Leslie’s Story

After falling, Leslie, a 56-year-old woman with Type 2 diabetes, goes to the Emergency Department. In this short storybook, we will look at how digital health services deployed by her family physician, Dr. John Smith, allow her to experience a seamless health care journey.

An X-ray reveals no fractures. The ER doctor is concerned about opioid usage or other medications that may have caused the fall and checks ConnectingOntario ClinicalViewer to view medication history. Leslie is discharged and Dr. Smith is informed through an eNotification via HRM that she had been admitted to hospital and discharged.

Dr. Smith has developed a Practice Improvement Plan through participation in the College of Physicians and Surgeons of Ontario Quality Improvement and Quality Assessment program. He has also requested advice from an OntarioMD Peer Leader, who recommends Dr. Smith deploy OntarioMD’s Insights4Care program to help him to identify high-risk patient population for COVID-19.

Through the i4C Advisory Service, Dr. Smith is advised he could also use i4C Dashboard to identify diabetic patients in need of care. Leslie has been identified as a high-risk patient and her last visit had been more than 12 months ago, with her HbA1C at 8.2.

Dr. Smith has notified staff to book Leslie for a diabetic follow up. When he receives the Health Record Manager (HRM) eNotification informing him Leslie had an ER visit, he is concerned the fall might be due to diabetic nerve damage, and expedites Leslie’s follow up visit.

Dr. Smith schedules an appointment with Leslie, and uses EMR tools to access relevant data, and ensure her HbA1C, Lipid Profile, Alb, Cr, retinal & foot exam will be monitored and tracked in accordance with best practice guidelines.

When he asks whether she had a recent blood test, Leslie confirms a blood test a few months ago, when she showed up to a walk-in clinic for flu like symptoms. She does not remember whether blood sugar was checked.

Dr. Smith did not receive that report, but is able to access it through an OLIS query. The lab record shows the HbA1C level has been 8.4, higher than recorded in her last visit.

Concerned that Leslie’s diabetes may not be in control, Dr. Smith uses eConsult to consult with an endocrinologist, who suggests a change in medication and follow-up every three months, as well as lifestyle and diet modifications. A dietician is recommended, giving Leslie greater control over her condition and helping to keep her out of hospital.

Dr. Smith prescribes the new medication and orders new blood work. He books Leslie’s next appointment. His EMR will remind the receptionist to follow up with Leslie if lab results are not received when expected. Dr. Smith feels confident that they are effectively monitoring Leslie’s condition.

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