Henry Ford Health tailors EHR to boost diabetes prevention

Jennifer Lubell , Contributing News Writer

Nearly 100 million U.S. adults have prediabetes, and among those with the condition, just 19% find out they have this condition from a physician or other health professional.

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Physician leaders at Henry Ford Health decided to tackle these troubling statistics by implementing functionalities within their certified EHR platform to screen, test and refer patients with prediabetes. As a result, the health system improved outcomes in weight loss, hemoglobin A1c levels and blood-pressure control for their patients with prediabetes. Henry Ford Health also saw a sevenfold increase in diabetes prevention program referrals from baseline.

Two diabetes leaders in the Henry Ford Health system shared how they achieved these improvements in an AMA webinar.

“Henry Ford worked with the AMA on implementing these changes to their EHR to really support the systematic identification and management of prediabetes,” said moderator Kate Kirley, MD. She’s the director of chronic disease prevention and programs at the AMA.

Dr. Kirley joined Gina Aquino, DNP, RN, CHSP, clinical quality facilitator with Henry Ford Health, and Jill Yore, RN, diabetes expert and director of faith and community health at Henry Ford Health to discuss this platform.

Henry Ford Health is part of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

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Henry Ford Health is a recognized provider of the National Diabetes Prevention Program (DPP), an intensive lifestyle-change program whose goal is to reduce risk of type 2 diabetes.

“As a health system, we know how important the community benefit piece is. And when Henry Ford Health started with diabetes prevention, we did it through our faith community nursing network,” training nurses as lifestyle coaches, said Yore.

Aquino said that type 2 diabetes prevention aligns with value-based care trends.

“Ultimately, it achieves the goals of providing better care, better outcomes, lower costs to manage patients, and improves the caregiver experience by reducing the prevalence of type 2 diabetes.”

The AMA’s Diabetes Prevention Guide supports physicians and health care organizations in defining and implementing evidence-based diabetes prevention strategies. 

This comprehensive and customized approach helps clinical practices and health care organizations identify patients with prediabetes and manage their risk of developing type 2 diabetes, including referring patients at risk to a National Diabetes Prevention Program lifestyle-change program based on their individual needs.

The EHR initiative was designed to support the diabetes prevention program. AMA and Henry Ford Health worked together with the system’s EHR vendor software to create a prediabetes clinical program, which included a prediabetes registry to identify and monitor patients who were eligible for diabetes prevention services.

Registry reports make it easier to do patient outreach and tracking, said Aquino. Items on a report may include the patient’s demographics and diagnoses, the last office visit, and the last body mass index or blood pressure readings.

Staff can identify when patients are due for outreach. Staff can also review patients’ most recent lab results or order labs prior to the next visit. Reports also include payer information for billing purposes.

These improvements led to increased enrollment in the diabetes prevention program, said Yore.

“Using an electronic health record for referrals really did what we expected it to do. It also is important to note the improved outcomes we had,” she said.

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How the EHR can help ID, refer patients for diabetes prevention

Next steps are to explore social determinants of health in type 2 diabetes and integrate the use of a mobile app to support patient engagement and goals. The plan is to focus on those barriers, using a community health worker to work within the diabetes prevention program to screen for social determinants of health.

Existing features are already addressing patients’ social drivers. Through the electronic screening tool, if a patient has a transportation issue, Henry Ford Health can offer them virtual classes, noted Aquino.