Diabetes Discovery ProjectUsing technology to support the implementation of

standardised clinical care

Libby Owen-Jones Project Director

Dr Nic Woods Physician Executive, Cerner

Overview

Austin Health EMR Strategy & implementation

Diabetes Discovery Project

Change management and Clinical Adoption

Outcomes

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

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

Austin Health IT and EMR Strategy

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

From paper ……to mobile computing

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

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

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

.

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

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

Goal: patient safety & consistent practice

Clinical System supports Clinical practice

Clinician Led

Use evidence based protocols

BUT

Who needs the intervention?

Diabetes Management Project

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

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

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 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

Adding an Alert and notification – automated process

Adding an Alert and notification – automated process

Clinical Guideline

Clinical Guideline – e referrals

Clinical Guideline – e referrals

Communication with GPs

Communication with GPs

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)

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

%

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

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

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.

.

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

Acknowledgements

Cerner CorporationUniversity of Melbourne – Endocrinology Unit at Austin HealthAustin Health - Clinical Systems Projects Unit & Business Intelligence UnitHealth Shared ServicesBMJ – Action Sets