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Nine Essential Functions of an Information System for Optimal Diabetes Care

A set of nine essential functions derived by expert opinion allows an information system to support and improve the performance of clinical care. It is likely that these functions also are relevant to systems serving other chronic diseases.

  1. Identify individuals with diabetes
    A registry should be able to:

    • identify an individual patient's health care providers or health care team
    • confirm that a patient remains in the system
    • indicate how long it has been since the patient's last visit

    Patient death, or the transfer of a patient to another clinic needs to be recorded to allow these patients to be excluded from outreach interventions.

  2. Identify individuals for further intervention
    Stratify by risk
    Identification of individuals at risk for diabetes complications helps providers prioritize care so that patients at greatest risk receive the care they require. Such decisions should be based upon sound evidence that quantifies risk. Although the decision to modify risk factors involves clinical judgment, data systems can provide information to support decision-making such as ways to modify elements of health risk (e.g., weight, body mass index, patient motivation to change).

    A diabetes-specific risk stratification system related to required care intensity can be used to identify patients with high medical costs and can enable care providers to select patients for case management and triage into specific care programs.

    Click here for Risk Assessment Tools

    Identify patients with complications and other comorbidities
    Identifying patients with diabetes complications or other comorbidities in a previous 2-year period can help direct resources to high-risk individuals in order to modify the likelihood of additional injury. Analyses of administrative databases have demonstrated that a large fraction of health care dollars are allocated to a small proportion of the population with multiple comorbidities. [1] Patients with complications are an evolving group and for practical planning purposes periodic reassessment is essential.

    See Risk-Stratifying Patients - Two Examples www.advisory.com/Research/Health-Care-Advisory-Board/Blogs/The-Blueprint/2011/04/Risk-Stratifying-Patients-Two-Example-Approaches

  3. Provide patients with information and support
    An information system enables health care teams to provide patient information and support – appointment reminders, proactive outreach calls, laboratory test reporting, sharing laboratory test results, educational interventions, availability of educators and other team members, or sharing of new treatments and community resources. Interventions should promote and enable patient self-management.

  4. Provide the health care team with timely, complete, and structured information about the current status of an individual patient

    It is important that current information be delivered completely and in a structured manner.

    One example from Penn State Institute for Diabetes & Obesity presents a sample patient profile (see inset).

    The other example from the East Metro Disease Initiative registry (St. Paul, MN) contains a summary of tests recommended by DQIP for the patient identified. It also provides an example of patient-specific decision support for providers (see inset).

    Two Patient Profiles

    Penn State Institute for Diabetes & Obesity - sample profile
    patient profile image
    Click to open full-sized image

    East Metro Disease Initiative registry - sample profile
    patient profile image
    Download (MS Word, 37kb)

  5. Provide the health care team with an up-to-date summary of patient requirements to meet current guidelines for quality care
    Basically, this is decision support. Although challenging, it is critically important that the team is equipped with the knowledge required for optimal patient care based on evidence-based diabetes practice care guidelines. Access to such decision support at the point of care brings the latest broadly accepted research findings into practice.

  6. Generate population based reports of quality of care for a defined population
    Aggregate reporting of care to groups of patients can give meaningful feedback to health care teams about the overall effectiveness and variability of the care and support provided. Care teams are able to identify areas of priority for improvement.

    Aggregate reporting can help practices set performance goals, create benchmarks and compare data against practice standards such as NCQA standards for recognition, meaningful use, or healthcare effectiveness data and information set (HEDIS) measures.

  7. Facilitate communication between all team members and team access to important information
    Prepared proactive provider teams are critical to the implementation of optimal care. Timely access to information, consistent documentation and sharing of information, and creating a "patient care trail" are fundamental to bridging the various team members and care settings. Extended care team members can include the primary care provider, endocrinologist, nurse, diabetes educator, dietitian, mental health provider, exercise physiologist, other team members and specialists, as well as hospital-based providers.

    Patient-health care professional interactions can occur in a variety of ways, such as face-to-face appointments, group education settings, telephone calls, or Internet messages. At the time of care, up-to-date information access is critical in both clinical as well as remote settings, such as nurse call centers and phone-counselor support service centers.

    Appropriate safeguards must be in place to abide by the standards set to protect patient privacy and confidentiality. (See the Health Insurance Portability and Accountability Act (HIPAA) of 1996 health information privacy rule.

  8. Enable patient-centered care
    Tailor the delivery of care around the unique and disparate needs of your patients by providing patient-centered care that is “respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions."[2] The patient feels listened to, respected, and cared for and may become more involved in team decision-making and self-care. [3]

    Access to and use of information and resources helps individual patients in their self-management efforts; support patients and their families in dealing with disease-related concerns; and optimize the patient’s chances for living a vital life with as few physical and emotional limitations as possible. The components and processes for effective self-management include:[4]

    • effective communications between the patient and health care team
    • the ability to define problems
    • the ability to set priorities and focus
    • establishing goals that are specific, measurable, attainable, reasonable, and stated in both short-term and long-term contexts
    • identification of barriers
    • creation and understanding of treatment plans with clearly identified areas of patient ownership and accountability
    • problem solving

    Counseling by nurses, dietitians, diabetes educators, and other team members is usually essential for the accomplishment of these self-management components.

  9. Enhanced patient-provider interaction
    Information systems should be designed to optimize the professional-patient interaction in terms of timeliness, efficiency, and effectiveness of care and process. Data input during a patient visit should not diminish the value of patient-professional time. A good system can be expected to:

    • deliver information promptly
    • be clearly organized
    • provide additional information
    • benefit rather than burden the patient-professional interaction

    Skills that contribute to a positive professional-patient relationship include looking at the patient, listening to his or her concerns, and not appearing rushed. An effective "bedside manner" that promotes relationships between people is central to provision of excellent and compassionate care. Click here for more information on how to Build Cultural Competency.

    Registries can support professional-patient interactions from four different aspects:

    • the health system – to support clinical performance and quality between clinics,
    • a clinic – to compare providers and evaluate patterns and gaps in the provision of care,
    • a provider – to give providers a perspective on their performance and access to their roster of individual patients, and
    • a patient – to support education and individual goal-setting.