refers to the use of health information to monitor, manage and improve the health of Canadians and the health care system.

International Statistical Classification of Diseases and Related Health Problems, Ninth Revision

ICD-9 ICD-9 is a publication from the World Health Organization comprising a set of codes that are used worldwide to classify diseases and injuries. The ICD-9 is split into several sections that correspond to a type of disease or injury. Each section is assigned to a range of numbers, each of which denotes a medical condition.

International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada

ICD-10-CA ICD-10-CA is an enhanced version of ICD-10 developed by CIHI for morbidity classification in Canada. ICD-10-CA represents the broadest scope of any previous ICD revision to date. Unlike ICD-9, ICD-10-CA applies beyond acute hospital care. ICD-10-CA also includes conditions and situations that are not diseases but represent risk factors to health, such as occupational and environmental factors, lifestyle and psycho-social circumstances.

Jurisdictional Advisory Group

JAG The JAG is a pan-Canadian working group that supports adoption and implementation of the PHC EMR CS by providing approval, advice and strategic guidance on adoption, implementation, stakeholder engagement and ongoing governance. The group consists of senior-level representatives from jurisdictions across Canada.

Primary Health Care

PHC PHC refers to first-contact care that deals with the majority of health problems. It is the foundation of any health care system, and countries with strong primary care seem to have better health than those without.


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Term Acronym (if Applicable) Description

Primary Health Care Electronic Medical Record Content Standard

PHC EMR CS The PHC EMR CS is composed of priority data elements that are commonly captured in EMRs in a PHC setting and that support both primary and health system use of EMR data.

Primary Health Care Reference Sets

PHC Ref Sets PHC ref sets are effectively constrained lists of allowable values from the source code system(s) that are applicable to the delivery and administration of PHC. They support the implementation of the PHC EMR CS by facilitating standardization of PHC data for primary and health system use.

Primary Health Care Voluntary Reporting System

PHC VRS The PHC VRS is a pan-Canadian PHC data source to support PHC performance measurement and health system improvement. It collects a minimum data set of patient data extracted from the PHC EMR systems of PHC VRS participants.

Systematized Nomenclature of Medicine—Clinical Terms

SNOMED CT SNOMED CT is a comprehensive clinical terminology that contains more than 300,000 active concepts with unique meanings, ranging from diagnoses and therapies, to medications, results and orders. For more information on SNOMED CT, please visit Canada Health Infoway’s website: https://infocentral.infoway-inforoute.ca/2_Standards.




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http://www.waittimealliance.ca/waittimes/sight_restoration.htm

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