Patient registry pilot eases diabetes prevention in practice

Sara Berg
Senior Staff Writer
AMA Wire
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A pilot patient registry is helping physicians and other clinicians use their electronic health records system to more easily identify patients at risk for type 2 diabetes and refer them to an evidence-based diabetes prevention program (DPP). The pilot aims to bring together all members of the health care team to ensure complete access to detailed patient information for prevention of diabetes.

According to the Centers for Disease Control and Prevention, more than 84 million Americans live with prediabetes. And in Michigan alone, 2.6 million have prediabetes—a number that Henry Ford Macomb Hospital is looking to decrease through the pilot program.   

Henry Ford Macomb Hospital, located in Clinton Township, Michigan, is part of the Henry Ford Health System and is evaluating the patient registry for its effectiveness in screening, testing and referring patients to a DPP in partnership with the AMA. The registry pilot went live March 15 and is accompanied by a year-long DPP. Patients referred to a DPP can learn about eating healthfully, adding physical activity to their daily routine, managing stress, and staying motivated and overcoming barriers to success.

“With a staggering number of Americans living with prediabetes and the vast majority unaware they have the condition, we must continue to ensure more patients have access to, and enroll in, proven lifestyle change programs that have been shown to cut in half participants’ risk of progressing to type 2 diabetes,” AMA President David O. Barbe, MD, MHA, said in a statement. “Through our partnerships with health systems, such as Henry Ford, we will be able to help even more Americans stave off or delay type 2 diabetes to improve health outcomes.”

The registry pilot aims to give physicians and care teams the technology they need to support their efforts to prevent chronic disease and improve population health.

The documentation-and-reporting system used by Henry Ford Macomb Faith Community Nursing Network, its DPP CDC-recognized provider, helped support closing the referral loop with the registry in the Epic electronic health record system. Through this system, physicians and other health professionals are able to view their patients’ progress after enrolling them in a DPP. The system allows the DPP to send reports to referring physicians on patients’ attendance in DPP classes, weight loss, blood pressure and physical activity levels.

User-friendly tools aid success

Before creating the registry, Henry Ford Macomb developed specific clinical protocols by using tools available in Epic. This was to ensure providers using the system would have access to the necessary tools available to effectively identify and screen patients for prediabetes.

“With the electronic tools that were developed, along with the AMA and Epic team, we’re able to electronically refer the patients to the diabetes prevention program,” Gina Aquino, a clinical quality nurse facilitator at Henry Ford Macomb, told AMA Wire®.

“The Faith Community Nursing Network handles the work queue so they are able to identify the patients coming to them and enroll them in classes throughout Macomb County,” she added.

The pilot program also provides access to necessary tools for medical assistants and providers. It also does the same with the DPP and allows staff at Henry Ford Macomb to work together as a care team with each patient. They can work on the initial screening, setting goals and readjusting goals based on the patient’s readiness to change.

And with faster responses than in the past, patients are also pleased with Henry Ford Macomb’s DPP.

“Previously, the information was faxed over,” Aquino said. “Now everything is in a work queue and the Faith Community Nursing Network can go through and schedule patients into classes, which is easier and less time consuming.”

The AMA provided materials on diabetes prevention to the Henry Ford pilot team. The team then used those materials as components of the program to train staff via four sessions using Skype. Aquino also created binders with tip sheets regarding the tools built into Epic and information on the DPP itself based on the two separate course sessions. She completed the preparation by visiting each clinic to train everyone individually.

“We wanted to make sure we were able to answer any questions,” Aquino said.

Identify, fix issues early on

When beginning the pilot registry, Aquino and Henry Ford Macomb expected some bumps in the road. To overcome any issues, she worked closely with the clinics to identify and fix problems promptly.

The biggest issue that had to be overcome was ensuring that everyone—from physicians and other practice team members to DPP staffers—had the proper permissions in Epic to access detailed information about each referred patient. At first, for some users, the only information displayed for patients was that they had a DPP appointment scheduled.

“We did have a few glitches, but now they’re fixed and everything is running smoothly,” she said.

The implementation phase of the pilot, which ended in June, will be reviewed by the AMA to determine its suitability as a national model. The evaluation phase of the pilot is underway now and will end next year.

“We have a few providers that want to pilot the project throughout the Henry Ford Health System,” Aquino said.

Due to the increased interest in the tools, Henry Ford Macomb is hoping to expand the pilot to other Epic users. A similar program is also planned for Wayne County, Michigan, the county in which Detroit is located. This would include the Macomb County Health Department and Greater Detroit Area Health Council.

“Rolling this out has been very helpful to our staff and to the diabetes prevention program,” Aquino said. “It is helping to benefit our patients to make sure they’re reducing their risk for developing type 2 diabetes and other comorbidities.”

Recently, the AMA, CDC and the Ad Council launched a public service announcement ad campaign to urge Americans to take the one-minute prediabetes risk test. The campaign highlights the importance of following up with a physician to learn more about prediabetes.

The AMA offers online CME to expand your knowledge in diabetes management. Explore educational content such as “Prevent Diabetes STAT.”

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