1. STFM Foot Exam

2. Increasing Diabetic Foot Exam Compliance through Documentation
Mohammed Zare, MD, MS1; Jennifer S. Lahue2; Michelle R. Klawans, MPH1
1University of Texas Health Science Center at Houston, 2Harris Health System
Introduction
Figure 1: EPIC Procedure
Results
Annual diabetic foot exams are necessary in order to assess neuropathy, infection, ulceration, and circulation.
The National Committee for Quality Assurance (NCQA) requires that 80% of diabetic patients receive an annual foot exam.
However, gaps in the electronic medical record (EMR) often make it difficult to track documentation of foot exams.
Harris County Health Clinics provide care to over 30,000 diabetic patients at 25 clinics annually.
However, EPIC EMR only allowed for foot exams to be documented in text fields, and as result many diabetic patients did not receive annual exams.
During the year prior to implementation, 4,568 out of the 5,160 patients reviewed received an annual foot exam. (89%)
During the year following implementation, 29,367 out of all 32,396 diabetic patients received an annual foot exam (91%).
An independent two-sample t-test revealed that this increase was significant at the p<0.001 level.
Figure 3: Compliance Rates *
Methods
The primary goal of this project was to ensure that all diabetic patients visiting Harris Health clinics received an annual foot exam, in line with NCQA requirements.
Creating an EPIC procedure that would remind physicians to complete the foot exam was determined to be a feasible way to increase compliance.
IT technical analysts created a Health Maintenance reminder that would appear in patient’s charts when they needed a foot exam.
A procedure note, containing the sensory, vascular, and visual field of the foot exam, was also added to the EMR.
Once the foot exam was marked as complete in the EMR, a tracking code was sent to the Health Maintenance section to tell the system that the exam had been completed.
Meetings were held with medical directors at all 25 clinics to show them the new EPIC procedure note, and get their feedback.
The new EPIC procedure note on diabetic foot exams was added to the EMR in March 2014.
Figure 2: Diabetic Foot Exam
Conclusions
Annual diabetic foot exams are necessary in order to assess neuropathy, infection, ulceration, and circulation.
The National Committee for Quality Assurance (NCQA) requires that 80% of diabetic patients receive an annual foot exam.
However, gaps in the electronic medical record (EMR) often make it difficult to track documentation of foot exams.
Harris County Health Clinics provide care to over 30,000 diabetic patients at 25 clinics annually.
However, EPIC EMR only allowed for foot exams to be documented in text fields, and as result many diabetic patients did not receive annual exams.
Analyses
Data on compliance prior to EPIC procedure implementation was collected on a small sample of diabetic patients from March 2013-February 2014 (n=5160).
Data on compliance following EPIC procedure implementation was collected from all diabetic patients from March 2014-February 2015 (n=32,396).
Frequentist statistics were used to determine the compliance rate along with any significant change between the two time periods.

4. Nursing Expectations:
Effective Friday, March 25, 2016, the system smart phrase for nursing documentation of Diabetic Foot Exam will be available for use in Epic Production.
Please see attached file for the Quick Reference Guide (QRG).
Many thanks for Donna McKee, Katie Kerbow and Salim Rahimtoola (Epic Clinical team) for their hard work!

8. Provider Expectations:
Patients with Flaged HM need to have Foot Exam
Provider uses the Procedure note or .Procdoc to document the foot exam.
Provider will sign off the order for foot exam.

13. Ambulatory Care Services HEDIS Monthly Scorecard 2016
HEDIS Metrics
50%
National Benchmarks
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Effectiveness of Chronic Care
Comprehensive Adult Diabetes Care
HbA1c Testing
> 93%
93.6%
94.0%
94.3%
94.2%
94.1%
93.9%
HbA1c Poor Control (>9%)
> 22%
29.8%
29.9%
30.5%
31.3%
31.8%
31.9%
32.8%
33.5%
34.1%
High Blood Pressure Control (<140/90)
> 66%
68.9%
68.5%
68.6%
68.3%
67.9%
67.1%
66.6%
66.8%
Diabetes Eye Exam
> 69%
61.6%
62.1%
63.8%
62.3%
60.4%
58.3%
57.1%
72.4%
Diabetes Foot Exam
> 80%
61.2%
64.3%
64.5%
64.8%
64.0%
62.9%
62.6%
64.1%
72.5%
Nephropathy Screening/Attention
> 62%
97.0%
97.1%
96.9%
96.8%
Met
Partially Met
Not Met
Not Available

15. Baytown DM Pilot Program
Baytown-Pilot HEDIS Score vs. (Baytown and ACS)

17. Conclusions:
We have Improved Annual DM foot Exam by Primary care Providers.
We have moved from Internal Benchmark to the one now recommended by NCQA for DM medical Home.
We have moved to text format of documentations to smart phrase format of documentations.
We have improved compliance to all major components of the exam.
We have Upgraded EPIC and Business intelligence to provide Data to each provider for their compliance efforts.