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Using EHRs For Quality Improvement:  Diabetes Care

Dr. Jones has attested to Meaningful Use and his first incentive check is in the mail. He has harmonized his elective quality measures around diabetes because he knows his EHR product is certified for all the diabetes measures, and he can consistently get the same denominator with accurate reports. Dr. Jones discovers the percentage of patients in his practice with A1c > 9.0% (NQF# Not Applicable; CMS122v9) is much higher than he'd like. Dr. Jones's REC representative works with IT staff and his vendor to review his system's functionality, repeat the reports, and confirm they are accurate. Knowing these patients are at very high risk of diabetic sequelae and death, Dr. Jones wants to learn about systematic ways to improve. First the REC advises Dr. Jones’s to use the appropriate method and personnel for his practice's EHR product to utilize the patient list function and identify the names and phone numbers of all his patients with A1c > 9.0% that have not been seen in the last 3 months. The REC then presents Dr. Jones with these potential options:

Engage at Risk Patients

  • Schedule individual office visits purely dedicated to diabetes care
  • Employ a team huddle before each of these clinic sessions to review the patients who have been difficult to control from the entire staff’s perspective and divide the important tasks summarized below.
  • Dedicate time blocks when appropriate support staff (e.g. your nursing staff) can supplement your visit with educational options, including:
    • Self-management
    • Goal setting with diet and exercise, medication adherence;
    • Insulin injecting, if needed; and
    • Diabetic complications.
  • Use group visits for patients that would be comfortable in this format (note they can be billed as individual visits):
    • Ask for examples of group visit templates and billing methods.

Use EHRs to Engage Patients

  • Activate clinical decision support to:
    • Highlight missing diabetes services at every visit; and
    • Suggest the need for medication intensification.
  • Use the e-prescribing system
    • Obtain refill history
    • Have a staff member perform a medication reconciliation
    • Have a staff member perform an adherence analysis either electronically or through patient discussion
  • Use the patient educational function
    • Use print-outs, websites, and/or kiosks specified for a low-health literacy audience.
    • Have staff use it to assess patient knowledge and use teach back at subsequent visits
  • Create templates that allow nurses to advise the patient on medication intensification
    • Use them by phone or e-portals between visits

Implement a Workflow that Supports Quality Improvement

  • Maximize the educational skills of office staff (e.g. motivational interviewing/self-management training)
  • Build educational roles into the workflow and/or office progression of the patient.
    • one nurse could specialize in negotiating simple diet changes, while another could teach insulin injections
  • Start this change cycle and workflow with one provider:
    • Perfect the mechanics and team roles,
    • Repeat process measures to see if process is consistent,  
    • Repeat measurement and assess if improvement has occurred;
  • Spread to other providers and set up staff meetings to give provider-specific feedback
    • If the feedback is public in a peer group, the incentive to adhere to the workflow and achieve improvement is intensified.

Produced by Meaningful Use Quality Workgroup -March 27, 2012

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