Diabetes Registry

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

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Who We AreAn 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

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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

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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 TargetDiabetes
• Physician Champion identified (Karen Cabell, DO)

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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

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VHA TargetDiabetes 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

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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 (lt130/80)
• HEART/CHOLESTEROL- April through June. Goal
  Annual cholesterol assessment. Act on results of
  BP and cholesterol. Patient education on the
  importance of LDLlt 100 and BP lt130/80.

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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

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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)

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NCQA-DPRP Billings Clinic Diabetes Goals

• HgA1c gt 9 Goal is less than 20 of patients
• HgA1c lt 7 Goal is more than 40 of patients
• BP lt140/90 Goal is more than 65 of patients
• BP lt130/80 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 lt 130mg/ dL More than 65
• LDL lt 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

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• 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
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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.
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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 providers 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.
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Red Light / Green Light Monthly Report to
Providers
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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)

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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

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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)

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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

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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.

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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

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Diabetes Registry Specifics

• Process
• Patients with diabetes on the providers 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.

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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

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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 providers 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

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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

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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 gt7.0, BP gt 140/90 and LDL gt 100
• ADA summary reports

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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

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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

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Questions??
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Contacts

• Jan Bechtold, RN, Quality Specialist
• jbechtold_at_billingsclinic.org
• Sue Garcia, System Consultant II, IS
• sgarcia2_at_billingsclinic.org