1. 1422 Pre- Diabetes and Undiagnosed HTN Measures

2. What is DRVS?
Data Reporting and Visualization System (DRVS) is a reporting platform that collects data from each CHC nightly and uploads it into a reporting system. It is EMR agnostic.

3. Pre-Diabetes and Undiagnosed HTN Measures
Identify undiagnosed HTN and at- risk for DM population
Measures support but don’t replace decision making
Will need workflows and business decisions:
Decision making
Patient follow-up
Linkage to care
Getting started
Break list into smaller groups
Pilot workflows

4. Undiagnosed Hypertension

5. Undiagnosed Hypertension Definition
Undiagnosed HTN
Endorser: CDC
Percentage of patients age who do not have a hypertension diagnosis but had at least one Stage 2 HTN Blood Pressure reading or at least two Stage 1 HTN Blood Pressure readings in the last year.
Numerator:
Patients who had at least one Stage 2 Blood Pressure reading or at least two Stage 1 Blood Pressure readings in the last year.
Two Stage 1 HTN BP’s at least 1 week apart (BP at last visit and one other visit during the year)
Systolic >=140  and  < 160 mm Hg OR
Diastoic >=90 and < 100 mm Hg
           OR
One Stage 2 HTN BP at any visit
Systolic >=160 mm Hg  OR
Diastolic >= 100 mm Hg
Denominator:
All patients age who do not have a hypertension diagnosis (including pregnant and CKD patients) and had a medical visits in the last 12 months.
Medical Visit in the last 12 months
Age 18-85
No active diagnosis of hypertension 
Measures built as part of CDC funded Million Hearts project
Note age range

6. Undiagnosed Hypertension

7. Undiagnosed Hypertension
Current results by provider, team or health center– 3% - 29%

8. Undiagnosed Hypertension
Patient level detail with data for decision making and outreach:
Inactive Patient flag
Exceptions (pregnancy, ESRD)
Demographic, language and contact information
Dates of last encounter, next appointment
Dates with noted high Blood Pressures
Show from xls sample
Use list to support decision making and outreach according to center workflows

9. Undiagnosed HTN Detail
Example of patient detail – can be exported to Excel for analysis
Demo Data
11/17/2018

10. Pre-Diabetes / High Risk for Diabetes

11. Pre-Diabetes / High Risk for Diabetes
Percentage of patients years of age who meet the clinical criteria for Pre-Diabetes.
Denominator:
All patients seen for at least one primary care visit in the measurement period (previous 12 month) who do not have a diagnosis of diabetes.
Age 18-75
Without a diagnosis of diabetes (ICD-9: 249.* *; ICD-10: E08, E10, E11, E13)
Qualifying primary care visit in the past 12 months
Numerator:
Patient meets the clinical criteria for Pre-Diabetes based on pre-diabetes diagnosis, hemoglobin A1c or fasting glucose test. Includes one of the following:
Active diagnosis of Pre-Diabetes (ICD-9: , , , 277.7; ICD-10: R73.01, R73.02, R73.09, E88.81)
OR Fasting Glucose result ≥ 100 and ≤ 125 mg/dl
OR HbA1c ≥ 5.7 and ≤ 6.4% a Negative Retinal or dilated eye exam result in the past 24 months
Exclusions:
Pregnancy
End Stage Renal Disease (ESRD)
Measure built part of 1422 Grant (PWTF)
Emerging standard
Age Range

12. Pre-Diabetes / High Risk for Diabetes
Centers already coding for Pre-Diabetes appear much higher
Centers need to confirm Fasting Glucose test mappings if using as diagnostic
Current results comparison by provider, team or health center  – 9% - 42%

13. Pre-Diabetes / High Risk for Diabetes
Patient level detail with data for decision making and outreach:
Inactive Patient flag
Exceptions (pregnancy, ESRD)
Demographic, contact and language information
Dates of last encounter, next appointment
Diagnosis of Pre-Diabetes
Dates and results of A1c, Fasting Glucose labs
Work from Sample file

14. Pre Diabetes Detail Demo Data
Example of patient detail – can be exported to Excel for analysis
Demo Data
11/17/2018

15. Scorecard Report
Asthma Scorecard Sample – Centers can have custom scorecards created to highlight priority areas – can add targets to all scorecard measures to goals and progress.
11/17/2018

16. Visit Planning Report Combines Registry & Preventative Care Alerts, by Provider, ordered by appointment, in one report.
1:25 PM l Friday, September 11, Visit Reason: Well Child Visit
Gomez, Jose DOB: 11/23/ Gender: M Phone: PCP: Cranston, Bill
MRN: Age: Risk Level: Moderate Language: Spanish
Diagnoses_______________________ Alert ______________ _ Message_________ Most Recent Date _ __Most Recent Result
Asthma Nutritional Counseling Missing
Physical Activity Counseling Missing
Risk Factors______________________ BMI Percentile Overdue 8/15/
OBS Asthma Severity Overdue 8/15/2014
3:45 PM l Friday, September 11, Visit Reason: Headaches
Perkins, Sonja DOB: 3/18/ Gender: F Phone: PCP: Gunther, Eric
MRN: Age: Risk Level: High Language: English
Diagnoses_______________________ Alert ______________ _ Message_________ Most Recent Date _ __Most Recent Result
DM, HTN, DEP, COPD Mammogram Missing
Pap Smear Missing
Risk Factors______________________ A1c Overdue 8/15/
SAD, SMIP BP Result out of Range 8/15/ /95
Eye Exam Missing
Flu Missing
Tobacco Status Missing
LDL Overdue 5/15/
Demo Data

17. Change is hard
Importance of senior leadership and other stakeholder support
Work flow mapping
QI structure
PDSA cycles
Who has responsibility for new processes?
Project versus work - sustainable change mentality
Small, measurable steps
CHWs, non-english speakers, complexity of instructions, HIE