the austin health diabetes discovery: using technology to support the implementation of standardised...
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Diabetes Discovery ProjectUsing technology to support the implementation of
standardised clinical care
Libby Owen-Jones Project Director
Dr Nic Woods Physician Executive, Cerner
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Overview
Austin Health EMR Strategy & implementation
Diabetes Discovery Project
Change management and Clinical Adoption
Outcomes
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Major Tertiary Health Provider in Northeast Melbourne
3 Campuses - The Austin Hospital - Heidelberg Repatriation Hospital - Royal Talbot Rehabilitation Centre
Major Services - Liver and Gastro-Intestinal Transplantation - Spinal Cord Injuries - Oncology - Victorian Respiratory Services - Olivia Newton John Cancer Centre
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93,000 Inpatient Admissions 900 Beds 73,000 Emergency Attendances 57,000 Placement
Days for Entry Level to Practice Students in 17 disciplines
176,000 Outpatients 176,000 Outpatients
(360 clinics) 8,000 staff >26,000 Surgical Operations Large Nursing
and Medical Post Graduate Education Program
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Austin Health IT and EMR Strategy
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Austin Health – Strategic Priorities
Build Capacity in Systems Redesign to Improve Quality, Value and Efficiency
Provide Contemporary Clinical and Business Information Systems that Support Excellence in Decision Making, Patient Care and Accountability
Continually Enhance Information Technology and Communication Systems
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From paper ……to mobile computing
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EMR Journey
2011Rad/Lab ordersePrescribingDisch SummaryResults
2012E-Meds ManagementFluid balance chartE-Referrals
2013E-Meds ManagementDiabetes Discovery
2014ED - FirstNetPhysician Handover
2015 -2016Vital Signs & ObsTheatres -SurginetOncology systemBI/Data warehousingNursing documentationProgress notes
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Transformational Change
More than 70% of all major transformation efforts fail.
Why? Because organisations do not take a consistent,
holistic approach to changing themselves, nor do they
engage their workforce effectively.
Kotter 1995
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Prevalence of Diabetes
Prevalence of diabetes in Australia is estimated at 7% (AusDiab)1
23% for people older than 75 years2
40% of diabetes undiagnosed3
1 Diabetes Care 2002; 25: 829-834 2 Dunstan DW, Zimmet PZ, Welborn TA, et al. Diabetes Care 2002; 25: 829-834 3 Diabetes Care 32:287–294, 2009
.
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Background – Inpatient hyperglycaemia
Known diabetes New hyperglycaemia (FPG >7mmol/L)
Uncertain glycaemic status (FPG, 5.6–
6.9mmol/L)
Normoglycaemia (FPG, < 5.6mmol/L)
0
2
4
6
8
10
12
Mor
talit
y (%
)
p=0.04
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Diabetes in the Surgical Units• Comparison of Length of Stay data for Surgical
patients from 2009 to 2013:– Ave LOS is 6.91 days– Patients with a coded diagnosis of Diabetes 10.61
days– Diabetes patients stay 53% longer
• Comparison of Readmission rates– Diabetes patients have higher readmission rate –
but may be due to other reasons
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Goal: patient safety & consistent practice
Clinical System supports Clinical practice
Clinician Led
Use evidence based protocols
BUT
Who needs the intervention?
Diabetes Management Project
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Diabetes Discovery Project• Aim
– To investigate the prevalence of diabetes (diagnosed and undiagnosed) at Austin Health via routine HbA1c testing in inpatients using the CERNER Millennium Health IT System
– To identify inpatients with poor glycaemic control (HbA1c≥ 8.5%, 69 mmol/mol)
• Hypothesis – Information technology tools such as CERNER Millennium
aid the identification of patients with undiagnosed and patients with poor glycaemic control
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Change Management Workflow for Medical staff
Who sees which patients? How do they know who they need to see ?
Alerts and Notifications
Tools to support Medical staff workflow HbA1c Results Extract Report Improve communication with GPs via discharge summary documentation Clinical Guideline translated to a PowerPlan
Nursing Workflows Patient Access List : Referrals , Meds to be administered, Path to be collected
Diabetes education team – e-referral workflows Task List Reports Documenting outcomes
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Automated ordering of HbA1c
Austin Health Admissions (July 2013 to Jan 2014)
Inclusion criteria:
≥ 54 years
Acute admissions
Austin campus
Exclusion criteria:
Day cases
Palliative care
Psychiatry
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Automated ordering of HbA1c
Austin Health Admissions (July 2013 to Jan 2014)
Inclusion criteria:
≥ 54 years
Acute admissions
Austin campus
Exclusion criteria:
Day cases
Palliative care
Psychiatry
Automated CERNER order for HbA1c% generated if no result within 3 months
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Adding an Alert and notification – automated process
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Adding an Alert and notification – automated process
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Clinical Guideline
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Clinical Guideline – e referrals
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Clinical Guideline – e referrals
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Communication with GPs
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Communication with GPs
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Outcomes – Diabetes Discovery
Known Diabetes 28%
No Diabetes 67%
Undiagnosed Diabetes5%
Previous diabetesdiagnosis and HbA1c≥6.5%
No previous diabetes diagnosis and HbA1c<6.5%
Nil previous diabetesdiagnosis and HbA1c≥6.5%
8892 Admissions analysed 6721 HbA1C orders (70% autogenerated)1791 patients had HbA1C > 6.5%
380 (21% ) was not previously known 34 Type 1 Diabetes1,295 Type 2 Diabetes10 Other (gestational diabetes, etc)
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Outcomes – LOS by HbA1c and Unit
Medical Surgical 0
2
4
6
8
10
HbA1c <6.5 HbA1c ≥ 6.5
Days
%
8.2 ±10.86.8 ±8.8 7.2 ±8.36.9 ±9.7
p=0.35 p=0.03
%
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Outcomes – Readmits < 6 months
p=0.007
No Diabetes New Diabetes Known Diabetes0%
10%
20%
30%
22% 23%
26%%
of p
atien
ts re
adm
itted
with
in si
x m
onth
s
Undiagnosed Diabetes
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Outcomes – Rates by Specialty
Nuclear M
edicin
e
Toxic
ology
Neurology
Epile
psy
Resp &
Sleep Med
Spinal
Haematology
Infectious D
isease
s
Rheumatology
Oncology
Cardiology
Stroke
General M
edicin
e
Emerg
ency
VRSS/Ventilation W
eaning
Gastro/H
epato/Hematemesi
sDerm
Intensive Care
Ophthalmology
Renal
Endocri
nology0
200
400
600
800
1000
1200
No Diabetes Known Diabetes New Diabetes
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Conclusions
Higher HbA1c is associated with • increased admission rates• Longer length of stay in surgical patients
Routine inpatient HbA1c testing using CERNER addresses a currently missed opportunity to identify patients with newly diagnosed diabetes and poor glycaemic control.
.
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Evolving Changes to practice Inclusion of Mental Health patients – with different auto
ordering criteria Refinement of parameters – who sees which patients General medicine Outpatient Clinic- follow-up of poorly
controlled patients post discharge Ongoing education in diabetes management to junior medical
staff
Research in ICU – using HbA1c results – changes to protocols The impact of early identification and treatment of poor
glycaemic control on patient outcomes requires further study
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Acknowledgements
Cerner CorporationUniversity of Melbourne – Endocrinology Unit at Austin HealthAustin Health - Clinical Systems Projects Unit & Business Intelligence UnitHealth Shared ServicesBMJ – Action Sets