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

Sara Berg, MS , News Editor

When the COVID-19 pandemic began, referral of patients to a National Diabetes Prevention Program (National DPP) lifestyle-change program had to go virtual. Resident physicians at Duke Health in Durham, North Carolina, created a new electronic referral process to successfully identify and refer patients at risk for developing type 2 diabetes to a virtual DPP.

Join the fight on chronic disease

The AMA is leading the charge against chronic disease and premature mortality rates in the U.S.

Be a part of these important efforts to improve public health.

“COVID definitely paused everything for a while, in particular because all of a sudden there were no DPPs to refer people to while the YMCAs were transitioning to offering online virtual programs,” said Karen Scherr, MD, PhD, a chief resident at Duke in the family medicine department. “There were a lot of competing priorities at the time when COVID began. We took a pause for some months, but now we have been able to come back and restart the project.”

After working “out so many of the barriers and issues along the way through designing, testing and retesting the process, we are ready to roll out the referral process and start getting patients referred more widely,” said Dr. Scherr, who partnered with Matt Geisz, MD, a third-year resident at Duke, and Anthony Viera, MD, the chair of family medicine at Duke, to create the program.

The pilot began in the summer of 2019 but shifted to virtual options in 2020 to align with the COVID-19 pandemic. Since beginning, about 60 patients with prediabetes have been referred to an evidence-based lifestyle-change program.

This program is part of the statewide initiative DiabetesFreeNC, which aims to put an end to type 2 diabetes in North Carolina, and many of its in-person programs have pivoted to using a distance-learning platform to reach patients during the pandemic.

As part of the initiative, the AMA, North Carolina Medical Society and other organizations across the state are asking physicians, care teams and health care organizations to lead the way by identifying patients with prediabetes and referring them to an evidence-based National DPP lifestyle change program. Learn more about how amid the pandemic, diabetes prevention goes virtual in North Carolina.

Related Coverage

6 lifestyle changes doctors wish patients would make

For the care-management referral process, Dr. Scherr got some help from an EHR superuser, endocrinologist Susan Spratt, MD. Together they created a new prediabetes registry that “uses an automated algorithm to create a list of patients with prediabetes who might be eligible for a DPP,” said Dr. Scherr.

“As primary care providers, we are then able to review these lists to determine which of our patients would most benefit from referrals to DPPs.” Once identified, a patient will receive a notification “to learn more about what a diabetes prevention program is and whether or not they’d be interested in enrolling,” Dr. Scherr said.

Related Coverage

How to successfully offer diabetes prevention at a distance

The second part of the EHR identification and referral is through a point-of-care model “where physicians identify and refer patients during appointments,” said Dr. Scherr. However, “we have some initial data showing that knowledge about the program was historically low.”

That is why “we are educating providers about the program and where they're available in the local area,” she said. “Then, similarly to how providers would place an ambulatory referral to a podiatrist or an ambulatory referral to an ENT doctor, they can now place an ambulatory referral to the diabetes prevention program.

“What's nice is that it integrates perfectly into the physician workflow during appointments,” added Dr. Scherr. “It is very quick and easy to place the order that then automatically gets routed to the YMCA’s EHR with the information that they need to contact and enroll the patient.”

Discover how to successfully offer diabetes prevention at a distance.

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 the risk of developing type 2 diabetes, including referring patients to a National DPP lifestyle change program based on their individual needs.