Submitted by Tracy Colburn, RN, Author
Electronic Medical Record: How its Use Facilitated an Increase in the Number of Patients with Diabetes to Achieve the Target Measurement of Having at Least 2 HbA1c Tests Performed in a 12 Month Period.
We are in the midst of an unprecedented era, the convergence of technology and medicine. Even stories of failures are not true failures because of all we stand to learn from the experience of others. Technology has enabled those in the field of medicine to move forward with their own improvement projects. Because of the advancements in technology, the pace at which these projects can evolve is astonishing and is yet another reason why it is important to share our undertakings. This is an overview of a very small yet successful process which a midsized family practice office in New Hampshire has undertaken. The process is not perfect, and is still being refined. However, it would not have been possible to develop this project without the use of an electronic medical record (EMR) to identify a specific population. I will describe how, from March 2010 to present, through the use of an EMR, the number of patients with diabetes who have had two HbA1c tests in 12 months has increased from 55% to 73%.
A patient with diabetes having two HbA1c tests in the last12 months is a common measurement or target endorsed by quality organizations across the United States. The physician organization I am employed with also uses this measurement as one of many components that are known to improve outcomes for patients with diabetes. Examples of other measurements scrutinized are blood pressure readings, low- density lipoprotein, aspirin use, and smoking status. There is an Advanced Practice Registered Nurse (APRN) who is also a certified diabetes educator (CDE) in the physician’s office where I am employed. In November, 2009, she began work on increasing the number of HbA1c tests our patients with diabetes get done in a 12 month period. In March, 2010, I took over this venture and began the process of refining the method. We both used and I still rely upon a monthly report generated from our EMR data which identifies patients with a diagnosis of diabetes. The report also identifies those patients that are due or over due for HbA1c testing.
This monthly report allows me to easily and quickly obtain the patient’s contact information in their EMR and make phone contact. If I am able to speak with the patient, they are gently reminded of the need to obtain HbA1c. I also take the opportunity start relationship building. Inquires about blood sugar readings, medications, supplies and their general, overall well-being are made. I have had success with relationship building by employing both Katherine Kolbaca’s Theory of Comfort and various motivational interviewing techniques.
Access to our electronic scheduling system permits an appointment to be scheduled with the patient’s primary care physician (PCP) or the APRN, CDE while the patient is still on the phone with me; there is no transferring to the receptionist or a call back later. In January, 2011, the office where I am employed obtained a point –of- service (POS) HbA1c device. This allows a patient with diabetes to have choice of scheduling a visit with the office nurse for a finger stick or to have a lab slip printed and put it into the mail thus allowing the patient to have venipuncture done at their convenience.
If a patient doesn’t return the phone call, their address is accessed in EMR and a letter is sent requesting an office visit be scheduled as well as an explanation of the enclosed lab slip. In my experience, patients who don’t respond to phone calls do often obtain the labs they have received in the mail. If a patient gets his or her lab done within our network the result is auto-populated into the patients chart. The ordering provider receives an automatic notification of a new lab result arriving in the patients chart via a message in the EMR system because of an interfacing program. The physician reviews the HbA1c result. Based on the result a provider will revise medication regiments and encourage life style changes via the phone, email or Next MD, a secure electronic communication portal. Ideally, the patient will be agreeable to a face- to- face office visit with his or her practitioner. This is not always possible for a variety of reasons.
Another common scenario in our practice is one where a patient with diabetes comes in for a sick visit such as a sore throat. During this encounter, because of the EMR, the medical staff is able to promptly identify that this patient has diabetes and assess whether he or she needs HbA1c testing. If the patient is due or overdue a medical staff person can perform a finger stick, run the HbA1c test, obtain the result and relay the result to the ordering practitioner all within a few minutes during the same visit for the sore throat.
Increasing the number of patients with diabetes who have two HbA1c tests in a 12 month period is a well known factor towards improving overall diabetic outcomes. Making patient contact, encouraging testing and explaining why the HbA1c test is important can be a great starting point for developing a relationship with a patient. That one small act is really one huge opportunity. It can turn into an occasion to promote and encourage self efficacy and motivation. As evidenced by the chart below not only has the number of patients with diabetes and two HbA1c in 12 months increased but so has our total population of patients with diabetes. This number is only expected to grow. Informatics generates many possibilities for healthcare process development and improvement.
Chart courtesy of Donna Cliff, RN, CPHQ