Optimizing Electronic Health Record Use for Management of Type 2 Diabetes Mellitus in Primary Care

Primary care providers bear much of the responsibility for the ongoing management of the costly, disabling, and deadly chronic disease, type 2 diabetes mellitus (T2DM).  A preponderance of evidence demonstrates that implementation of diabetes management guidelines improves patient outcomes.  However, primary care providers have inconsistent to poor adherence to guidelines, resulting in significant gaps between evidence based and actual care for people with T2DM.  Barriers to optimal care include limited appointment times, lack of ready access to patient information, and limited knowledge of guideline recommendations. Three key objectives for diabetes management defined by the ADA are optimizing provider and team behavior, supporting patient behavior change, and changing the system of care.   Optimizing the use of the electronic health record (EHR) by configuring a clinical decision support system (CDSS), changing workflow patterns to include team management, and implementing a structured patient education and behavior change system can improve management of T2DM in primary care.  In a Doctorate of Nursing Practice scholarly project at a small primary care clinic, (EHR) use was expanded to incorporate T2DM management guidelines, and clinic workflow was structured for efficient evidence based care. 

Core functions of the EHR include effective care delivery, facilitation of chronic disease management, improved efficiency, and enhanced patient safety. Yet, studies of the effect of the EHR on quality of care reveal mixed results including superior care, inferior care, and no association between EHR use and quality of care.  Researchers agree that EHR use does not guarantee superior care, but that advanced functions such as CDSS and registry activation make the EHR invaluable.  Registries and CDSS tools, which organize, filter, and present useful and timely information contribute to improvement in care.  However, small clinics struggle with optimal use of advanced EHR functions because the systems are complex.  Optimization of the EHR is a necessary but insufficient means to improve care; modification to workflow is also required.

Although the EHR used at the project clinic came programmed with a Diabetes Registry and a CDSS, the EHR lacked full optimization.  Specifically, the system did not capture the data entered during the visit or from laboratory test results and insert the data in the the Registry or the CDSS.  The author of this project is not a trained informaticist, but used a systematic process to optimize the system.  First, a literature review was conducted regarding diabetes management guidelines and use of the EHR for improving management of patients with diabetes.  Then, the website for the EHR vendor was searched.  Product development and release webcasts were viewed to obtain an overview of the EHR system and its functionality.  Finally, the help documents on the system were examined to determine configuration technique.  Following the document instructions, the EHR was configured to allow visit and test result data to populate the Diabetes Registry and activate alerts.  When following the directions failed to achieve the intended results, contact with the EHR vendor resulted in interventions by the vendor at the server level to turn on desired capabilities.

A variety of interventions were implemented to augment the EHR.  Logical Observation Identifiers Names and Codes (LOINC) were linked with Current Procedural Terminology (CPT) codes to facilitate data capture.  Because laboratories use different codes, it is important to choose the laboratory specific code.  Structured data was created in Progress Notes section of the EHR, and alerts were configured to provide reminders for guideline based intervention.  In addition, a diabetes flowsheet was configured to give providers a graphic view of patient progress. To facilitate barriers to providers’ of lack of time and lack of easy access to guidelines, a Diabetes Order Set was developed.  Commonly used medications, evidence based tests, procedures, and referrals were integrated into the order set.  In addition, PDF documents were uploaded into the system including the American Association of Clinical Endocrinologists’ Comprehensive Diabetes Management Algorithm 2013 and the basal insulin algorithm from the American Diabetes Standards of Care 2015.  Documents from the National Institutes of Health including foot care, chronic kidney disease, and hypertension management were also uploaded.  The PDF documents provide quick access to guidelines from the order set screen of the EHR, reducing time needed to locate references.

During the literature search, reference was found to federally funded Regional Extension Centers, which provide assistance to clinics with EHR implementation.  A Google search led to the Regional Extension Center for the state. Although the Regional Resource Centers are being phased out, the Centers for Medicare and Medicaid have collaborated with Quality Improvement Organizations and will continue through 2019. In many states, Qualis Health is the contractor designated to assist in data collection, analysis, and interventions to improve care.

As a result of this DNP project, the clinic has partnered with Qualis Health in an innovation to improve diabetes care.  Qualis Health will assist the clinic in ongoing quality improvement strategies and technical assistance in gathering data and improving workflow and documentation.  Assistance with Physician Quality Reporting System (PQRS), Value-Based Modifiers (VM), and Quality and Resources Use Reports (QRURs) is provided by Qualis, along with strategies for participating in federal reimbursement programs.  The clinic will be responsible to report quarterly data on diabetes intermediate outcomes including HbA1c, lipids, blood pressure, foot exam, and eye exam. The clinic will also refer eligible patients to self-management education identified by Qualis. Assistance for data collection, reporting, and workflow configuration will be provided by Qualis. 

An office workflow process was developed to integrate team activity for efficient evidence based care for patients with T2DM.  First, a flowchart was developed to describe existing practice. Based on literature evidence, the workflow was revised to integrate staff as part of the team to increase efficiency.  Nursing staff identify patients with T2DM by diagnosis or medications, ascertain the managing provider, establish the date of last laboratory work, follow a protocol for influenza and pneumococcal immunizations, lay out a monofilament, and prepare the patient for the provider by asking the patient to remove footwear for foot checks. Front staff ensures that patient education given verbally by the provider and nursing staff is offered to the patient in paper form or is uploaded to the patient portal. Future training with Qualis regarding quality improvement will empower staff to see processes from a quality perspective.

To evaluate the effectiveness of these innovations, an acceptability and satisfaction survey was developed and feedback from providers, staff, and content experts was incorporated into the project.  Partnership with Qualis Health ensures the sustainability of this project, and will assist this clinic in providing ongoing quality healthcare.  In conclusion, this technology solution can assist all staff, nurses and providers in the clinic in better meeting the needs of patients with diabetes and can promote improved patient outcomes through continuous quality improvement initiatives.  Nurses at other clinics can use the results of this project to optimize the EHR and clinic workflow to improve patient management not only for diabetes but also for other diseases.