Heidi Ekstrom

Impact of Electronic Health Record Clinical Decision Support on Diabetes Care: A Randomized Trial

PURPOSE We wanted to assess the impact of an electronic health record–based diabetes clinical decision support system on control of hemoglobin A1c (glycated hemoglobin), blood pressure, and low-density lipoprotein (LDL) cholesterol levels in adults with diabetes. METHODS We conducted a clinic-randomized trial conducted from October 2006 to May 2007 in Minnesota. Included were 11 clinics with 41 consenting primary care physicians and the physicians’ 2,556 patients with diabetes. Patients were randomized either to receive or not to receive an electronic health record (EHR)–based clinical decision support system designed to improve care for those patients whose hemoglobin A1c, blood pressure, or LDL cholesterol levels were higher than goal at any office visit. Analysis used general and generalized linear mixed models with repeated time measurements to accommodate the nested data structure. RESULTS The intervention group physicians used the EHR-based decision support system at 62.6% of all office visits made by adults with diabetes. The intervention group diabetes patients had significantly better hemoglobin A1c (intervention effect −0.26%; 95% confidence interval, −0.06% to −0.47%; P=.01), and better maintenance of systolic blood pressure control (80.2% vs 75.1%, P=.03) and borderline better maintenance of diastolic blood pressure control (85.6% vs 81.7%, P =.07), but not improved low-density lipoprotein cholesterol levels (P = .62) than patients of physicians randomized to the control arm of the study. Among intervention group physicians, 94% were satisfied or very satisfied with the intervention, and moderate use of the support system persisted for more than 1 year after feedback and incentives to encourage its use were discontinued. CONCLUSIONS EHR-based diabetes clinical decision support significantly improved glucose control and some aspects of blood pressure control in adults with type 2 diabetes.

Simulated Physician Learning Program Improves Glucose Control in Adults With Diabetes

OBJECTIVE Inexpensive and standardized methods to deliver medical education to primary care physicians (PCPs) are desirable. Our objective was to assess the impact of an individualized simulated learning intervention on diabetes care provided by PCPs. RESEARCH DESIGN AND METHODS Eleven clinics with 41 consenting PCPs in a Minnesota medical group were randomized to receive or not receive the learning intervention. Each intervention PCP was assigned 12 simulated type 2 diabetes cases that took about 15 min each to complete. Cases were designed to remedy specific physician deficits found in their electronic medical record observed practice patterns. General linear mixed models that accommodated the cluster randomized study design were used to assess patient-level change from preintervention to 12-month postintervention of A1C, blood pressure, and LDL cholesterol. The relationship between the study arm and the total of intervention and patient health care costs was also analyzed. RESULTS Intervention clinic patients with baseline A1C ≥7% significantly improved glycemic control at the last postintervention A1C measurement, intervention effect of −0.19% mean A1C (P = 0.034) and +6.7% in A1C <7% goal achievement (P = 0.0099). Costs trended lower, with the cost per patient −

Outpatient EHR-Based Diabetes Clinical Decision Support That Works: Lessons Learned From Implementing Diabetes Wizard

71 (SE = 142, P = 0.63) relative to nonintervention clinic patients. The intervention did not significantly improve blood pressure or LDL control. Models adjusting for age, sex, and comorbidity showed similar results. PCPs reported high satisfaction. CONCLUSIONS A brief individualized case-based simulated learning intervention for PCPs led to modest but significant glucose control improvement in adults with type 2 diabetes without increasing costs.

Educating Resident Physicians Using Virtual Case-Based Simulation Improves Diabetes Management: A Randomized Controlled Trial

In Brief Electronic health record-based clinical decision support (CDS) can improve key intermediate outcomes of diabetes care in primary care settings and could be deployed in conjunction with additional care improvement strategies. It is important to understand how to incorporate CDS strategies into primary care practices to obtain high provider use rates and satisfaction. This article describes the process for successful implementation of a CDS tool called Diabetes Wizard.

TeenBP: Development and Piloting of an EHR-linked Clinical Decision Support System to Improve Recognition of Hypertension in Adolescents

Purpose To test a virtual case-based Simulated Diabetes Education intervention (SimDE) developed to teach primary care residents how to manage diabetes. Method Nineteen primary care residency programs, with 341 volunteer residents in all postgraduate years (PGY), were randomly assigned to a SimDE intervention group or control group (CG). The Web-based interactive educational intervention used computerized virtual patients who responded to provider actions through programmed simulation models. Eighteen distinct learning cases (L-cases) were assigned to SimDE residents over six months from 2010 to 2011. Impact was assessed using performance on four virtual assessment cases (A-cases), an objective knowledge test, and pre–post changes in self-assessed diabetes knowledge and confidence. Group comparisons were analyzed using generalized linear mixed models, controlling for clustering of residents within residency programs and differences in baseline knowledge. Results The percentages of residents appropriately achieving A-case composite clinical goals for glucose, blood pressure, and lipids were as follows: A-case 1: SimDE = 21.2%, CG = 1.8%, P = .002; A-case 2: SimDE = 15.7%, CG = 4.7%, P = .02; A-case 3: SimDE = 48.0%, CG = 10.4%, P < .001; and A-case 4: SimDE = 42.1%, CG = 18.7%, P = .004. The mean knowledge score and pre–post changes in self-assessed knowledge and confidence were significantly better for SimDE group than CG participants. Conclusions A virtual case-based simulated diabetes education intervention improved diabetes management skills, knowledge, and confidence for primary care residents.

Using Simulation Technology to Teach Diabetes Care Management Skills to Resident Physicians

Context: Blood pressure (BP) is routinely measured in children and adolescents during primary care visits. However, elevated BP or hypertension is frequently not diagnosed or evaluated further by primary care providers. Barriers to recognition include lack of clinician buy-in, competing priorities, and complexity of the standard BP tables. Case Description: We have developed and piloted TeenBP— a web-based, electronic health record (EHR) linked system designed to improve recognition of prehypertension and hypertension in adolescents during primary care visits. Major Themes: Important steps in developing TeenBP included the following: review of national BP guidelines, consideration of clinic workflow, engagement of clinical leaders, and evaluation of the impact on clinical sites. Use of a web-based platform has facilitated updates to the TeenBP algorithm and to the message content. In addition, the web-based platform has allowed for development of a sophisticated display of patient-specific information at the point of care. In the TeenBP pilot, conducted at a single pediatric and family practice site with six clinicians, over a five-month period, more than half of BPs in the hypertensive range were clinically recognized. Furthermore, in this small pilot the TeenBP clinical decision support (CDS) was accepted by providers and clinical staff. Effectiveness of the TeenBP CDS will be determined in a two-year cluster-randomized clinical trial, currently underway at 20 primary care sites. Conclusion: Use of technology to extract and display clinically relevant data stored within the EHR may be a useful tool for improving recognition of adolescent hypertension during busy primary care visits. In the future, the methods developed specifically for TeenBP are likely to be translatable to a wide range of acute and chronic issues affecting children and adolescents.

Recidivism to uncontrolled blood pressure in patients with previously controlled hypertension

Background: Simulation is widely used to teach medical procedures. Our goal was to develop and implement an innovative virtual model to teach resident physicians the cognitive skills of type 1 and type 2 diabetes management. Methods: A diabetes educational activity was developed consisting of (a) a curriculum using 18 explicit virtual cases, (b) a web-based interactive interface, (c) a simulation model to calculate physiologic outcomes of resident actions, and (d) a library of programmed feedback to critique and guide resident actions between virtual encounters. Primary care residents in 10 U.S. residency programs received the educational activity. Satisfaction and changes in knowledge and confidence in managing diabetes were analyzed with mixed quantitative and qualitative methods. Results: Pre- and post-education surveys were completed by 92/142 (65%) of residents. Likert scale (five-point) responses were favorably higher than neutral for general satisfaction (94%), recommending to colleagues (91%), training adequacy (91%), and navigation ease (92%). Finding time to complete cases was difficult for 50% of residents. Mean ratings of knowledge (on a five-point scale) posteducational activity improved by +0.5 (p < .01) for use of all available drug classes, +0.9 (p < .01) for how to start and adjust insulin, +0.8 (p < .01) for interpreting blood glucose values, +0.8 (p < .01) for individualizing treatment goals, and +0.7 (p < .01) for confidence in managing diabetes patients. Conclusions: A virtual diabetes educational activity to teach cognitive skills to manage diabetes to primary care residents was successfully developed, implemented, and well liked. It significantly improved self-assessed knowledge and confidence in diabetes management.

Clinical decision support for recognition and management of hypertension: A randomized trial

BACKGROUND Control of hypertension has improved nationally with focus on identifying and treating elevated blood pressures (BPs) to guideline recommended levels. However, once BP control is achieved, the frequency in which BP falls out of control and the factors associated with BP recidivism is unknown. In this retrospective cohort study conducted at 2 large, integrated health care systems we sought to examine rates and predictors of BP recidivism in adults with controlled hypertension. No change for methods, results and conclusion. METHODS Patients with a prior diagnosis of hypertension based on a combination of International Classification of Diseases, Ninth Revision, codes, receipt of antihypertensive medications, and/or elevated BP readings were eligible to be included. We defined controlled hypertension as normotensive BP readings (<140/90 mmHg or <130/80 mmHg in those with diabetes) at 2 consecutive primary care visits. We then followed up patients for BP recidivism defined by the date of the second of 2 consecutive BP readings >140/90 mmHg (>130/80 mmHg for diabetes or chronic kidney disease) during a median follow-up period of 16.6 months. Cox proportional hazards regression assessed the association between patient characteristics, comorbidities, medication adherence, and provider medication management with time to BP recidivism. RESULTS A total of 23,321 patients with controlled hypertension were included in this study. The proportion of patients with hypertension recidivism was 24.1% over the 16.6-month study period. For those with BP recidivism, the median time to relapse was 7.3 months. In multivariate analysis, those with diabetes (hazard ratio [HR] 3.99, CI 3.67-4.33), high normal baseline BP (for systolic BP HR 1.03, CI 1.03-1.04), or low antihypertensive medication adherence (HR 1.20, CI 1.11-1.29) had significantly higher rates of hypertension recidivism. Limitations of this work include demographics of our patient sample, which may not reflect other communities in addition to the intrinsic limitations of office-based BP measurements. CONCLUSIONS Hypertensive recidivism occurs in a significant portion of patients with previously well-controlled BP and accounts for a substantial fraction of patients with poorly controlled hypertension. Systematic identification of those most at risk for recidivism and implementation of strategies to minimize hypertension recidivism may improve overall levels of BP control and hypertension-related quality measures.

CC1-01: A Simulated Diabetes Learning Intervention Improves Provider Knowledge and Confidence in Managing Diabetes

In this cluster-randomized trial conducted in a large health system, an EHR-linked CDS improved the recognition and guideline-adherent management of hypertension. OBJECTIVES: Although blood pressure (BP) is routinely measured in outpatient visits, elevated BP and hypertension are often not recognized. We evaluated whether an electronic health record–linked clinical decision support (CDS) tool could improve the recognition and management of hypertension in adolescents. METHODS: We randomly assigned 20 primary care clinics within an integrated care system to CDS or usual care. At intervention sites, the CDS displayed BPs and percentiles, identified incident hypertension on the basis of current or previous BPs, and offered tailored order sets. The recognition of hypertension was identified by an automated review of diagnoses and problem lists and a manual review of clinical notes, antihypertensive medication prescriptions, and diagnostic testing. Generalized linear mixed models were used to test the effect of the intervention. RESULTS: Among 31 579 patients 10 to 17 years old with a clinic visit over a 2-year period, 522 (1.7%) had incident hypertension. Within 6 months of meeting criteria, providers recognized hypertension in 54.9% of patients in CDS clinics and 21.3% of patients in usual care (P ≤ .001). Clinical recognition was most often achieved through visit diagnoses or documentation in the clinical note. Within 6 months of developing incident hypertension, 17.1% of CDS subjects were referred to dieticians or weight loss or exercise programs, and 9.4% had additional hypertension workup versus 3.9% and 4.2%, respectively (P = .001 and .046, respectively). Only 1% of patients were prescribed an antihypertensive medication within 6 months of developing hypertension. CONCLUSIONS: The CDS had a significant, beneficial effect on the recognition of hypertension, with a moderate increase in guideline-adherent management.

Clinical decision support directed to primary care patients and providers reduces cardiovascular risk: a randomized trial

Background/Aims Provider performance on diabetes measures is variable, and is at least partially due to differences in provider knowledge and confidence in managing patients with diabetes and multiple co-morbidities. Objective To evaluate whether a simulated learning program can improve provider knowledge and self-confidence in diabetes management. Methods 19 primary care residency programs and 341 consented residents were randomized to (a) intervention (177 residents) or (b) control (164 residents) conditions. Intervention subjects were assigned 18 learning cases using SimCare Diabetes, a web-based immersive simulation program that challenges providers to achieve blood sugar, blood pressure, and lipid goals in 6 months of simulated time, as well as to address other issues such as severe obesity and insulin resistance, hypoglycemia, depression, obstructive sleep apnea, and non-adherence. Between simulated encounters with a patient, providers receive personalized feedback on progress to goals and treatment actions taken or omitted. 92 intervention and 128 control subjects completed a post-intervention follow-up online survey with 10 multiple choice knowledge and 5 self-confidence assessment questions using a 5-point Likert scale (1=not at all confident, 5=very confident). Mean (95% CI) knowledge test and self- confidence measures, adjusting for residency program clustering, were compared by group. Results On knowledge testing, 46% of the intervention group answered more than half the answers correctly compared to 16% of the control group. The mean knowledge score (95% CI) was 5.31 (4.87–5.75) for intervention and 4.1 (3.69–4.50) for control subjects (p<.001). Self-confidence measures were higher for intervention compared to control subjects for: use of all available drug classes to manage diabetes (3.64 vs. 3.09, p<.001), insulin use (4.12 vs. 3.36, p<.001), interpretation of blood sugars (4.21 vs. 3.58, p< .001), setting individualized treatment goals (4.06 vs. 3.42, p< .001), and overall confidence in managing diabetes (3.97 vs. 3.28, p< .001). Discussion An immersive online simulated diabetes learning program was effective at improving knowledge and self-confidence for diabetes management in primary care residents. Support and partnerships to maintain and spread the technology are desirable.