The Diabetes Data War

By John Pulley
Government Health IT
Feb. 19, 2007

A Korean War veteran begins his day by responding to an electronic message that prompts him to check his feet for sores.

  • A computer in a Salt Lake County, Utah, classroom reminds a 9-year-old student to drink fruit juice before taking a spelling test.
  • A physician in Florida shows his patient a computer-generated graph that tracks her blood sugar and cholesterol levels.
  • Health department workers in New York City use an electronic registry to identify a disease's hot zones.

Each person, in a unique way, is dealing with the so-called quiet epidemic that afflicts nearly 21 million Americans, a third of whom are unaware that they have the disease.

There is no cure, but patients can control diabetes by modifying their behavior with their doctor's help. In the rush to get in front of a fast-moving problem, the medical community has begun using information technology - and a growing body of evidence suggests it's working.

Breakout applications One breakout IT application is electronic registries, which collect and sort clinical data for large numbers of diabetes sufferers. Those databases make it possible for doctors to extract comparative information about entire populations of people with diabetics. Knowing which patients have abnormally high levels of cholesterol, a risk factor for cardiovascular complications, or A1C, a measure of blood sugar concentration over time, can prompt health care providers to take corrective action when it is likely to have the most benefit.

E-registries also allow physicians to contrast the clinical outcomes of their patients with diabetics treated by other doctors. Access to this detailed information enhances physicians' ability to benefit from pay-for-performance schemes, thereby providing a financial motivation for doctors to invest in the technology. 

Until recently, the only way to capture clinical data was to mine mountains of paper records, a method that is too expensive for most physicians. And without any means of measuring the problem, physicians work in the dark. "If you don't know how many patients you have [with the disease], how would you know how well you are taking care of them?" asked Dr. Janet Sullivan, chief medical officer of the Hudson Health Plan, a not-for-profit managed care organization.

The Hudson Center for Health Equity and Quality is putting e-registries in the hands of private practitioners who otherwise might not be able to afford them. The initiative is a joint project of the Hudson Health Plan and the New York Diabetes Coalition, a partnership of professional medical societies, health plans, health care-focused agencies and community organizations dedicated to improving the health of people with diabetes.

The project seeks to build on the experience of a Westchester, N.Y., community health center that has participated in a treatment-enhancement program that the federal Bureau of Primary Health Care operates. Using registries, the bureau sought to improve care delivered at public health centers throughout the country to patients with diabetes and other chronic diseases. "They've had dramatic results," Sullivan said. "They demonstrated that if you change how physicians keep track of things and give them the tools, you can make dramatic improvements."

Eager to build on that success, the Hudson project installed CareFocus registry software on the PCs of participating physicians' practices. When employees identify patients with diabetes, they enter them into the registry. After each subsequent office visit, employees update the database with patient notes, including lab results and new symptoms. Collecting and combining diabetes information in a single database provide doctors with a broader view of their patients' status and lead to more productive patient/doctor interactions.

"Instead of having a physician madly thumbing through a chart while the patient is sitting there twiddling his thumbs, the physician has something in front of him with the information he needs, in a format he can discuss with his patient," Sullivan said. "This is a tremendous tool for improving communication and getting people to change lifestyles."

Overcoming technophobia
But epidemics have a way of getting the attention of some members of the medical community, prompting them to overcome their technophobia and think about the health of large populations.

Last year, Melbourne Internal Medicine Associates (MIMA), a 110-physician practice in Florida, began using CareManager, an e-registry Kryptiq produced. At night, the registry's diabetes module mines the office's electronic medical record system, a General Electric EMR called Centricity, and captures values for factors associated with the long-term effects of diabetes. Among the clinical variables are blood pressure, blood sugar levels and three process goals, including regular exams of patients' retinas and feet. Loss of feeling in the extremities of diabetic patients can result in untreated infections, gangrene and amputation.

The cost of adopting the registry is being covered by Health First, a not-for-profit health care delivery system in Florida that "is devoted to integrating quality health care services with state-of-the-art technology," according to its Web site. Health First is promoting the registry as a means "to incentivize doctors to take care of diabetic patients better," said Richard Baney, MIMA's assistant medical director for quality improvement and managed care.

The registry's interface has uses color-coded dashboards for clinical and support staff. Office workers can see at a glance which patients are due for lab work or routine exams. Physicians viewing the treatment screen see a patient's individual clinical data, with troublesome data tagged in red. The status of groups of patients can also be checked, providing a population view and the ability to do truly proactive population-wide disease management, said Nathan Loveless, a Kryptiq product marketing manager.

"It has dramatically improved the way we take care of diabetic patients," Baney said. "The patients themselves are getting the chance to see for themselves how they are doing and how they compare with their care."

The registry tracks patients and compares their progress against benchmarks, showing, for example, the percentage of diabetic patients within a practice who have successfully controlled their cholesterol levels and how that compares to the national average. The database also makes it easy to see how well individual doctors are treating diabetic patients and how physicians are performing relative to their peers. "Physicians enjoy collegial competition," Loveless said. "It's a great motivating factor."

The ubiquity of diabetes has spurred adoption of IT solutions by a broad swath of health care providers. Since January 2006, the New York City Department of Health and Mental Hygiene has collected A1C results, a critical measure of disease progression, from 39 labs to develop a citywide diabetes registry. Changes to the city's health code prompted the tracking, which relies on a system of electronic reporting originally used to identify lead poisoning and the spread of communicable diseases, such as HIV infection.

About 9 percent of New Yorkers, or 530,000 people, have been diagnosed with diabetes. Undiagnosed cases are estimated to total 265,000. Despite the prevalence of the disease, only about 16 percent of the city's diabetics who had undergone A1C testing in the past year knew their lab results. The national average is between 30 and 40 percent. "If people know their lab results, they can better learn to monitor" their diabetes and behavior, said Shadi Chamany, director of the Diabetes Prevention and Control Program and director of the registry program.

The city's health department is exploring how best to use data captured by the registry to educate patients and doctors and improve management of the disease. A test program set to begin this year will test interventions in the South Bronx, where an estimated 12 percent of the population is diabetic. "The ultimate goal of this is to decrease diabetes complications and improve quality of life," Chamany said.

Health Buddy
On the home front, people with diabetes are benefiting from electronic devices that deliver education, monitoring and feedback from health care providers.

One such product is the Health Buddy appliance, a component of the Health Hero Network, which provides technology solutions for remote health monitoring and management. The home unit, which connects through the user's home telephone line to a remote server, has ports for uploading readings from a glucose meter, weight scales, devices to measure blood oxygen, peak flow meters and other medical appliances.

Using software that health care providers customize to meet the needs of patients, Health Buddy solicits critical information. Each day, it begins with basic questions such as "How are you feeling today, Mr. Jones?", it processes those answers and "branches off and goes into asking you about symptoms depending on what stage of condition you have," said Steve Brown, chief executive officer of the Health Hero Network.

Depending on a patient's profile, Health Buddy could inquire about foot care, medication or nutrition. There is also a program for managing obesity, a major risk factor for diabetes, and other comorbidities, including heart disease, hypertension and depression. "People with diabetes who are depressed are more likely to end up in the hospital," Brown said. "The big driver of cost for chronic health ends up being hospitalization for complications."

The biggest user of Health Buddy to date is the Department of Veterans Affairs, which has implemented the system in more than 100 VA medical centers and has reported a 50 percent reduction in hospital admissions. The company has also won a contract to do a test program with Medicare. "Changing behavior is the key to managing chronic illness," Brown said. "This whole field of remote monitoring is going through the roof."