Diabetes Registry & Chronic Disease Management August 27, 2008

1. Diabetes Registry & Chronic Disease Management August 27, 2008 Sue Garcia, System Consultant II, IS Jan Bechtold, R.N., Quality Specialist

2. Who We Are…An outstanding medical foundation built upon these cornerstones: • A Multi-Specialty Physician Group Practice in which a “community of physicians” work together in a collegial manner is at the core of this model. • The Partnering of Physicians, Leadership, Professional Staff and Volunteers Create a Team Whose Synergies Drive our Success. • Not-for-profit, Community-Owned and Governed • Mission-driven Decision-Making Dedicated to Higher Purpose in the Community and the Region • An Obsessive Dedication to Quality and Service

4. Background – DQCMS (Diabetes Quality Care Monitoring System) • Our main clinic used DQCMS for a short period of time • Abandoned that effort in 2002 due to a number of factors: • Manual entry • Only on select computers • Double charting • Time consuming • 2003 – Our CEO (Dr. Nicholas Wolter) placed the diabetes registry and enhancing care to our diabetes population a top priority • 2004 – Cerner – Clinical Information System (CIS) implemented

5. Development of Diabetes Registry • Quality Specialist position added: • Through a grant acquired by the Center on Aging Dept (Translational Research) • To develop the diabetes registry • Billings Clinic became part of the VHA collaborative Target:Diabetes • Physician Champion identified (Karen Cabell, DO)

6. Development of Diabetes Registry • From our financial system we pulled lists of pts with 250.xx diagnosis that were within our service region • Manually reviewed those records (using CIS) to determine: • Did pt have diabetes? • Did the have their primary diabetes provider at Billings Clinic? • Reviewed 15,000 records • Active registry is 4800+ patients • Registry housed in CIS data base • Wanted data to be pulled from the data already being entered • Accessible to all • Discovered data from Cerner was hard to retrieve in a meaningful way

7. VHA Target:Diabetes Collaborative • Focused on inpatient diabetes care and clinic (outpatient) care • Involve the entire clinic team in the delivery of care to the patient with diabetes. • Engage patients in education • Modeled our patient education after the American Association of Clinical Endocrinologists (AACE) Medical Guidelines for the Management of Diabetes Mellitus • Started the quarterly education module/ focus in 2004 on main campus, out to all sites in 2005 • Quarterly education sheet for patients and posters for exam rooms • Education is provided to any pt with diabetes not just the ones in our registry • Intent is to improve patient education and understanding

8. Quarterly Education Modules • FOOT- July through Sept. Goal: Annual complete foot exam done and documented in CIS. Patient education • EYE - Oct. through Dec. Goal: Annual eye exam completed and documentation received from eye care provider. Staff to document this in CIS. Patient education • KIDNEY- Jan. through Mar. Goal: Annual nephropathy assessment and act on results. Patient education - kidney disease in diabetes and the importance of BP control (<130/80) • HEART/CHOLESTEROL- April through June. Goal: Annual cholesterol assessment. Act on results of BP and cholesterol. Patient education on the importance of LDL< 100 and BP <130/80.

13. Current Database – January 2004 to 2008 • Worked with Akcia (Cerner) to develop 3 reports for the Diabetes Registry that pull data directly from CIS: • Patient Education Report Card (goes to all DM pts not just those in the registry) • Provider “Point of Service” Flow sheet (used for all DM pts) • Monthly Provider Reports with list of patients and data (flat report) • Attempted to replicate what DQCMS had to offer in our CIS but there were numerous issues and barriers

14. Diabetes Registry- Goals • NCQA - DPRP: National Committee for Quality Assurance Diabetes Physician Recognition Program. • Co-sponsored by the American Diabetes Association • Voluntary Program for individual physicians or physician groups that provide care to patients with diabetes (20 Billings Clinic providers received the NCQA DPRP in the fall of 2006. 4 of these are in Cody, 1 in Columbus and 15 in Billings) • Program assesses key measures of care (using Hedis measures)

15. NCQA-DPRP & Billings Clinic Diabetes Goals • HgA1c > 9%: Goal is less than 20% of patients • HgA1c < 7%: Goal is more than 40% of patients • BP <140/90: Goal is more than 65% of patients • BP <130/80: Goal is more than 35% of patients • Smoking status/ advice: Goal is more than 80% of patients • Lipid panel performed yearly: Goal is more than 85% • LDL < 130mg/ dL: More than 65% • LDL < 100mg/dL: More than 36% • Nephropathy assessment yearly: More than 80% of patients (even if on an ACE or ARB) • Foot exam documentation yearly: More than 80% of patients • Eye exam yearly: Goal is more than 60% of patients

16. Goals of report card: • Quick and easy summary of data for patient • Provide education “points” for the patient that are easy to read • Reinforce the goals that the provider has given the patient Health Care Education and Research

17. This report is printed for the provider. It contains the last 12 months of data for this particular pt. It includes outside labs (outside labs are designated with *). It is used as a communication tool between the provider and their nurse.

18. This report is printed monthly. It gives the provider a list of their diabetes pts. It also shows their latest test results, if they were done in the past 12 months. The provider’s summary information is placed on a report with all the other providers in their department. The provider can compare themselves to the others in their dept as well as the Billings Clinic system overall.

19. Red Light / Green Light Monthly Report to Providers

21. Current Database (January 2004 to 2008) • Investigated diabetes report writing capabilities of CIS – limited report writing • Investigated report writing programs – did not find one that would meet our needs • Decided to look at DQCMS a second time • Decided that the most flexible and comprehensive system is DQCMS • DQCMS offered to us at no cost from the QIO • Fall 2005 – decided to pursue building a bridge from CIS to DQCMS to help with data management • Did invest dollars into building the bridge • The process of building the bridge has taken 2.5 years (mainly due to our lack of programming resources)

22. Building the Bridge - DQCMS • Contracted with Energy & Environmental Research Center (EERC) at the University of North Dakota (UND) to assist in the mapping of the data from CIS to DQCMS (DQCMS was developed originally by EERC) • DQCMS has specific import specs so CCL (Cerner Computer Language) programming had to be written to create the tables to upload into DQCMS • Before import we have to review all the tables as data can be outside the import specs. These issues have to be corrected before importing the tables into DQCMS • It has been a collaborative effort by IS and Quality Resources to get DQCMS up and running • Required validation of data between IS and Quality Resources

23. Diabetes Registry • All patients with a 250.xx diagnosis were reviewed to determine if the pt did indeed have diabetes. • They were placed in the registry if: • They indeed did have diabetes & • Their diabetes provider was a Billings Clinic provider (any site)

24. Diabetes Registry- Goals • Improve quality of diabetes care provided by our health system: • “Point of Service” reports- collate info at time of patient visit • Disease management of population • Process improvement around problem areas • Involve the entire office staff to care for the DM pts. Automate as much as possible • Getting ready for “pay for performance” and “public reporting” of data (ex. our CMS project). • Set targets for each measure

27. Diabetes Registry Specifics • Labs: these pull directly to all three reports • HgA1c • Lipid Panel • creatinine, microalbumin/ creatinine ratio (or 24h urine microalbumin, 24h urine protein, & protein to creatinine ratio) • Outside Labs: • If labs done outside of our system, they are entered through Power Chart Office as an “outside lab” and pull to the reports.

28. Diabetes Registry Specifics • The following pull from information entered into CIS: • Immunizations • Smoking • Medication from medication list • Foot and Eye exam information comes from direct entry by staff or the provider • Diabetes Education – pulls the hours of education. After some enhancements it will also display the education topics

29. Diabetes Registry Specifics • Process: • Patients with diabetes on the provider’s daily office schedule are identified prior to the appt. • When patients are roomed by the nurse, vitals taken & entered. • The Provider Flowsheet is to be printed - nurse looks for deficiencies: • If eye exam is not documented, ask when & where and fax form to the eye provider • If foot exam not documented, ask patient to remove shoes and socks and remind provider to do exam. • If labs, immunizations needed, aspirin etc., circle on the flowsheet for provider.

30. Diabetes Registry Specifics • Process (continued): • Once Flowsheet is prepared, place on front of chart and along with a copy of the patient “report card”. • Provider/ nurse teams can customize the process • Nurse/provider does foot exams • Nurse orders lab tests if due, gives immunizations if due, etc. • Nurse gives patient copy of report card before patient sees provider (and reviews, if time) • Have a site specific “diabetes panel” of labs- A1c, Lipid, CMP, Microalbumin/ creatinine ratio • New Issues: • Ability to document “refusal” or “contraindicated” or “intolerance” • Enhancement of all diabetes reports

34. CERNER DATA TO DQCMS • Validation helped us identify education and system issues such as: • Multiple medical record numbers • Weights with numbers after the decimal • Date with no data attached • Provider entry into DQCMS vs. CIS can be different • Example Karen Cabell, DO in CIS, K Cabell, DO in DQCMS. The provider information will not load for any of that provider’s pts • No data is entered directly into DQCMS, all pt information is charted in CIS and pulled across to DQCMS • No ability to make it “read-only”

35. DQCMS • Currently no logons or levels of security • The data is on the network. The application is on the individual computers • It requires an IS person to load – communicate to all users that loading is in process and DQCMS is not available during that time • Constant backup system • Access data base – when running reports the computer needs to be dedicated to this function only

36. Reports from DQCMS • Some examples of reports from DQCMS: • Reports that summarize all Billings Clinic providers in 9 major categories • A1c • Lipid • Renal • Blood Pressure • Foot • Eye • Preventative • Tobacco Usage • Education • Lists of pts who have not had a A1c for 6 months • Pts with A1c >7.0, BP > 140/90 and LDL > 100 • ADA summary reports

40. Current Status - DQCMS • Just completed a program enhancement that combines all the medical records numbers and their information prior to information pulling to the tables • Completed cleanup of the existing multiple medical record numbers • Have installed DQCMS to all Billings Clinic sites: • Cody, WY • Columbus • Miles City • Red Lodge • Billings Westend • Billings Heights • Billings Main Campus • Provide education to staff regarding DQCMS

41. SUMMARY • Diabetes registry • Information System – developed diabetes registry data entry screens • Report writing – DQCMS • Information to all providers about their individual pts and their population of pts • Providers/office staff can pull their own reports to track their patients • Comparative information – provider to provider • NCQA-DPRP

42. Questions??

43. Contacts • Jan Bechtold, RN, Quality Specialist • jbechtold@billingsclinic.org • Sue Garcia, System Consultant II, IS • sgarcia2@billingsclinic.org