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Diabetes Testing Automation @ Tufts

Keywords: Diabetes, Automation


Automating appropriate point-of-care (POC) hemoglobin A1c testing at primary care visits for patients with diabetes


Julie Tishler MD

Kristin Huang MD



Selena Zhang


Tufts Medical Center Adult Primary Care, Boston, MA

Organizational Context

  • The Tufts Medical Center Adult Primary Care Service consists of 40 Physicians (~28 FTE), 6 NPs (~4.5 clinical FTE), 2 PAs, 3 social workers, 72 residents, 8 FTE RNs, and 60 support staff
    • Sees 38,000 patients in 6,500 office visits a month. Receives 14,000 incoming phone calls a month
  •  In the course of a year, all patients with diabetes need to undergo A1c testing every six months.  If the A1c level for a patient is over 7.5%, the patient needs to be tested every three months. About half of the patients at Tufts Medical Center fall in this latter category.  
  • Prior to this intervention, A1c testing was performed only when clinicians requested it during a visit, which caused a 7 minute delay while the test was running. 

Population Served

  • Tufts serves a diverse patient population, with ~10% of its population African American, 10% Asian, and 9% Hispanic. 25% of its patients are on Medicaid, and 32% are on Medicare
  • Tufts Medical Center Adult Primary Care has around 12,500 patients with diabetes. 

Project Leadership

  • Three MDs were central to setting up the program. 
  • Two physician assistants help to manage the program, and three social workers assist with behavioral health management. 
  • Tufts Primary Care’s IT specialist set up the EMR components supporting the program.


  •  A $2000 grant was awarded for development of EMR-derived algorithm & for training time necessary for medical assistants (MAs).

Project Tools and Components

  • The leadership team first designed the alert system within the EMR to appear in charts of patients needing A1c testing at the start of a visit.
  • The leadership team also designed a monitoring system within the EMR to measure how often the appropriate A1c tests were being conducted.


  • MAs were then trained in the operation and workflow of using the HbA1c POC testing machines by members of the intervention leadership team during their weekly staff meetings.
  • The NP who supervised the MAs at the practice identified MAs who continued to struggle with the new workflows and re-trained them individually as needed.
  • The new alert system and MA workflow protocols were then communicated to all clinicians in the practice.


  • EMR-based registry

Team Members

  • Physicians
  • NPs
  • MAs

Daily Workflow Steps

  •  In the context of a visit, an alert bar appears in the patient's EMR chart when a hemoglobin A1C test should be performed. 
  • The MA performs the test using a POC machine and prints out the results so that the primary care clinicians can then review the test results with the patient directly during the patient's visit. 



  • $150,000 for a part-time project manager (who had already been employed by the health system) for one year to manage:
    • Administration of a provider cohort study in collaboration with the Providence Medical Group’s research group to observe any change in patient costs and healthcare utilization (PCP visits, ER visits) for patients of providers who had adopted MAT practice
    • Project management of video distribution, scheduling clinic meetings, scheduling monthly conference calls, sending out monthly newsletters
  • $5000 for the production of the 12-minute educational video


The intervention is currently ongoing


  • The testing rate of appropriate A1c testing for patients with diabetes increased from approximately 30% to 76%.
  • Primary care clinicians received A1c testing measurements from their patients with diabetes at appropriate intervals in a timely manner, which helped inform their care.

Future Outcomes

  • The practice continues to collect data to investigate whether this intervention has contributed to improvement in patients’ A1c measurement values over time. 

Personnel Challenges

  • The program created additional work for MAs. Thus, some clinicians viewed the program as delaying clinic flow.
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