Kate Kirley, MD, MS: How EHRs Can Identify Prediabetes, Chronic Conditions

March 16, 2020
Kate Kirley, MD, MS

Kate Kirley, MD, MS

Electronic health records (EHRs) have long been known as a burdensome tool that many physicians do not particularly care for. This tool, though, offers the potential to help identify patients with underlying chronic health issues. If used properly, EHRs can address issues that can otherwise fall through the cracks and not get attended to as they should.

Kate Kirley, MD, MS, director of chronic disease prevention at American Medical Association (AMA), spoke to HCPLive® about how practices can optimize their EHRs to identify prediabetes patients, why patients may fall through the cracks, and other ways in which providers can leverage digital tools and their EHRs to improve chronic care.

Editor’s note: This transcription has been lightly edited for style, length, and clarity.

HCPLive: What role does the EHR play in identifying prediabetes patients?

Kirley: There are multiple gaps in care that we have observed when it comes to identifying and managing people with prediabetes, including the fact that somewhere between 10-15% of people with prediabetes are actually aware that they have the condition. Probably around half of people who should be screened for abnormal glucose and prediabetes are actually getting screened in a systematic way. And then a very small percentage of people who have prediabetes are actually getting treated.

So, optimizing the EHR really allows healthcare organizations and sufficient practices to systematize how they close those gaps in care. Having systematic screening, even tools like clinical decision support, can prompt clinicians when they have a patient that needs screening, for example. Things like clinical decision support, patient reports, and registries are really useful within the EHR to support closing the care gap.

HCPLive: Why are so many patients falling through the cracks?

Kirley: There are probably multiple reasons. Clinicians are extremely busy and are trying to fit many, many things into a single visit. And so, screening for abnormal glucose doesn't always rise up to the top of their priority list. Additionally, patients typically don't have any symptoms of their abnormal glucose, so they don't come in complaining about anything or really seeking the screening. This is one of these times where I think both the clinician and the patient can benefit from that reminder that screening should happen.

HCPLive: How can the EHR be used to prevent or manage other chronic conditions?

Kirley: We have tons of structured data that are captured in our EHR now that we can use to get pictures of both our individual patients, as well as the overall population, to understand different conditions that people may be at-risk of developing, or conditions that people currently have. So, EHRs are really useful if we can figure out how to do it well, to consolidate those data and identify people who need any number of different interventions, whether that's a preventive intervention, or an intervention to treat condition. For example, people who have diabetes who benefit from intensifying their glycemic treatment. It's really a useful tool to correlate and examine data and find where you have gaps in care.

HCPLive: Some physicians report that their EHRs create more work and burden. Are there any obstacles that a physician might face when trying to identify these patients using these systems?

Kirley: We hear a lot of complaints from physicians—especially as more and more clinical decision support is put into place—that they get alert fatigue with too many alerts going off. And what AMA found in a project with Henry Ford was that we could be thoughtful and really identified to the 2 key time points where we wanted to draw attention to medical gaps. Those 2 key time points were when a patient was sitting in front of them who needed screening. So, an advisory would fire off to notify them that they need to do that screening.

The second time point was with a patient in front of them who likely had a diagnosis of prediabetes and needed to have that diagnosis documented and some treatment initiated. What we found was that the physicians actually appreciated this notification. They didn't find it overly burdensome, so it was not too many alerts for them to deal with.

I think that whenever you're thinking about how to use your EHR, effectively, you just have to be really mindful that you are not overburdening your clinicians with too many notifications. And if you are notifying them, the data that support that certification are accurate and you're giving them an actionable step that they can take once you've notified them about a gap in care.

HCPLive: Is this something that a lot of healthcare facilities are doing? And if not, can they follow what these other, larger systems are doing?

Kirley: Yeah, great question. At AMA, we, through our diabetes prevention work, have been working with dozens of healthcare organizations of all shapes and sizes. They are all working to define their diabetes prevention strategy and implement that. Those strategies look a little bit different from organization to organization, but there are definitely common trends and they are all thinking about how they can optimize their EHR to support those preventive activities. So, I think the granular details of what that EHR optimization looks like at a given site can look different from site to site, but I think there are also some higher order sort of commonalities that organizations are focusing on in decisions about how to optimize their EHR to use them for the common things that people are thinking about.

How can we build that registry or generate reports so that we can identify groups of people? What is the clinical decision support that we want to have in place? Do we need to have it in standardized documentation or standardized order steps as well? Then, what can we do to engage our patients, particularly with the patient portal?

Those are some of the commonalities when folks are thinking about optimizing their EHR.

HCPLive: What are some trends that you're seeing nationally in regard to diabetes prevention and management?

Kirley: I started our work in this space about 6 years ago when we really committed to focusing deeply on diabetes prevention. We actually found that with the conversations we were having with healthcare organizations, it was difficult to get those organizations to prioritize this as an issue. Many organizations are very, very focused on diabetes management, understandably. But prevention felt like too much to bite off.

And the tide has completely turned over the past 6 years. Healthcare organizations are actively thinking about how they can look upstream and be more proactive in terms of prevention. They're recognizing as well that while they can do a lot of this work internally within their organizations, they also need to be connecting with the external communities and connecting their patients to community-based resources.

So, definitely 1 of the trends we’ve observed is not only how do I optimize my EHR within my own clinical site for diabetes prevention, but also the questions around interoperability and how do I achieve bidirectional referrals or community-based organization and move data from 1 organization to another to support preventive care?

HCPLive: What was the reason for the additional emphasis on prevention?

Kirley: I think it's probably a number of factors. AMA, CDC, the Ad Council, and others have done a lot of work just to raise awareness nationally about this issue, and we've seen awareness levels increasing.

I do think the value-based care environment is definitely getting physicians, care teams, and healthcare organizations to think more creatively about how they can generate cost-savings and prevention. They're quickly realizing that prevention is an important piece of that and I think it also fits in with this much needed trend that we're seeing as more clinicians think about social needs, social determinants of health, and just broader recognition that our health could need something that is not completely controlled by the healthcare system—there are many determinants of health.

I see many, many organizations thinking about, again, how they partner with the community and how they really extend their care or expand upon their care by addressing some of these determinants of health that used to not really fit into that traditional health care model.

HCPLive: How else can digital tools be used for chronic care management?

Kirley: We’re seeing a huge surge in digital health apps and tools that are patient- or consumer-facing. These represent a great opportunity to engage people in their health and particularly in living healthy lifestyles when they're not at their doctor's office.

I do you think we have to be a bit cautious in terms of identifying which of these solutions actually have a good evidence base and are likely to truly be effective for patients. But there's clearly a lot of interest—among both physicians and patients—in using more of these digital health-oriented tools to really support healthy lifestyles outside of the clinic.
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