Using an EHR to Improve Diabetes Care: A Practical Approach

1. Using an EHR to Improve Diabetes Care: A Practical Approach By Donald T. Stewart, MD DonS@PineLakeMed.com

2. My Background Family Practice, started solo from scratch in 1983 after residency Grew to 6 provider practice which was sold to Swedish Hospital in 2003 Now Medical Director of 7-provider clinic in 12-clinic system First EMR 1997 on Newton Message Pad Migrated to Practice Partner in 2001. Paperless since 2003

3. What do we need to do improve the quality of diabetes care? Most of us do just fine with the patients who come in for a scheduled visit and follow-up when we tell them to. The problem is with the patients who do not follow-up for scheduled care We need to educate them And, we need to keep track of them, and get them into the office when they need it.

4. The Registry, a Necessity Database of patients with problems you are interested in following Useful for identifying the patients you never see because they fail to come in Tracks specific outcomes measures Reports that give you feedback on which of your goals you need to work harder to meet A way to compare performance of physicians and practices to each other

5. Examples of Registries CDEMS: Chronic Disease Electronic Management System http://www.cdems.com/ For an excellent review of 16 registry products by the California HealthCare Foundation, try this: http://www.chcf.org/documents/chronicdisease/ChronicDiseaseRegistryReview.pdf

6. How an EMR Can Help:Data at Your Fingertips No time wasted looking for charts or lab reports or in doing double data entry You should chose an EMR with built-in registry capabilities, or at least ease of generating the data you want The EMR can remind you at the time of care what services are overdue for the patient whose own agenda was an urgent care visit.

7. How an EMR Can Help:During the Visit Remind the provider of what needs to be done Reminding the provider when not to goal Formulary compliance Presenting data to patients Patient education materials

8. How an EMR Can Help:When There is No Visit Scheduling patients Documenting phone contacts and Rx refills Lab letters, patient reminders Messaging and workflow Information access when on call

9. How an EMR Can Help:Financial Incentives More reimbursement through better documentation Greatly increased operating efficiency of the office Documenting quality for better patient acceptance Pay for Performance

10. The Visit Note:Basic Issues Templates vs free-form data entry Templates for data you want to analyze or remember Free-form to personalize the note. Voice recognition vs typing Learn to type Pen based systems Slick, but slow

11. Diabetic Data You Care About(that you want to automagically go into your visit note) Diagnosis Date Diabetes Educator Endocrinologist Frequency of glucose monitoring Frequency of blood pressure testing Frequency of exercise Diet Symptom Status Painful Neuropathy Numbness Hypoglycemic episodes Sexual function Patient Concerns Amputation Blindness Renal failure

12. Lab Data to Follow FBS HgbA1c LDL HDL Trigs VLDL AST ALT Microalbumin Creatinine

13. Treatment Data to Follow Aspirin Metformin ACE/ARB Statins Thiazoladinediones Fibrates Sulfonureas Niacin

14. Patient-Centered Data Fears about diabetes Exercise behaviors Smoking Status Diet behaviors Self-management goals

15. The Practical Part--- Examples: MA Check-in (These examples are with Practice Partner) Patients who have diabetes are flagged in the system, so when our MA�s put them in the room, the template that they enter the vitals on reminds the MA to take the patient�s shoes off, check the HgbA1c, lipids, and microalbumin if not up to date, and give pneumovax and flu shots if not up to date. The MA�s have standing orders to do this no matter what the supposed reason for the visit was.

16. MA Check-In Example� Non-Diabetic .D: 04/04/06 : 12:19am .T: �*�Visit & Vitals MA:� �req� �&Cindi� �&Anita� �&Barbara�� �*Corey� �&Monika� �&Virginia� �*Marilyn� Type of Visit: �*OV� �*BP� �*UA� �*AllerShot� �*Immu�� �*FluShot� �*OtherShot� �*EKG� �*Weight� Treating provider today: �REQ� �*DTS� �*CML� �*LLC� �*GHP� �*DYP� �*CCL� �*SPF� .V1: Syst. BP� �*�� :� Diast. BP� �*�� :� P.� �*�� : .V2: T� �*�� :� Ht.� �*��� :� Wt.� �*� : .V3: OFC �*�� :� Resp. �*�� : .L: Visual Acuity OD: �del�� �*WithCorr� �*NoCorr� .L: Visual Acuity OS: �del�� �*WithCorr� �*NoCorr�

17. MA Check-In Example � Diabetic Patient MA:� �req� �&Cindi� �&Anita� �&Barbara�� �*Corey� �&Monika� �&Virginia� �*Marilyn� DiabetesDxDate: 12/2001 on 07/16/2002�***************POSSIBLE DIABETIC PATIENT***************...� �del�Influenza: X on 09/29/2005 �del�To Update Influenza, Click the following: �del� �*LastFlu� �del�Pneumovax: 06/03/02 on 06/03/2002 �del�To Update Pneumovax, Click the following: �del� �LastPneumo� LastEyeExam: 8/04 on 10/21/2004 .L: LastEyeExam: �del��� .L: *Ophthalmologist: �del�� .L: *Optometrist: �del�� �del�HEMOGLOBIN A1C: 6.2 on 03/06/2006� �del�GLUCOSE, FASTING: 111 on 03/06/2006� �del�CHOLESTEROL: 123 on 03/06/2006� �del�HDL CHOLESTEROL: 47 on 03/06/2006�� �del�LDL CHOLESTEROL: 68 on 03/06/2006�� �del�TRIGLYCERIDES: 123 on 03/06/2006�� �del�ALT: 34 on 09/26/2003� �del�MICROALBUMIN, UR: 20 on 08/03/2001 �del� �*****No MICROALBUMIN/CREATININE Recorded -- Please get� one per standing orders*****...� �**** Please Have Patient Remove Shoes*****...�

18. The Practical Part:Physician Note We use the same master template for all visits, which gives us a basic structure to the notes. We can add any number of problems to a given note, which enables us to update diabetes status no matter why the patient scheduled the visit.

19. Physician Template Examples . . For my practice are included at the end of this slide set. These are too busy for new users. They give you an idea of the richness of information on chronic disease management that can be included in your note Do not show what the note looks like when saved NOT for an urgent care practice Just one person�s way of doing it.

20. Physician Note: Subjective(1)

21. Physician Note: Subjective(2)

22. Physician Note: Problem Menu

23. Physician Note: Diabetes(1)

24. Physician Note: Diabetes(2)

25. Physician Note: CV Labs

26. Physician Note: Diabetic ROS

27. Physician Note: Exam(1)

28. Physician Note: Exam(2)

29. Physician Note: Assessment

30. Physician Note: Plan

31. Once you get the data into your system, then what do you do about it?

32. Practice Partner Research Network Quality Research Network coordinated by Medical University of South Carolina Agency for Healthcare Research and Quality funding � Future funding guaranteed by PP 10+ years experience, over 25 peer-reviewed articles 960,000 patients --- 7,700,000 patient contacts Quality Reports available to all Practice Partner users

33. How PPRNet Works See patients using Practice Partner Enter your data any way you want to Send in a data extract every quarter (5 minutes of operator time to do this) Receive Quality Report and Patient Level Reports a month later Meet with your group and decide what to change

34. Quarterly PPRNet Reports65 pages Diabetes Heart Disease & Stroke Cancer Screening Immunizations Infectious Disease Mental Health Substance Abuse Alcohol Abuse Nutrition and Obesity Inappropriate Prescribing for Elderly Summary Performance Indicators

35. Diabetes Reports % HgbA1c measure in last 6 months % HgbA1c < 7.0 % BP Measure in 6 months % BP < 130/80 % LDL meas. Last year % LDL < 100 % HDL meas last year % HDL > 45 % Trig meas. last year % Trig < 150 % >=40 yrs on asa % microalbumin meas last year % on ACE/ARB

36. Just below 80% of our diabetics have a most recent HgbA1c < 7.0Just below 80% of our diabetics have a most recent HgbA1c < 7.0

37. Our BP control is not so good, only about 52% have a BP < 130/80, but we have improved markedly over the last 3 years.Our BP control is not so good, only about 52% have a BP < 130/80, but we have improved markedly over the last 3 years.

38. 75% have LDL less than 100, which is not that remarkable in diabetics75% have LDL less than 100, which is not that remarkable in diabetics

39. 61% with HDL > 45, is an accomplishment61% with HDL > 45, is an accomplishment

40. 45% on anti-platelet therapy45% on anti-platelet therapy

41. 60% microalbumin measures in the last year60% microalbumin measures in the last year

42. Patient Level Reports In addition to the Quarterly report, you get a Excel Spreadsheet that enables you to sort your data on any number of variables, and get the list of patients meeting the criteria. This enables you to pull out the patients who, for example, haven�t been seen in > 6 months and had last HgbA1c > 6.5 You can use the list for recall letters

43. Patient Level Reports The Patient Level Report spreadsheet is basically a Registry that enables you to focus on whichever patient group you want to for quality improvement Also enables you to generate any custom reports you want to generate for P4P, insurance contracting, or other purposes

45. Thank You . . .Questions?

46. A Template Example Practice Partner is incredibly customizable, and comes with a set of basic and easy-to-use templates The following is an example of the variety of prompts and reminders that can be put into a template by someone who is perhaps too compulsive in his documentation

47. Physician Note: Subjective(1)

48. Physician Note: Subjective(2)

49. Physician Note: Problem Menu

50. Physician Note: Diabetes(1)

51. Physician Note: Diabetes(2)

52. Physician Note: CV Labs

53. Physician Note: Diabetic ROS

54. Physician Note: Exam(1)

55. Physician Note: Exam(2)

56. Physician Note: Assessment

57. Physician Note: Plan