Impact of an EHR Smart Phrase and Resident Education on Adherence to ADA Standards of Medical Care

in Diabetes

Javier Guevara Jr. MD, Julia Gold MD, Corina Marshall MD, Kajal Patel MDSt. Mary and Elizabeth Medical CenterFamily Medicine Residency Program

Completed project.

May 7th, 2015.

Overview

•Importance•Objective•Methods•Results•Discussion•Questions

Importance•Poor adherence to ADA diabetic care

recommendations among FP has been long documented.

•Critical factors to compliance include education to providers and use of EHR.

• Isolated interventions do not show lasting effect in improving compliance

• It is important to further develop tools and interventions to improve adherence to recommendations.

Objective

•To assess improvement in resident adherence to ADA diabetic care recommendations through educational interventions (via a conference and posters), as well as with the implementation of an EHR smart phrase.

Methods

•Setting:▫Two urban outpatient clinics.

•Participants:▫PGY-2 and PGY-3 Family Medicine

Residents

Methods

•Pre-Intervention period ▫01/01/2013 – 02/28/2014▫Retrospective analysis of data collected

from 120 randomly selected patient charts that met the inclusion criteria of 4 or more diabetes management office visits.

▫The data gathered was the compliance with 14 ADA recommendations for diabetic management (Table 1.)

Methods

Annual Labs Foot Exam

Medications

Vaccinations Referrals

HbA1c Visual ACE-i/ARB Influenza Ophthalmology

Lipid panel DTR Statin Tdap

Urine Microalb/Cr Pulses Aspirin Pneumococcu

s

Monofilament

Table 1. ADA Recommendations

Abbreviations: HbA1c = hemoglobin A1c; Microalb = microalbumin; Cr = creatinine; DTR = deep tendon reflexes; ACE-I = angiotensin converting enzyme inhibitor; ARB = Angiotensin Receptor Blocker; Tdap = tetanus diphtheria pertussis

Methods• Intervention date

▫03/10/2014▫ADA guidelines review and smart phrase

introduction conference.▫Smart phrase pulls patient’s most recent lab results

and vaccinations with dates of completion.▫Then guides providers, through questions, to

review patients meds, referrals to Ophthalmology and last diabetic foot exam.

▫Posters placed in clinic reminding of recommendations and encourages use of smart phrase.

Methods

•Post- Intervention period▫03/10/2013 – 10/10/2014▫Prospective analysis of comparison of

compliance rates collected from 120 randomly selected patient charts.

Results

HbA1c

Lipid

Pan

el

Urine

Micr

oalb

umin

/Cr R

atio

Visual

Insp

ectio

n

Pulse

s

10-p

oint

Mon

ofila

men

tDTR

ACE-I

Statin ASA

Optho

mol

ogy Ref

erra

l

Influe

nza

Tdap

Pneum

ovax

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

116104

82

65

91

37

62

109101

8373

66

15

39

416

3755

29

83

58

58

28 4754

105

81

0 0 1 0 0 0 0 6 11 90 0 0 0

NOT APPLICABLENOT DONEDONE

PREINTERVEN-TION

Results

HbA1c

Lipid

Pan

el

Urine

Micr

oalb

umin

/Cr R

atio

Visual

Insp

ectio

n

Pulse

s

10-p

oint

Mon

ofila

men

tDTR

ACE-I

Statin ASA

Optho

mol

ogy Ref

erra

l

Influe

nza

Tdap

Pneum

ovax

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

116103

93 88 93

5867

115

9681

68 64

24

43

417

27 32 27

6253

2

18

31 52 56

96

77

0 0 0 0 0 0 0 3 6 80 0 0 0

NOT APPLICABLENOT DONEDONE

POSTINTERVEN-TION

Results

•No statistically significant change in rates of compliance in 11 of the 14 variables studied.

•Modest statistically significant (p=0.05) increase in compliance rate with visual inspection and monofilament portions of the diabetic foot exam.

•Modest statistically significant (p=0.05) decrease in compliance rate with prescribing statin medications.

Discussion

•Overall, resident education and implementation of an EHR smart phrase did not improve adherence to ADA guidelines in our study.

•A second chart review showed only 15% compliance with EHR smart phrase.

Discussion

•Limitations:▫Poor conference attendance▫Deficiency in use of the smart phrase▫Limited post-intervention time▫Adding a research group member and

change of some study participants due to graduation and promotion

▫Change in statin therapy recommendations▫EHR ordering limitations▫Randomized chart selection

Discussion•Further research is needed to identify factors

interfering with the use of our smart phrase and poor adherence to ADA recommendations.

•Recommendations:▫Frequent reminders via conferences, email and

fliers▫Alternative strategies including patient

education and involving attending physicians and supportive staff.

Acknowledgements

•Alicia Milan-Flanigan, MD

•Stephanie Place, MD

•David M. Berdy, MD

•Lisa Stevak, Med

•Resident Physicians, Nurses and Staff

THANK YOU!!!

Questions?

References• American Diabetes Association. Standards of medical care in diabetes--2013.

Diabetes Care 2013; 36 Suppl 1:S11.

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