Health Management Technology

There are 17 to 18 million Americans with diabetes, and incidence of the disease is increasing. Diabetes is a leading cause of blindness, kidney failure, cardiovascular disease and premature death. Care of diabetes costs the U.S. economy about $132 billion a year, consuming one-seventh of health- care dollars.

Darin M. Camarena Health Centers Inc. is a three-site clinic that serves a diverse patient population from Madera County, California. Located in San Joaquin Valley, the Centers treat a high incidence of diabetes because of the highly concentrated Hispanic population in the region. According to the National Institute of Diabetes and Digestive and Kidney Diseases, Hispanics are nearly twice as likely to develop diabetes as white, non-Hispanics. About 2.5 million Hispanic Americans have been diagnosed with diabetes.

The Centers see approximately 1,500 patients each year who have diabetes, with nearly 90,000 documented patient visits overall. They are attempting to reign in healthcare costs and improve patient care with an electronic health records (EHR) system by InteGreat, which has been certified by the Certification Commission for Healthcare Information Technology (CCHIT) for meeting ambulatory EHR criteria for 2006. This EHR solution, which replaced another EHR system, was selected specifically for its disease management capabilities and implemented in September 2006.

The clinic currently has 15 providers and 166 staff members, of whom 150 are using the EHR. It is very intuitive and user-friendly, so clinicians are up and running after only a half day of training. The EHR contains patient demographic information, laboratory reports, transcribed documents, radiology reports and a health summary. Patient records can be accessed from any computer remote location so information is immediately available for patients who visit any of the three clinic locations.

The clinic is an excellent example of how our group practice is using an EHR’s disease-management functionality to take a leadership approach in enhancing compliance for its diabetic patients, which ultimately could result in a healthier population. For patients with chronic diseases, such as diabetes, EHRs are viewed as a means of managing treatment most efficiently, monitoring patient compliance and treatment regimes, and gaining easier access to real-time patient diagnostic information for better patient treatment.

What is Compliance?

Compliance in managing diabetes is a broad term, used to describe how likely patients are to take their medication. It also encompasses changes in lifestyle, exercise habits and dietary requirements that often are difficult to maintain. More than 95 percent of diabetes care is self-managed by the patient, and healthcare professionals have very little control over how closely patients follow their treatment therapy between office visits.

Approximately 50 to 55 percent of the clinic’s diabetic patients are not in compliance in some way, such as watching their diet or adhering to drug therapy. At the time of a patient visit, the EHR will post an automatic alert if the patient is in non-compliance; for example, the patient has not performed an A1C test in the past three months.

Thanks to its EHR capability, the Centers can analyze trend data of its diabetic patients and help patients enhance compliance. For example, clinicians can review patients who are not compliant, analyze the medications they are taking, see if they are following special dietary requirement, identify which doctors are providing care and what each doctor is doing differently. By drilling down to these levels, the Centers can better determine the breakdown of non-compliant patients.

Darin M. Camarena Health Centers shares its patient data with the U.S. Department of Health and Human Services’ Health Resources and Services Administration, a branch of the Bureau of Primary Health Care, which is a funding source for the clinic.

How an EHR Monitors Compliance

In the clinic’s first phase of disease management implementation, the EHR shows a thumbnail sketch of the patients’ medical history, past and present medications, and provides a very efficient overall picture. It flags indicators for each patient with diabetes to show the progression of the disease and the latest readings for vitals, cholesterol, hemoglobin and body mass index. By showing patients a graphic representation of their illness displayed on the EHR screen, patients are more motivated to comply with their treatment regimen. Physicians have found that the visual impact of seeing their disease progression, instead of just looking at numbers, is the key to patient compliance.

Patients can request and receive a printout on the spot that illustrates their personal stats in a chart format.
The EHR system can recall and print any type of patient-specific information, including A1C, cholesterol, blood sugar and hemoglobin readings. The Centers have observed that patients who take home a "hard copy" of their readings are empowered to take a more active role in their own treatment.

Best Practice Reminders

The EHR also functions as a computer-generated, best-practice reminder system to improve physician compliance with diabetes preventive care guidelines. For instance, when a patient with diabetes has an office visit for a sore throat, the EHR might indicate that the patient is due for an eye exam or a hemoglobin test. When a physician selects a guideline, order entry is done with a few mouse clicks. Clinicians also can point-and-click to modify an order set.

The EHR’s filtering process shows everything that pertains to a specific patient and interfaces directly with lab results. It provides clinical reminders for glycosolated hemoglobin A1C, blood pressure, cholesterol and other tests. Lab results are received almost immediately after the referenced laboratory completes them.

The Centers also implemented automated tracking for generalized health maintenance using age-specific guidelines, including mammography and pap smears for women and prostate screening for men.

In phase two of disease management implementation, the Centers will implement the EHR functionality for automatic patient alerts, reminders and auto-generated letters for reminding patients about upcoming lab tests and appointments. The Centers also plan to have diabetes case managers who will examine patient charts regularly on an automated basis.

Benefits of an EHR System

While the goal of the EHR was to enhance our disease management capabilities, we have realized many other unexpected benefits. The EHR has been a boon to streamlining the time-consuming prescription process of manually writing orders followed up by medical office personal making countless phone calls to pharmacies. E-prescriptions are easier to expedite and help ensure quality medical care. The prescription refill process is easier, faster and less labor intensive, with a 30 percent increase in turnaround time. Pharmacy calls (nine to 10 daily) have been eliminated, freeing up staff to handle other job responsibilities.

As an element of an EHR system, electronic transmission of prescriptions helps reduce the potential for mistakes, and monitor the patient’s compliance and progress. Drug interaction also is eliminated—the EHR does not allow clinicians to move to the next screen if something is prescribed that has a potential interaction. Physicians can print out a list of drug interactions and contraindications directly from the EHR and give it to the patient at the time of the office visit.

For physicians, EHR systems are indispensable virtual assistants that not only provide important medical alerts and reminders, but offer meaningful medical assistance through an extensive database to directly improve overall patient care, evaluation and disease management of diabetic patients and others suffering from chronic conditions.

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Kenneth E. Bernstein, M.D., F.A.A.F.P., is medical director/chief medical officer at Darin M. Camarena Health Centers Inc., with three locations in Madera County, Calif. Contact him at
kbern@ camarenahealth.org.