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The use of EMR tools in IFH’s Diabetes Initiative

Learn how IFH's Diabetes Initiative is utilizing EMR tools to improve care for patients living with diabetes. Discover actionable decision-support tools during patient encounters and guidance outside of patient encounters. Track clinical measures, identify at-risk patients, and monitor progress towards meeting national goals with IFHstats.

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The use of EMR tools in IFH’s Diabetes Initiative

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  1. Elizabeth I. Molina Ortiz, MD MPH Diabetes Medical Director, IFH Mt Hope Family Practice The use of EMR tools in IFH’s Diabetes Initiative

  2. Objectives • Simply having EMR in office is a good start, but not enough • Studies have demonstrated no difference between paper charts and adoption of EMR (without decision support) • Need to add decision-support tools for improved care

  3. Objectives The following slides will demonstrate two types of decision support: Actionable during patient encounter Guide outside of patient encounters

  4. EMR tools to improve care to patients living with diabetes At patient encounter: Nursing BPA for monofilament and A1c testing Physician and CDE Smartsets for easy documentation and ordering Outside of patient encounter: IFHstats Track clinical measures by site or by provider Easily identify at risk patients from panel Identify disparities in outcomes

  5. During encounter: nursing BPAs

  6. During patient encounter: nursing BPAs Automatic review of chart, actionable orders appear if A1c or monofilament testing needed Completed prior to provider visit

  7. During encounter: Smartsets

  8. During encounter: Smartsets In one screen, provider prompted to choose note (which prompts appropriate documentation), labs, referrals, diagnosis and LOS

  9. Outside of patient encounter: Diabetes Registry • Important first step towards monitoring care at population level • Versatile, vast amount of information • Basis for IFH stats

  10. Outside of patient encounter: IFHstats IFHstats allows us to: Monthly track individual patient’s important diabetes clinical markers (10 markers based on NCQA DPRP) Monthly track population’s clinical markers (presented by provider, clinic, or institute-wide) Track progress towards meeting national goals Determine when ready for application and accreditation

  11. IFHstats: Easily accessible

  12. IFHstats – Track Progress by Site

  13. IFHstats – Site lists active providers

  14. IFHstats – or by provider

  15. IFHstats – Areas for improvement highlighted

  16. IFHstats – Easily review diabetic panel and clinical markers

  17. IFHstats – Download and sort data

  18. IFHstats – Identify disparities

  19. Ability to monitor patient population in important clinical markers Westchester increase rate of A1c<7% by 10% Amsterdam decreased rate of A1c >9% by 11% Mt Hope increased rates of ophthalmology consults by 7% Sidney Hillman increased rate of neuropathy screen by 21% 62% patients at Phillips screened for nephropathy (up by 12%) Ability to use PDSA cycle, monitor progress, identify success, and propagate it IFH’s Diabetes Initiative: Notable Improvements (Nov – March)

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