Framework for Making Systems Changes

• Identify individuals with diabetes at the level of the provider.
• Identify individuals requiring further intervention to achieve quality care.
• Provide patients with information and support.
• Provide health care providers with timely, complete, and structured information about the current status of an individual patient.
• Provide health care providers with an up to date summary of patient requirements to meet current guidelines for quality care.
• Generate population-based reports of quality of care for a defined population.
• Facilitate communication between all team members and team access to important information.
• Enable patient-centered care.
• Enhanced patient-provider interaction.

Identify individuals with diabetes
Identification of individuals with diabetes within a practice is the basic function of a simple registry. It is a way to effectively define the population to be served with the critical element of individual-level unique identifiers. A registry should be able to:

• identify an individual patient's health care providers or health care team
• confirm that a patient remains in the system
• indicate how long it has been since the patient's last visit

Patient death, or the transfer of a patient to another clinic needs to be recorded to allow these patients to be excluded from outreach interventions. Identification of the patient's health care provider or health care team enables contact with appropriate personnel if further information or action is necessary. [back]

Identify individuals requiring further intervention to achieve quality care

Stratifying by risk
A useful information system enables health care providers to prioritize the care that they deliver according to evidence-based risk. Because resources are limited, identification of individuals at risk for diabetes complications helps providers prioritize care so that individuals at greatest risk receive the care they require. Such decisions should be based upon sound evidence that quantifies risk.

Although the decision to modify risk factors involves clinical judgment, data systems also can provide information to support decision-making. This may include up-to-date descriptions of ways to modify important elements of health risk assessment (e.g., weight, height, BMI, patient motivation to change).

Click here for Risk Assessment Tools

Identifying patients with complications and other comorbidities
Identifying patients with diabetes complications or other comorbidities in a previous 2-year period can help with resource allocation.^3,4 Analyses of administrative databases have demonstrated that a large fraction of health care dollars are allocated to a small proportion of the population with multiple comorbidities. For example, data from Mayo Clinic show that 20 percent of patients account for 70 percent of the medical costs associated with diabetes and 40 percent of patients account for 90 percent of the costs.⁵ Identification of complications and comorbidities enable resources to be directed at high-risk individuals in order to modify the likelihood of additional injury Patients with complications are an evolving group and for practical planning purposes periodic reassessment is essential. [back]

Provide patients with information and support
An information system enables health care professionals to arrange for patients to be supported in the continuation of care and to be aware of new equipment and community resources. These types of services include appointment reminders, proactive outreach calls, laboratory test reporting, educational interventions, or availability of educators and other team members. Information should promote and enable self-management among patients. [back]

Provide the health care team with timely, complete, and structured information about the current status of an individual patient

Examples

Patient Profile, Patient Care Summary and Audit Sheets Click for a larger image Download Patient Care Summary and Audit sheets Click to download File Format MS Word File Size 37k (2 pages) Download Time: 56k modem < 30 seconds Download Time: cable or dsl < 5 seconds

Medical charts can contain large amounts of historical information that can challenge providers to rapidly access essential data. Time pressures can lead to errors of omission, or can result in repeating tests unnecessarily. It is important that information be delivered completely and in a structured manner. (See sidebar for two examples.)

One example from the East Metro Disease Initiative registry (St. Paul, Minn) contains a summary of tests recommended by DQIP for the patient identified. It also provides an example of patient-specific decision support for providers.

The other example includes a Diabetes Patient Care Summary and an Individual DM Audit from the Indian Health Service's Resource and Patient Management System. [back]

Provide health care professionals with an up-to-date summary of patient requirements to meet current guidelines for quality care.
Basically, this is decision support. It is challenging for a health care professional to be aware of the latest information in all diseases. Yet, it is critically important that health care professionals are equipped with the knowledge required for optimal patient care. This knowledge is embedded in the evidence-based practice care guidelines related to diabetes. Access to such decision support at the point of care is an example of how computer information systems can help bring the latest broadly accepted research findings into practice. [back]

Generate population based reports of quality of care for a defined population
The presence of a registry of all patients with diabetes allows for aggregate reporting of overall care to this entire group of patients. This ability can give meaningful feedback to health care teams about the overall effectiveness of the care and support provided. Since the registry is based on the total group of individuals, it is also possible to provide insight on the variability of care. Using this insight, providers and care teams are able to identify areas of priority that are especially in need of improvement. Areas of care that suffer from large variability may be appropriate targets for systematic interventions and improvement.

Furthermore, aggregate reporting across all patients can help set performance goals, create benchmarks and be used for comparability against standards of care or practice as outlined by others-for example, DQIP measures. Again, using comparability, specific areas can be identified by providers and care teams and targeted as opportunities for quality improvement projects. [back]

Facilitate communication between all team members and team access to important information
Prepared provider teams are critical to the implementation of optimal care. Timely access to information, consistent documentation and sharing of information, and creating a "patient care trail" are fundamental to bridging the various team members and care settings. Extended care team members can include the primary care provider, endocrinologist, health educator, certified diabetes educator, dietitian, mental health provider, physiologist, as well as hospital-based providers, among others.

Patient-health care professional interactions can occur in a variety of ways, such as face-to-face appointments, group education settings, telephone calls, or Internet messages. At the time of care, up-to-date information access is critical, regardless of the health professional or the setting. Hence, information systems should not only be able to gather information and provide a "care trail" but also have the capacity to organize the data, focus on the most important elements, create a logical presentation flow, and allow for access in both clinical as well as remote settings, such as nurse call centers and phone-counselor support service centers.

An information system houses individual-level data that is sensitive and confidential, and appropriate safeguards need to be in place to abide by the standards set to protect privacy and confidentiality. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 created a health information privacy rule. HIPAA regulations need to be met and access should always be limited to providers of care who have been trained in the expected standards of confidentiality. In fact, for all providers, signed statements protecting the rights of the individual patient regarding data (both in print as well as electronic format) should be on file. [back]

Enable Patient-centered Care
A valuable information system allows health care prossionals to tailor the delivery of care around the unique and disparate needs of the patient. Recognizing a patient-centered approach is essential in the support of chronic disease. But what exactly constitutes "patient-centeredness" and what does a patient-centered approach look and feel like? Patient-centered care is defined as "providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions."⁶

A patient-centered approach to care addresses the patient's views, perspectives, perceptions, feelings, and concerns in such a way that the patient feels listened to, respected, and cared for. Since patient-centeredness speaks directly to the needs of the patient, it is an effective way to involve the patient in decision-making and self-care. ^7,8

Access to information and resources helps individual patients in their self-management efforts. Information and resources support patients and their families in dealing with the disease-related concerns and optimize their chances for living a vital life with as few physical and emotional limitations as possible.⁹ The components and processes for effective self-management include:¹⁰

• effective communications between the patient and health care team
• the ability to define problems
• the ability to set priorities and focus
• establishing goals that are specific, measurable, attainable, reasonable, and stated in both short-term and long-term contexts
• identification of barriers
• creation and understanding of treatment plans with clearly identified areas of patient ownership and accountability
• problem solving.

Counseling by nurses, dietitians, and other team members is usually essential for the accomplishment of these self-management components. Click here for more information on Patient-centered Care. [back]

Enhanced patient-provider interaction
Information systems should be designed to optimize the professional-patient interaction in terms of timeliness, efficiency, and effectiveness of care and process. If, for any reason, the quality of the interaction is compromised because of the information system, then that system falls short of putting the patients first.

A computer system that requires data input during a patient visit should not diminish the value of patient-professional time by changing the focus of attention from the patient to the computer or by further reducing an already short interaction time. A good system can be expected to:

• deliver information promptly
• be clearly organized
• provide additional information
• benefit rather than burden the patient-professional interaction.

Training may help the health care team understand ways to avoid compromising the professional-patient relationship, such as looking at the patient, listening to his or her concerns, and not appearing rushed. An effective "bedside manner" that promotes relationships between people is central to provision of excellent and compassionate care. Click here for more information on Cultural Competencies. [back]