Using EMRs to Change Practice for Better Diabetes Care

Submission Date: May 2015

Entry Type: Case Study

State/Territory Submitted on the Behalf of: Delaware

States/Territories Involved: Delaware

Funding Source: CDC, State/local sources

CDC Funding:

Yes

CDC Funding (Specified):

(1305) State Public Health

Other Funding:

State funding

Domain Addressed:

Health Systems Strategies

Public Health Issue:

• The Expanded Chronic Care Model (CCM) is a tested framework for improving healthcare services to better meet the needs of individuals with chronic diseases such as diabetes.
• Evidence-based strategies such as clinical decision support, delivery system redesign, self-management support and expanded use of information systems to improve the quality of clinical care are all supported by the CCM.
• Moving health care providers and systems toward implementing practice change related to the CCM is an important strategy for state diabetes prevention efforts.

Project Objectives:

Overall goal of the project: To help physicians effectively use their EMRs to efficiently manage patients in order to control patient A1c levels. Specific objectives include:

• To enroll as many active practice participants as possible
• To transform practices through improved workflows that include clinical decision supports, use of community health workers, application of clinical best practices, referrals for diabetes self-management education programs and patient reminders
• To decrease the proportion of patients with uncontrolled diabetes in participating practices by gathering data on NQF measure 0059.

Program Action:

• The Delaware Division of Public Health contracts with Quality Insights of Delaware, their Regional Extension Center (REC), to collect, identify and track state health systems and physician practices that utilize and report National Quality Forum (NQF) measure 0059 (HbA1c > 9%).
• Practices enter data through a Report For Quality Portal, by fax or by email to a REC Practice Transformation Specialist.
• Educational flyers on diabetes prevention and diabetes self-management were developed and disseminated to 600 Medical Society of Delaware members and 1,139 REC contacts. REC staff held face-to-face visits with 40 practices where these flyers were also provided. REC staff held 5 electronic medical record user group meetings with 60 practices participating, to discuss referring pre-diabetes patients to the Diabetes Prevention Program (DPP) and referring their type 2 diabetes patients to the a diabetes self-management program (DSME).

Data/Other Information Collected:

The REC is creating a cohort of 10 practices with 40 providers as a ‘Panel’ of PCPs to permit a more controlled study and monitored environment. They will be able to compare the Panel’s outcomes to the performance of all providers since all providers report meaningful use data to the REC.

Starting in February 2015, the REC will implement a data analysis feedback mechanism for practices. Practices that are not showing relative improvement rates and improved outcomes will receive monthly feedback reports and process improvement plans. Practices that demonstrate consistent controlled outcomes & maintain consistent improvement rates will receive quarterly updates.

Impact/Accomplishments:

• Practice participation in the project increased from 20 with intermittent participation at the onset to 60 with stronger and more consistent participation currently. Over 220 providers now participate regularly.
• The REC is now identifying practices, especially those with a high proportion of high risk patients, to develop systems interventions – workflow changes, clinical decision support, patient notifications and HIT alerts/reminders.
• The REC established a method for capturing data on the number of people referred to DSME programs and is in the process of gathering this data and implementing the needed redesign changes with practices.
• The REC is identifying CHW groups and will begin to provide trainings to CHWs on hypertension, procedures for self-monitoring, equipment types and proper use, importance of self-management plans, and interpretation of protocols and BP readings.
• The most recent report on 18 participating practices with a total active patient population of over 235,000 patients shows:
  • 56% have policies or practices to refer persons with prediabetes or at high risk for type 2 diabetes to a CDC-recognized lifestyle change program
  • 33% engaged CHWs to link adult patients with high blood pressure to community resources that promote self-management
  • 100% of the practices have appropriate EMRs in place and meet 1305 performance measures 3.1.01 through 3.2.04*, including reporting on NQF measure 0059.

* States receiving enhanced funding under CDC’s State Public Health Actions (1305) program, including Delaware, are reporting on these CDC-specified performance measures.

Challenges/Lessons Learned:

Time  and practice diversity are the greatest challenges:

• Practices are already operating at greater than full capacity and asking them to do more when they don’t have time to complete the work they already have is a huge barrier. In response, the REC makes it as easy as possible to participate initially.  This allows the REC to gather data and provides an opportuntiy for a more in-depth discussion about provider’s current patients.
• Participating practices use a wide variety of EMRs– over 20 different EMRs versions so far. Standardized NQF reports are not included in most EHR systems. The REC’s Customer Relationship Management (CRM) system did not have capacity to extract raw data for Meaningful Use Alternate Clinical Quality Measure # 38 (NQF#0059), this is a limitation of the system as it was designed only for Meaningful Use. For this reason REC staff entered NQF 59 data for providers directly into the Report for Quality Portal for this project. This allows a practice to review monthly feedback and comparative reports but was labor-intensive. The REC is working through a painstaking process of documenting how to accomplish desired outcomes for each EMR they encounter. Stage 2 Meaningful Use requirements are leading vendors to ask practices to upgrade their systems.  These upgrades may mean hardware upgrades, major functionality upgrades in the software and changes in how data is being produced on reports.

Other challenges/lessons learned:

• Surveys: Emailing surveys to providers did not result in a high return rate so results aren’t statistically valid.  Future surveys should be accomplished by having staff visit the office or through telephone calls.
• Distributing Educational Information: Emailing flyers to practices had on average an 18 – 19% open rate.  Handing out flyers and speaking to the practice personnel during office visits or meetings generated a significantly higher level of interest.  Practices seem to be more inclined to integrate the referrals into their EHRs when this information is discussed with them instead of just reading a flyer.
• Customizing Reports in the Practices’ EHRs: Very few practices know how to pull customized reports and they require assistance in customizing reports.  In some practices EHR and NQF reporting is managed by offsite management companies and not readily available to the REC or the practice. The REC, working through the practice, is working with the vendors and management companies to gain timely data.
• Practices Utilizing the Measures Portal:  Several large practices resist using the Measure Portal due to the amount of data to input.  These practices are looking for interfaces or electronic ways of uploading the data from their EHR into the Measures Portal to eliminate the need to manually input the data.

Next Steps:

Besides the continuous work of adding new practices and documenting how to work within their EMRs, the REC also expanding the resources available to practices, including training community health workers and promoting their use in managing patients.

Program Areas:

Diabetes, Epidemiology and Surveillance

State Contact Information:

DE
Don Post
Delaware Division of Public Health, Bureau of Chronic Disease
302-744-1039
donald.post@state.de.us

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