1. Impact of an EHR Smart Phrase and Resident Education on Adherence to ADA Standards of Medical Care in Diabetes Javier Guevara Jr. MD, Julia Gold MD, Corina Marshall MD, Kajal Patel MD St. Mary and Elizabeth Medical Center Family Medicine Residency Program Completed project. May 7 th, 2015.

2. Overview Importance Objective Methods Results Discussion Questions

3. Importance Poor adherence to ADA diabetic care recommendations among FP has been long documented. Critical factors to compliance include education to providers and use of EHR. Isolated interventions do not show lasting effect in improving compliance It is important to further develop tools and interventions to improve adherence to recommendations.

4. Objective To assess improvement in resident adherence to ADA diabetic care recommendations through educational interventions (via a conference and posters), as well as with the implementation of an EHR smart phrase.

5. Methods Setting: ▫Two urban outpatient clinics. Participants: ▫PGY-2 and PGY-3 Family Medicine Residents

6. Methods Pre-Intervention period ▫01/01/2013 – 02/28/2014 ▫Retrospective analysis of data collected from 120 randomly selected patient charts that met the inclusion criteria of 4 or more diabetes management office visits. ▫The data gathered was the compliance with 14 ADA recommendations for diabetic management (Table 1.)

7. Methods Annual Labs Foot ExamMedications Vaccinations Referrals HbA1cVisualACE-i/ARBInfluenza Ophthalmology Lipid panelDTRStatinTdap Urine Microalb/Cr PulsesAspirin Pneumococcus Monofilament Table 1. ADA Recommendations Abbreviations: HbA1c = hemoglobin A1c; Microalb = microalbumin; Cr = creatinine; DTR = deep tendon reflexes; ACE-I = angiotensin converting enzyme inhibitor; ARB = Angiotensin Receptor Blocker; Tdap = tetanus diphtheria pertussis

8. Methods Intervention date ▫03/10/2014 ▫ADA guidelines review and smart phrase introduction conference. ▫Smart phrase pulls patient’s most recent lab results and vaccinations with dates of completion. ▫Then guides providers, through questions, to review patients meds, referrals to Ophthalmology and last diabetic foot exam. ▫Posters placed in clinic reminding of recommendations and encourages use of smart phrase.

9. Methods Post- Intervention period ▫03/10/2013 – 10/10/2014 ▫Prospective analysis of comparison of compliance rates collected from 120 randomly selected patient charts.

10. Results

12. No statistically significant change in rates of compliance in 11 of the 14 variables studied. Modest statistically significant (p=0.05) increase in compliance rate with visual inspection and monofilament portions of the diabetic foot exam. Modest statistically significant (p=0.05) decrease in compliance rate with prescribing statin medications.

13. Discussion Overall, resident education and implementation of an EHR smart phrase did not improve adherence to ADA guidelines in our study. A second chart review showed only 15% compliance with EHR smart phrase.

14. Discussion Limitations: ▫Poor conference attendance ▫Deficiency in use of the smart phrase ▫Limited post-intervention time ▫Adding a research group member and change of some study participants due to graduation and promotion ▫Change in statin therapy recommendations ▫EHR ordering limitations ▫Randomized chart selection

15. Discussion Further research is needed to identify factors interfering with the use of our smart phrase and poor adherence to ADA recommendations. Recommendations: ▫Frequent reminders via conferences, email and fliers ▫Alternative strategies including patient education and involving attending physicians and supportive staff.

16. Acknowledgements Alicia Milan-Flanigan, MD Stephanie Place, MD David M. Berdy, MD Lisa Stevak, Med Resident Physicians, Nurses and Staff

17. THANK YOU!!! Questions?

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