Diabetes Measures in EHRs Linked to Improved Care

Health and Wellness for all Arizonansazdhs.gov

Diabetes Measures in EHRs Linked to Improved Care

Omar A. Contreras, MPHDiabetes Prevention and Control Program

Arizona Department of Health ServicesJune 27, 2014

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What does What does medicine do? public health do?Saves lives one at a time Saves lives millions at a time








Essential Services of Public Health

Monitor health status Diagnose and investigate Inform, educate, and empower Mobilize community

partnerships Develop policies and plans

Enforce laws and regulations Link people to needed

services/assure care Assure a competent

workforce Evaluate health services Research

Source of Ten Essential Public Health Services: Core Public Health Functions Steering Committee, 1994








Health Department

+PH System

+Community

Partners+

Workforce

OperationalCapacity

(Infrastructure)

EveryCommunity

Program and Public Health

Activity

(Chronic Disease, Inf. Disease, EH)

Builds Impacts

Whichleads

to

Investments here Pay big dividends here

Better HealthOutcomes

Reduced Disparities

Better Preparedness

Framework for Improving the Performance of Public Health

Source: D. Lenaway. Centers for Disease Control and Prevention, Office of Chief of Public Health Practice. 2009 (unpublished)








Governmental Public Health

State and Local Health Departments

Tribal Health Departments

Local Health Departments

State and the District of Columbia

Health Departments

Territorial Health

Departments

Retain the primary responsibility for health under the US Constitution

51** 8**2,565*

* Number based on 2010 National Profile of Local Health Departments (NACCHO, 2011)** Numbers cited from ASTHO, Profile of State Public Health, Volume Two, 2011








Tribal Health Departments

State and the District of Columbia

Health Departments

Territorial Health

Departments

51** 8**

Local Health Departments

2,565*

Federally Qualified

Health Centers








Outline• Arizona Department of Health Services/Arizona Diabetes

Program– Diabetes in Arizona– Epidemiology and Surveillance– Trends and Cost Analyses

• The Arizona Diabetes Coalition• Diabetes measures and systems change• Public Health in Action Grant• EHR and non-physician team base approach to diabetes

care• Summary








Arizona Department of Health ServicesHierarchy








Arizona Diabetes ProgramWhat we do and what we provide?• Ongoing technical assistance to internal and

external partners• Information and guidance on funding resources• Develop diabetes specific strategies and public

health interventions at a systematic, policy, and environmental levels

• Supports and oversees the activities Arizona Diabetes Coalition and Leadership Council








Diabetes in Arizona








Leading causes of death in the United States for 2011

Leading Death Death rate per 100,000

1. Heart disease 191.4

2. Cancers 184.6

3. Chronic lung diseases 46.0

4. Strokes 41.4

5. Accidents 39.4

6. Alzheimer’s disease 27.2

7. Diabetes mellitus 23.5

8. Pneumonia and influenza 17.2

9. Kidney diseases 14.7

10. Suicides 12.3Source: National Center for Health Statistics, www.cdc.gov/nchs.

http://www.cdc.gov/nchs








Diabetes in Arizona• 1/9 Arizonans have diabetes• 1/3 of those who have diabetes in Arizona are

unaware that they have it• Diabetes is the leading cause of new cases of

blindness and kidney failure• Known risk factors

– Obesity – Physical inactivity or increase in sedentary lifestyle– Built environment








How do rate by county?County* Diabetes Arizona Hypertension** Arizona Obesity Arizona

Apache 8.0% 10.6% 17.5% 28.1% 25.1% 26.0%Cochise 15.7% 10.6% 44.4% 28.1% 27.4% 26.0%Coconino 13.3% 10.6% 17.2% 28.1% 22.3% 26.0%Gila 15.6% 10.6% 28.8% 28.1% 25.1% 26.0%Graham 17.0% 10.6% 27.5% 28.1% 34.5% 26.0%Greenlee 15.9% 10.6% 27.0% 28.1% 34.3% 26.0%La Paz 16.0% 10.6% 34.8% 28.1% 32.0% 26.0%Maricopa 10.0% 10.6% 26.5% 28.1% 26.0% 26.0%Mohave 14.6% 10.6% 38.2% 28.1% 29.4% 26.0%Navajo 12.1% 10.6% 34.8% 28.1% 31.1% 26.0%Pima 12.2% 10.6% 25.6% 28.1% 23.5% 26.0%Pinal 14.4% 10.6% 35.7% 28.1% 25.7% 26.0%Santa Cruz 10.3% 10.6% 34.5% 28.1% 33.7% 26.0%Yavapai 10.6% 10.6% 38.5% 28.1% 33.8% 26.0%Yuma 11.8% 10.6% 40.8% 28.1% 28.6% 26.0%

*Source: Arizona Behavioral Risk Factor Surveillance System, (AZ-BRFSS, 2013)** 2011 Numbers shown as 2012 data not available








Arizona Adults with Diabetes by Race/Ethnicity, 2012

Black Hispanic Other White Overall 0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

14.7%

12.5%

9.9% 9.4%10.6%

Source: AZ Health Matters (2012), AZ BRFSS

Prev

alen

ce (%

)








Arizona Age-adjusted Death Rate due to Diabetes, by Gender (2012)

Female Male Overall 0

5

10

15

20

25

30

35

18.6

29.2

23.5

Rate

per

100

,000

pop

ulati

on









Arizona Age-adjusted Death Rate due to Diabetes, by Race/Ethnicity (2012)


American

Indian

/Alas

ka Nati

ve

Asian/Paci

fic Islan

der

Black/A

frican

American

Hispan

ic/Lati

no

White, N

on-Hisp

anic

Overal

l 0

10

20

30

40

50

60

70

80

9080.2

27.6

49.4

40.8

18.323.5

Rate

per

100

,000

pop

ulati

on








Estimated Costs of Diabetes, 2007Total $174 billion

Direct medical costs

$116 billion

Indirect medical costs

$58 billion

Source: http://www.diabetes.org/advocate/resources/cost-of-diabetes.html, retrieved 11/25/2013

Estimated costs

Estimated Costs of Diabetes, 2012Total $245 billion

Direct medical costs

$176 billion

Indirect medical costs

$69 billion

http://www.diabetes.org/advocate/resources/cost-of-diabetes.html










Estimated costs AZ, cont.

Arizona Diabetes Cost Data (2010) – CDC Chronic Disease Cost Calculator

2011 Arizona Hospital Discharge Data indicated a total of 7,065 discharges related to diabetes and chronic conditions.

$167,815,464

Parameter Treated Population

Cost per Person

Total Costs (2010)

Adjusted to 2013

All Payers 416,200 $5,420 $2,258,000,000 $2,412,300,000

MEDICAID 81,800 $3,750 $307,000,000 $327,980,000

MEDICARE 168,100 $3,580 $602,000,000 $643,140,000

Private Insurers 236,500 $2,580 $610,000,000 $651,680,000








Arizona Diabetes Coalition








VisionA state without diabetes

MissionTo reduce the health, social, and economic

burden of diabetes in Arizona








How are the Coalition and Council structured?








Arizona Diabetes Leadership Council• Reorganized Fall 2006• >18-21 member leadership council

– Representation from academia, health plans, government, private companies, non-profit organizations, etc.

• Meet 6 times a year as a council and quarterly with the coalition

• Each Coalition workgroup chair is represented in the Leadership Council.

• Ex-Officio members• Well established by-laws: www.azdiabetes.gov• Constant communication between leadership body and ADHS

Diabetes Program

http://www.azdiabetes.gov/








Diabetes Measures and Systems Change








Health Care Flowchart








Pillars of Health Care Reform

Cost Access Coverage Quality








Quality and access to CareThere are thousands of new doctors and nurses in communities around the country

and millions more patients getting care.








Improving Quality• Increase the utilization of EHR in multiple healthcare

systems• Encourage completion of NQF standard measures for

diabetes and hypertension• Require reporting and accountability for health plans

Coordinate care and medical home models Improve patient safety, reduce medical errors, promote

health and wellness• Capacity development for FQHCs and other health

systems








National Quality Forum (NQF) Measures (Diabetes)

Measure Recommended Measure Title

0055 Eye Exam (no evidence of retinopathy)

0056 Foot Exam

0059 HbA1c Poor Control (HbA1c >9%)

0061 Blood Pressure Management

0062 Urine Screening

0064 LDL Management and Control

0575 HbA1c Control (<8%)

0018 Controlling High Blood Pressure








Role of EHR systems in FQHCs

• Advocate for your patients• Referral mechanism for DSME and prevention

programs• Provision of preventative care for chronic care

patients• EHRs can help avoid re-admission rates and

improve and adherence to self-management








Public Health in Actions Grant








What is the Public Health in Actions Grant?

• 5 year collaborative grant • Focuses on policy, system, and environmental

change• 32 states funded

– Basic and Enhanced components • Year 1 has been completed








Implementation of EHR system change and performance measures

• Proportion of health care systems reporting on NQF measures 18 and 59

• Proportion of health care systems with EHRs appropriate for treating patients with high blood pressure and diabetes

• Increase the institutionalization and monitoring of aggregated/standardized quality measures at the provider and systems level








System level changes and non-physician team based care in Federally Qualified Health

Centers








Summary• Diabetes remains a prevalent disease in Arizona,

specifically in rural areas• Diabetes NQF measures offers the ability to detect care

when the recommended care was given or when recommended care was not received.

• Non-physician staff will continue to be on high demand and integration into a team base approach to diabetes health should be warranted

• Health systems changes via the utilization of electronic health records show positive trends in the improvement of diabetes care








Looking into the future

• Establish a data sharing agreement between ADHS and FQHCs and/or the Alliance for Community Health Centers

• Ability to generate standardize reports on patients with diabetes and hypertension

• Reducing the gaps and inconsistencies resulting in lack of data within the EHR








Our ever changing public health system

MCDPHHome Health

Parks

Economic Development

Mass Transit

Employers

Nursing Homes

Mental HealthDrug

Treatment

Civic Groups

Laboratory Facilities

Hospitals

EMS

FQHCS

Doctors

ADHS

Churches

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

Urban Planners








Questions?

Contact InformationOmar A. Contreras, MPH

Diabetes Prevention and Control Program Manager

Arizona Department of Health [email protected]

(602) 542-2758







Diabetes Measures in EHRs Linked to Improved Care

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