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Employing the electronic health record to improve diabetes care: a multifaceted intervention in an integrated delivery system.

ABSTRACT: INTRODUCTION: Type 2 diabetes is one of the nation's most prevalent chronic diseases. Although well-known practice guidelines exist, real-life clinical performance often falls short of benchmarks. AIM: Employ an electronic registry derived from a fully integrated electronic health record (EHR) as the cornerstone of an intervention to improve compliance with recommended diabetes performance measures in an integrated practice network. SETTING: Geisinger Health System's network of 38 practice sites providing care to over 20,000 persons with diabetes located in a 40-county region of central and northeastern Pennsylvania. PROGRAM DESCRIPTION: A multidisciplinary group of physicians worked to create a "bundle" of best practice measures for diabetes. This measurement tool was then used as part of a multifaceted intervention to improve physician performance in diabetes care, including audit and feedback, computerized reminders, and financial incentives. Changes in performance of individual measures and the total "bundle" were tracked monthly over 1 year. PROGRAM EVALUATION: Significant increases were seen in all measures of diabetes care over the 12-month period of the study. Vaccination for pneumococcal disease and influenza improved from 56.5% to 80.8% (p < .0001) and 55.1% to 71.0% (p < .0001), respectively. The percentage of patients with ideal glucose control (HBA1c < 7.0) increased from 32.2% to 34.8% (p < .001), and blood pressure control (<130/80) improved from 39.7% to 43.9% (p < .0001). The overall number of patients receiving all 9 "bundled" measurements improved from 2.4% to 6.5% (p < .0001). DISCUSSION: Diabetes care improved significantly in response to a multifaceted intervention featuring the use of an EHR-derived registry in an integrated delivery system. More work is needed to demonstrate that such improvements will translate into improved patient health outcomes.

SUBMITTER: Weber V

PROVIDER: S-EPMC2359509 | biostudies-other | 2008 Apr

REPOSITORIES: biostudies-other

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Project description:ObjectiveTo assess the effects of an electronic health record (EHR) intervention that prompts the clinician to prescribe nicotine replacement therapy (NRT) at hospital admission and discharge in a large integrated health system.DesignRetrospective cohort study using interrupted time series (ITS) analysis leveraging EHR data generated before and after implementation of the 2015 EHR-based intervention.SettingKaiser Permanente Northern California, a large integrated health system with 4.2 million members.ParticipantsCurrent smokers aged ≥18 hospitalised for any reason.ExposureEHR-based clinical decision supports that prompted the clinician to order NRT on hospital admission (implemented February 2015) and discharge (implemented September 2015).Main outcomes and measuresPrimary outcomes included the monthly percentage of admitted smokers with NRT orders during admission and at discharge. A secondary outcome assessed patient quit rates within 30 days of hospital discharge as reported during discharge follow-up outpatient visits.ResultsThe percentage of admissions with NRT orders increased from 29.9% in the year preceding the intervention to 78.1% in the year following (41.8% change, 95% CI 38.6% to 44.9%) after implementation of the admission hard-stop intervention compared with the baseline trend (ITS estimate). The percentage of discharges with NRT orders increased acutely at the time of both interventions (admission intervention ITS estimate 15.5%, 95% CI 11% to 20%; discharge intervention ITS estimate 13.4%, 95% CI 9.1% to 17.7%). Following the implementation of the discharge intervention, there was a small increase in patient-reported quit rates (ITS estimate 5.0%, 95% CI 2.2% to 7.8%).ConclusionsAn EHR-based clinical decision-making support embedded into admission and discharge documentation was associated with an increase in NRT prescriptions and improvement in quit rates. Similar systemic EHR interventions can help improve smoking cessation efforts after hospitalisation.

Project description:INTRODUCTION:Smoking remains a major public health issue and a leading cause of death and disability in the United States. The objective of this study was to determine the effect of a simple intervention on smoking guidance, based on the electronic medical record (EMR), including providing discharge instructions and/or cessation counseling to emergency department (ED) patients who smoke. METHODS:This was an interventional before-and-after study in an ED with 70000 visits per year. A pre-intervention and post-intervention chart review was performed on a random sample of ED visits occurring in 2014 and 2016, identifying smokers and the frequency with which smokers received discharge instructions and/or cessation counseling. In the fall of 2015, our EMR was programmed to deploy smoking cessation discharge instructions automatically. RESULTS:In all, 28.7% (172/600; 95% CI: 25.2-32.4%) reported current smoking in the pre-intervention ED population and 27.6% (166/600; 95% CI: 24.2-31.4%) reported smoking in the post-intervention population. Smoking cessation guidance was provided to a total of 3.5% of self-reported smokers in the pre-intervention group (6/172; 95% CI: 1.4-7.6%); 1.2% (2/172; 95% CI: 0.3-4.1%) were informed of smoking cessation resources as part of their printed ED discharge instructions and 2.3% (4/172; 95% CI: 0.9-5.8%) received smoking cessation counseling by the ED provider. There was a statistically significant increase in the proportion of patients receiving any smoking cessation guidance after the intervention. All patients (166/166; 95% CI: 97-100% in this period received ED discharge instructions and a list of smoking cessation resources and 3.6% of smokers (6/166; 95% CI: 1.7-7.7%) received smoking cessation counseling by the ED provider. CONCLUSIONS:Automated deployment of smoking cessation discharge instructions in the EMR improves smoking cessation discharge instructions, and also has a positive impact on improving rates of in-person counseling by ED providers.

Project description:BackgroundA system that combines technology and web-based coaching can help treat chronic conditions such as diabetes. However, the effectiveness of apps in mobile health (mHealth) interventions is inconclusive and unclear due to heterogeneous interventions and varying follow-up durations. In addition, randomized controlled trial data are limited, and long-term follow-up is lacking, especially for apps integrated into electronic medical records.ObjectiveWe aimed to assess the effect of an electronic medical record-integrated mobile app for personalized diabetes self-care, focusing on the self-monitoring of blood glucose and lifestyle modifications, on glycemic control in patients with type 2 diabetes mellitus.MethodsIn a 26-week, 3-arm, randomized, controlled, open-label, parallel group trial, patients with type 2 diabetes mellitus and a hemoglobin A1c (HbA1c) level of ≥7.5% were recruited. The mHealth intervention consisted of self-monitoring of blood glucose with the automatic transfer of glucose, diet, and physical activity counseling data (iCareD system). Participants were randomly assigned to the following three groups: usual care (UC), mobile diabetes self-care (MC), and MC with personalized, bidirectional feedback from physicians (MPC). The primary outcome was the change in HbA1c levels at 26 weeks. In addition, diabetes-related self-efficacy, self-care activities, and satisfaction with the iCareD system were assessed after the intervention.ResultsA total of 269 participants were enrolled, and 234 patients (86.9%) remained in the study at 26 weeks. At 12 weeks after the intervention, the mean decline in HbA1c levels was significantly different among the 3 groups (UC vs MC vs MPC: -0.49% vs -0.86% vs -1.04%; P=.02). The HbA1c level decreased in all groups; however, it did not differ among groups after 26 weeks. In a subgroup analysis, HbA1c levels showed a statistically significant decrease after the intervention in the MPC group compared with the change in the UC or MC group, especially in patients aged <65 years (P=.02), patients with a diabetes duration of ≥10 years (P=.02), patients with a BMI of ≥25.0 kg/m2 (P=.004), patients with a C-peptide level of ≥0.6 ng/mL (P=.008), and patients who did not undergo treatment with insulin (P=.004) at 12 weeks. A total of 87.2% (137/157) of the participants were satisfied with the iCareD system.ConclusionsThe mHealth intervention for diabetes self-care showed short-term efficacy in glycemic control, and the effect decreased over time. The participants were comfortable with using the iCareD system and exhibited high adherence.Trial registrationClinical Research Information Service, Republic of Korea KCT0004128; https://tinyurl.com/bdd6pa9m.

Project description:BackgroundCare plan concordance among patients and clinicians during hospitalization is suboptimal.ObjectiveThis article determines whether an electronic health record (EHR)-integrated patient portal was associated with increased understanding of the care plan, including the key recovery goal, among patients and clinicians in acute care setting.MethodsThe intervention included (1) a patient portal configured to solicit a single patient-designated recovery goal and display the care plan from the EHR for participating patients; and (2) an electronic care plan for all unit-based nurses that displays patient-inputted information, accessible to all clinicians via the EHR. Patients admitted to an oncology unit, including their nurses and physicians, were enrolled before and after implementation. Main outcomes included mean concordance scores for the overall care plan and individual care plan elements.ResultsOf 457 and 283 eligible patients approached during pre- and postintervention periods, 55 and 46 participated in interviews, respectively, including their clinicians. Of 46 postintervention patients, 27 (58.7%) enrolled in the patient portal. The intention-to-treat analysis demonstrated a nonsignificant increase in the mean concordance score for the overall care plan (62.0-67.1, adjusted p = 0.13), and significant increases in mean concordance scores for the recovery goal (30.3-57.7, adjusted p < 0.01) and main reason for hospitalization (58.6-79.2, adjusted p < 0.01). The on-treatment analysis of patient portal enrollees demonstrated significant increases in mean concordance scores for the overall care plan (61.9-70.0, adjusted p < 0.01), the recovery goal (30.4-66.8, adjusted p < 0.01), and main reason for hospitalization (58.3-81.7, adjusted p < 0.01), comparable to the intention-to-treat analysis.ConclusionImplementation of an EHR-integrated patient portal was associated with increased concordance for key care plan components. Future efforts should be directed at improving concordance for other care plan components and conducting larger, randomized studies to evaluate the impact on key outcomes during transitions of care.Clinical trials identifierNCT02258594.

Project description:BackgroundAdvance care planning allows patients to articulate their future care preferences should they no longer be able to make decisions on their own. Early advance care planning in outpatient settings provides benefits such as less aggressive care and fewer hospitalizations, yet it is underutilized due to barriers such as provider time constraints and communication complexity. Novel methods, such as patient portals, provide a unique opportunity to conduct advance care planning previsit planning for outpatient care. This follow-up to our pilot study aimed to conduct pragmatic testing of a novel electronic health record-tethered framework and its effects on advance care planning delivery in a real-world primary care setting.ObjectiveOur intervention tested a previsit advance care planning workflow centered around a framework sent via secure electronic health record-linked patient portal in a real-world clinical setting. The primary objective of this study was to determine its impact on frequency and quality of advance care planning documentation.MethodsWe conducted a pragmatic trial including 2 sister clinical sites, one site implementing the intervention and the other continuing standard care. A total of 419 patients aged between 50 and 93 years with active portal accounts received intervention (n=200) or standard care (n=219). Chart review analyzed the presence of advance care planning and its quality and was graded with previously established scoring criteria based on advance care planning best practice guidelines from multiple nations.ResultsA total of 19.5% (39/200) of patients who received previsit planning responded to the framework. We found that the intervention site had statistically significant improvement in new advance care planning documentation rates (P<.01) and quality (P<.01) among all eligible patients. Advance care planning documentation rates increased by 105% (19/39 to 39/39) and quality improved among all patients who engaged in the previsit planning framework (n=39). Among eligible patients aged between 50 and 60 years at the intervention site, advance care planning documentation rates increased by 37% (27/96 to 37/96). Advance care planning documentation rates increased 34% among high users (27/67 to 36/67).ConclusionsAdvance care planning previsit planning using a secure electronic health record-supported patient portal framework yielded improvement in the presence of advance care planning documentation, with highest improvement in active patient portal users and patients aged between 50 and 60 years. Targeted previsit patient portal advance care planning delivery in these populations can potentially improve the quality of care in these populations.

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Employing the electronic health record to improve diabetes care: a multifaceted intervention in an integrated delivery system.

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