電子カルテを活用した糖尿病管理と2型糖尿病予防の支援 (Using Electronic Health Records to Support Diabetes Management and Type 2 Diabetes Prevention)

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Thank you for joining us for this
webinar titled "Using Electronic Health
Records to Support Diabetes Management
and Type 2 Diabetes Prevention" Our
presenter is Stephanie Rutledge who is a
Health Scientist with the Centers for
Disease Control and Prevention. I am
Michelle Knight with ICF next and I will
be your moderator today. The recording
and transcript as well as the PowerPoint
slide deck will be available on the CDC
website later this year. For the next 60
minutes we will share information that
will help you understand the importance
of EHRs in supporting type 2 diabetes
prevention and diabetes management. We
will also discuss how state and local
health departments can talk with
healthcare providers about the benefits
of using EHRs while being able to
acknowledge the limitations of EHR.
Then we will provide examples from the field
to aid in learning and understanding.
Finally we will wrap up by sharing
additional resources. The companion guide
for this webinar is titled
"Using Electronic Health Records to
Support Diabetes Management and Type 2
Diabetes Prevention" and will be
available on the CDC website later this
year. I will now turn the webinar over to
Stephanie, Stephanie. Thank you Michelle.
An EHR is a digital version of a
patient's medical chart. A typical
individual EHR may include a patient's
medical history, diagnosis, treatment
plans, pharmacy records, and laboratory
and/or test results. EHRs are real-time
records that make information available
securely to authorized users ideally
including users from multiple
organizations.
Electronic health record systems are in
common use in both hospital systems and
community-based health care provider
offices. EHRs can help streamline
communication among providers including
community-based providers. EHRs automate
and streamline provider workflows and
allow providers access to evidence-based
tools to help them make patient care
decisions. Because of the cost of
diabetes care improving the quality of
diabetes management and type 2 diabetes
prevention is an important priority. EHRs
are one promising tool in these efforts
and EHRs can help support efforts to
increase awareness, referral, enrollment
and retention in the National Diabetes
Prevention Program also called the National
DPP lifestyle change programs, LCPs,
and in diabetes self-management
education and support or DSMES
programs for type 2 diabetes prevention
and diabetes management. EHRs can help
support the patient journey
which we will further define later in
the webinar.
For example, EHRs can assist health care
providers to educate patients about
prediabetes and type 2 diabetes,
screen or test for prediabetes and type
2 diabetes and refer patients to type 2
diabetes prevention or diabetes
management programs. EHRs can also be
used to send health care providers
information about patient participation
and progress in National DPP lifestyle
change programs and diabetes
self-management education and support
programs.
Health care providers are the primary
users and owners of EHRs. Providers
include large health systems and
hospitals office based practices and
pharmacies although almost all hospitals
use EHRs not all providers use EHRs.
These differences in EHR use can lead to
challenges in interoperability or the
secure exchange of information between
authorized EHR users which can limit the
flow of information between providers
and other users. We will discuss
interoperability in more detail later in
the webinar. Individual patients are
secondary users of EHRs. Patient
access their health records that are
stored in an EHR through a secure web
site usually called a patient portal.
Community or clinically based
organizations may also be secondary
users of EHRs. Use by these
organizations can happen when they
receive referrals to their type 2
diabetes prevention and diabetes
management programs through an EHR in
limited cases. Such organizations may
also use EHRs to provide feedback on
patient progress to the provider making
referrals. Most EHRs are created by
independent companies or EHR vendors. EHR
vendors create a variety of EHR products
and platforms with varying features and
cost. On this slide are just a few of the
common vendors used by hospitals and
individual healthcare professionals.
Health care providers have many options
when choosing EHR vendors and products.
The American Medical Association
provides a detailed guide to selecting
and purchasing EHRs. There are complete
and modulate EHRs. One major distinction
is a complete EHR is a complete package
that has been certified as meeting all
of the Federal government criteria for
promoting interoperability or PI
programs. A practice with a complete
EHR has one
vendor and one system to work with, which
can make it easier to get support. A
modular EHR combines multiple EHR
modules that are individually certified
for PI programs. A modular approach
allows providers to use preferred
applications, and it can be less
expensive than buying a complete EHR.
When complete EHRs or combinations of
EHR modules meet federal government
criteria for PI programs they are
referred to as certified EHR technology.
HIPAA privacy and security rules protect
individually identifiable health
information, sometimes referred to as
protected health information or PHI.
EHRs must comply with HIPAA regulations
since they are electronic repositories
of PHI. EHRs must be HIPAA compliant
and providers are responsible for taking
the steps needed to protect
confidentiality, integrity, and
the availability of electronic PHI. You can
learn more in "The Guide to Privacy and
Security of Health Information". The 2009
American Reinvestment Recovery Act
included the HITECH Act that supported
Electronic Health Records Meaningful Use,
an effort led by CMS and the Office of
the National Coordinator for Health IT
ONC-HIT. Providers had to show
meaningful use, in other words that their
EHR was being used in a meaningful way
specifically to improve quality, safety,
efficiency, and reduce health disparities,
engage patients and families in their
health, improve care coordination,
improved population and public health
and, ensure adequate privacy and security
protection for PHI. In 2018, CMS
announced a new phase of the electronic
health record incentive program with an
increased focus on interoperability,
including the exchange of data between
health care providers and patient access
to health data. CMS renamed the EHR
Incentive program as
the Promoting Interoperability PI 177
programs. In 2019, CMS introduced the
Interoperability and Patient Access
Proposed Rule to expand access to health
information and improve the exchange of
healthcare data. Starting in 2019, CMS and
ONC require all eligible healthcare
providers and hospitals to use the 2015
edition criteria for certified EHR
technology to qualify for the PI
Program. Health department play an
essential role in partnering with health
care providers to support EHR used to
better manage and prevent type 2
diabetes in patients at high risk. In
some cases, you will also need to partner
with organizations offering type 2
diabetes prevention and diabetes
management programs. EHR strategies can be
used to increase patient awareness,
identify risk, appropriately refer
patients to evidence-based programs, and
help support better diabetes management.
When your healthcare provider partners
implement specific EHR strategies you
can provide support towards improved
outcomes. Let's talk about how EHR
interventions and partnerships with
local health systems and health care
providers can help you achieve your type
2 diabetes prevention and management
objectives. To focus your efforts
consider your overall objectives
especially as they relate to the patient
journey. Are you focused on improving
patient awareness and education related
to either prediabetes or type 2
diabetes? Increasing patient risk
assessment to identify patients with
prediabetes or undiagnosed diabetes?
Increasing the rates of appropriate
physician referral to type 2 diabetes
prevention and diabetes management
programs? Increasing enrollment in CDC
recognized LDP's or DSME as programs? Or,
improving diabetes management and
clinical quality of care?
Once you review your objectives and
begin to identify where to focus your
effort you will want to engage with
potential health care provider partners
to see what is feasible. You may want to
engage with potential providers partners to
understand what providers in your
targeted area are already doing with
EHRs and which EHR platforms are
used. This slide and the next slide include
several potential questions you could
ask in interviews or surveys including:
Do you use EHRs? What vendors and
specific platforms?
What subpopulations does your office or
hospital serve? What special
consideration should we be aware of? Can
the EHR vendor accommodate EHR changes?
Here on this slide are more questions
you can ask in interviews or surveys.
Would you be able to identify leadership
or staff champions to support
widespread adoption? What barriers or
challenges to implementation
do you anticipate? In summary use these and
other questions to explore whether
strategies you want to implement are
feasible given cost, time, and other
constraints. Let's explore how you can
talk with healthcare providers about EHR
use from the perspective of the patient
journey. The concept of patient journey
has developed as a way to describe how a
patient with type 2 diabetes or
prediabetes interfaces with the
healthcare system. It is shown as a
linear process in this webinar however
an individual patient might experience
the parts of the journey iteratively or
in a different order. The patient journey
includes these parts: awareness and
education, when a patient learns about
prediabetes or type 2 diabetes
including risk and available programs;
risk assessment and diagnosis, when a
patient learns they have prediabetes or
type 2 diabetes or learns about diabetes
complications; referral, when a provider
refers a patient to a type 2 diabetes
prevention or diabetes self-management
education and support program program;
enrollment, when a patient
enrolls in a type 2 diabetes
prevention or diabetes self-management
education and support program, and
management, when a patient works with
health care providers to manage their
condition and prevent type 2 diabetes or
diabetes complications. One part of the
patient journey is patient awareness of
and education about prediabetes or type
2 diabetes, including awareness of
individual risk and programs to help
prevent or manage these conditions. To
improve patient awareness and education
providers can strategically use patient
portals which are secure website through
which patients access health information
stored in the EHR. Patient portals can
increase access to health records by
allowing patients to download, share and
otherwise engage with their health data.
A patient might collect data manually or
with a tracking device and upload the
information via the patient portal.
Examples include blood sugar readings,
medication taking, body weight and
physical activity or nutrition logs.
Providers review health data that have
patient captures and records data in
EHRs. Providers can then better
understand their patients behaviors,
habits and health risk. To educate
patients providers can use patient
portals to increase patient awareness of
a disease and reduce the risk of
patients using unreliable information.
They can also provide tailored
information and educational resources to
involve patients and share
decision-making regarding treatment care
plans or tests. Let's discuss an example
from the field. The University of
California Davis health system initiated
a project to integrate patient generated
data into EHRs. One part of the project
focused on improving the health of
patients with type 2 diabetes. UC Davis
integrated fitness tracker data such as
steps, activity, sleep, and caloric
information from patients into their EHR.
This application of patient generated
data
mad it easier for providers to compare
the data to metrics like A1c and
have conversations with patients about
how behavior change impacts their
disease management. How state health
departments can facilitate awareness and
education using EHRs. First you will need
to determine the awareness and
educational opportunities and
limitations of the specific EHR system
used by the healthcare provider partner.
The following areas can be explored
during your conversation. Find out
whether your potential health care
provider partner currently use or would
promote the use of patient portals. More
patients access their records when
prompted by a provider. Identify the
limitations of what kinds of data and
information can be uploaded and
integrated into the EHR. You can provide
patient tailored educational resources
that providers can share through a
patient portal to promote awareness and
education. Using another example from the
field
Epic Systems and the Mayo Clinic
collaborated so that users of Epic
Systems My Chart patient portal can
access patient facing educational
resources relevant to diabetes developed
by the Mayo Clinic. The resources are
available in English and Spanish. Mayo
Clinic medical experts regularly review
and update their resources and update the resources as needed.
Another part of the patient journey is
risk assessment and diagnosis when a
patient learns that they have
prediabetes or type 2 diabetes. The
primary challenge for healthcare
providers and health departments is to
identify those patients with undiagnosed
type 2 diabetes or diabetes
complications. To address this challenge
healthcare providers and health
departments can use EHR data to apply
risk scores to identify individuals with
prediabetes or type 2 diabetes,
such as the prediabetes patient risk
assessment. Use EHR phenotyping, a
practice of developing algorithms or
formulas that use EHR data to identify
population characteristics associated
with prediabetes or type 2 diabetes.
Embed or use computerized disease
registry data, which is a list of
patients with a certain disease or
condition, within EHRs to aid with
identification of patients with
prediabetes or type 2 diabetes or risk
for diabetes complications. Use clinical
decision support systems, which combine
clinical knowledge with person specific
data, to help providers identify and
treat high-risk patients for instance.
EHR phenotyping can be used to screen
for prediabetes or potentially
undiagnosed type 2 diabetes. Phenotyping
can also be used to identify
non-traditional risk factors associated
with type 2 diabetes development.
Non-traditional risk factors may include
diet, markers of chronic inflammation, metabolic
abnormalities, genetic
markers, or other factors. If you're
implementing EHR phenotyping here are
some possible considerations. As a state
health department consider working with
healthcare partners to identify an
appropriate algorithm for data the
provider has collected. You can also
collaborate with your healthcare
provider partner to add to algorithms and
to provide appropriate training on the
use of the algorithms. In another example
from the field researchers at the
University of California Los Angeles
predicted patients type 2 diabetes risk
by using an algorithm applied to
information in de-identified electronic
health records. They also identified
previously unknown risk factors for type
2 diabetes. The researchers estimated
that in the United States using EHR
phenotype screening could identify an
additional 400,000 people with active
and untreated type 2 diabetes compared
with conventional approaches.
The purpose of Clinical Decision Support
or CTS systems is to help providers get
the right information at the right time
reducing the likelihood of misdiagnosis
or other errors. These systems help
organized large volumes of EHR data. They
combine specific, they combine scientific
knowledge with person-specific data and
can assist providers to identify
high-risk patients, consider alternative
diagnosis, order specific tests, and more.
A CDS system integrated within an
EHR can be used to identify patients at
higher risk for developing type 2
diabetes or to help in the early
detection of diabetes complications such
as chronic kidney disease.
Here are some considerations for
implementation of clinical decision
support systems. You can learn the
specific challenges your healthcare
provider partner faces in identifying
patients with prediabetes or
undiagnosed type 2 diabetes or in
detecting diabetes complications and
identify ways that a CDS system might be
able to address these challenges. You can
also determine how feasible it is to
implement a CDS system within the EHR
system. In the referral part of the
patient journey EHR can be used to refer
a patient to appropriate treatment. This
can include referral to a type-2
diabetes prevention or diabetes
management programs.
The referral process can be streamlined
by using EHRs or electronic referral
using embedded referral forms. We will now
turn our attention to the various ways
that EHRs can be used in the patient
referral process. EHRs can be designed to
allow healthcare provider partners to
electronically refer or refer patients
to a community health program such as
type 2 diabetes prevention or diabetes
management program. Bi-directional
e-referral occurs when a provider refers a
patient to a type 2 diabetes prevention
or diabetes management program through an
EHR and the organization offering the
program is able to provide feedback to
providers through the EHR. This feedback
means providers learn whether an
enrolled patient participates and the
details of their progress closing the
information loop between the
organization and the provider. Here are
some considerations for implementation
regarding eReferrals. For eReferral, you
can work with a health care provider
partner to understand why and how they
refer patients to programs and how
they access up-to-date information about
available programs. Try to determine how
electronic referrals can be part of the EHR
and provide workflows. You can also
learn how community or clinically based
organizations will receive the eReferrals.
For bi-directional referral recognize
that access to EHRs is rare
for community-based programs compared to
clinic based and that workarounds to
direct access to EHRs may be
needed for community based programs
to provide feedback. Consider working with
partner organizations to understand
existing referral practices and
communication. In the Bronx New York
Montefiore Health System partnered with
the YMCA of Greater New York to deliver
the YMCA's IVs prevention program,
YDPP. They developed a referral system
that was fully integrated with their EHR.
At first the health system relied on
paper referral but then shifted to
electronic referrals integrated in the EHR.
One of the first challenges encountered
in this partnership was getting
Montefiore providers to agree to the
referral workflow which required
obtaining written patient consent for
referral to be sent to the YMCA. After
program enrollment the final part of the
patient journey is prediabetes or type
2 diabetes management in which the
patient works with health care providers
to manage diabetes and prevent
complications. When providers, patients
and program sites can share information
readily and close feedback loops
prediabetes or type 2 diabetes
management can be a smoother process.
Patient portal used for patient data and
feedback and bi-directional
eReferral and
EHR Alerts can help stakeholders to learn
when a patient enrolls, stay connected,
and use available data for better
management of prediabetes or type 2
diabetes. As we noted earlier in the
presentation patient portals are secure
websites that allow patients to access
their health records from an EHR.
Patients can use portals to download,
share and otherwise engage with their
health data. Patient portals can be used
to support management of a patient's
condition.
Examples include integrating patient
generated health data, or data that a
patient captures and records in EHRs, such as blood
sugar readings, body weight, or medication
taking. Such data can be used to monitor
patient progress during a treatment
program. This can help providers create
more tailored strategies for the
management of chronic conditions.
Another example is allowing patients to
provide feedback via the patient portal
during their type 2 diabetes treatment program.
This can help patients feel a stronger
sense of connection to their healthcare
team. In addition providers can use
feedback from patients to adjust care
plans. As you're implementing patient
portals here are some considerations as
noted earlier. Find out whether your
potential healthcare provider partners
currently use, or would promote the use of
patient portals. More patients access
their records when prompted by a
provider. Try to identify limitations for
what kinds of data can be uploaded and
integrated into the EHR. EHR alerts are
reminders for providers that are
integrated into the clinical workflow.
Alerts can help with type 2 diabetes
management and maintenance of treatment
plans and ensure that critical points of
patient care are not overlooked by
patients or providers. As a part of
bi-directional eReferral
providers can receive alerts about a
patient's progress in a community
program. Alerts can help providers
understand which tests are needed,
problems that have been identified, and
topics a patient needs more education on.
Alerts and
reminders may be part of a clinical
decision support system within an EHR or
they may be separate. Here are some
considerations for implementation of EHR
alerts.
Learn how your health care provider
partner already uses alerts to support
type-2 diabetes management, if at all. You
can determine whether providers would
support the integration of alerts into
the EHR system. You can also find out
where alerts might offer the most
benefit.
Are there specific areas where the
provider can better support type-2
diabetes management such as ordering
appropriate tests, following up with
patients who've missed tests or
appointments or identifying patients with
prediabetes or undiagnosed diabetes. In
an example from the field Reliant
Medical Group took advantage of EHR
features to ensure a comprehensive
approach to type-2 diabetes management.
The EHR system includes alerts to
inform diabetes education nurses about
how a patient is doing in their type-2
diabetes self-management education and
support program, alerts to remind
providers to order needed tests,
reminders to patients to have tests
done including automated phone triggered
calls triggered by the EHR, reminders to
patients who miss appointments, and
processes to follow up with patients who
miss tests and appointments. EHRs have
the potential to change provider
workflows and improve patient care
including for type 2 diabetes prevention
and diabetes management, however there are
limitations in how EHRs are used and
perceived by providers, patients and
others. We'll take a few moments now to
provide an overview of these limitations.
Technological limitations for EHRs
include: interoperability. EHR systems
work in different ways. These differences
can limit the ability to exchange
information between EHR systems.
Standardization, EHR data are recorded,
stored and exchanged in different ways.
This lack of standardization can
interfere with communication between
EHRs. And adaptability, EHR vendors often
do not provide customized
products. Providers may be left with EHRs
that don't work as well as expected.
Legal limitations of EHRs include HIPAA.
The Health Insurance Portability and
Accountability Act law presents real and
sometimes perceived limits to sharing
patient data to improve patient care.
Another limitation is state regulations.
Because states have different patient
privacy and health data exchange laws
health care provider partners may be
confused by various state level
requirements and meaningful use policies.
Previous policies provided limited
incentives to ensure collaborative
healthcare as we discussed earlier. New
proposals aim to expand incentives for
collaboration and promoting
interoperability. Clinical workflow
limitations for EHRs include
interference with patient engagement. Use
of EHRs can decrease provider engagement
with patients and reduce the amount of
time they spend with patients. And
information overload and lack of readily
available information is another
clinical workflow limitation. EHRs can be
an administrative burden for providers
with too many alerts, decreased
quality of care and job satisfaction and
missing test results. Providers also may
not enter information into the EHR or
they may enter incorrect information.
There are also access limitations
associated with EHR. For instance not all
patients have access to providers who
use EHRs. Some patients don't have access
to portals and even patients willing to
access portals may not want to provide
other personal data. In addition some
patient populations prefer traditional
communication methods. In many rural
areas EHR technology has been
adopted more slowly. There are more
infrastructure barriers, less electronic
sharing of data and less overall
preventive care. Less buy-in, access and
exposure to new charts occur in some
urban areas as well.
Collaboration limitations for EHRs
include the standardization. Proprietary
EHR platforms, antiquated systems
and lack of standard referral processes
and reporting standards make it hard for
providers and community partners to use
EHR platforms as bi-directional referral
systems. Another collaboration limitation
is health care provider partner buy-in. A
lack of buy-in and product champions
leads to lags in referrals to community
programs. Resistance to change on the
part of health care provider partners
can also be a factor. If health care
provider organizations and community
organizations do not have a shared
vision and mission for how they will
work together to use EHRs success
is more challenging. One of the
challenges in working with EHRs is
changing policy and technology landscape.
Government policies and private sector
technologies specifically address
existing challenges and limitations of
EHR. CMS's focus on interoperability and
the emergence of third-party apps are
two areas that are rapidly changing.
Keeping current with these changes will
help you to keep your proposed
interventions relevant and effective. As
we mentioned earlier CMS announced new
proposed rules in 2018 and 2019 with an
increased focus on promoting
interoperability. Additional
announcements and policy changes related
to CMS's focus on interoperability are
emerging and expected. These changes
should help overcome some of the current
EHR interoperability challenges allowing
for better exchange of information between
healthcare providers, patients and
potentially community organizations. You
can stay current with updates by
visiting the CMS website and the Office
of the National Coordinator for Health
Information Technology ONC website. As
use of EHRs become increasingly common
the need for solutions to common EHR
challenges is being recognized. Third
parties are developing applications or apps
to help healthcare provider partners to
address specific EHR challenges.
One app platform is Smart Health IT
which is run by the not-for-profit
institution Boston Children's Hospital
Computational Health Informatics Program
and a Harvard Medical School Department
for Biomedical Informatics. The platform
was initially funded by the US
government to develop standards, open
source technology, and a community of app
developers. Smart Health IT are publicly
accessible. You should now be able to
define EHRs, describe the importance
of the EHRs, discuss EHR capabilities
with health systems and healthcare
providers, identify EHR strategies to
support type 2 diabetes prevention
and diabetes management objective and
describe the limitations of EHRs
including the changing landscape of EHR
policy and technology. Here are some
links to resources that you might find
useful. Additional resources are
available at www.cms.gov and www.cdc.gov. On
behalf of CDC I want to thank you for
participating in the "Using Electronic
Health Records to Support Diabetes
Management and Type 2 Diabetes
Prevention" webinar.