Overview

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

Organization Name

Tufts Medical Center Adult Primary Care

Organization Type
  • Academic Hospital
  • Academic Medical Center
  • Community outpatient clinic
  • Integrated healthcare system/network
National/Policy 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.

Patient Population Served and Payor Information

  • 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.

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.

Funding

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

Tools or Products Developed

  • 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.

Training

  • 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.

Tech Involved
  • EMR-based registry
Team Members Involved
  • MAs
  • NPs
  • Physicians
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.

Budget
  • $100K to $500K
Where We Are

The intervention is currently ongoing

Outcomes

  • 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.

Metrics

Key Quality Metrics: 

2018 MIPS Quality Payment Program (QPP) Measures:  Providers participating in the QPP are required to report their performance on at least six metrics chosen from a list provided by CMS. Providers may be able to improve their performance on a number of these metrics by improving care for high risk diabetic patients. Sample metrics include:

  •  Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
    • Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.  This is a high priority measure.
  • Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
    •  Percentage of patients – all considered at high risk of cardiovascular events – who were prescribed or were on statin therapy during the measurement period.  One high-risk subgroup includes adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL

More details can be found here.

Medicare Shared Savings Program (MSSP) ACOs: Clinics associated with an MSSP ACO are required to report their performance on measures for Hemoglobin A1c (AbA1c) Poor Control (>9%).  More information about this measure and requirements can be found here.

HEDIS Diabetes-Related Measures: The HEDIS Comprehensive Diabetes measure for 2018 includes components for:

  • A1c testing
  • A1c control or lack of control
  • Eye exam
  • Attention for nephropathy
  • LDL screening and LDL control

More information available here.

Medicaid ACOs: As of 2017, a number of states operating Medicaid ACO or ACO-like programs included measures related to diabetes care in order to assess quality.  Most commonly, these measures assess the percentage of patients with an A1c that is controlled/uncontrolled.  Most states require participating organizations to submit diabetes quality measure performance; in some cases, submission is voluntary.  More information can be found here.

Commercial Insurance: A number of large commercial insurers use provider performance on at least one diabetes metric (typically the HEDIS composite diabetes metric) to either award bonus payments or determine a provider’s quality tier. Examples of such programs include those sponsored by United Healthcare, Humana, and Aetna.  For information on programs offered by other insurers, providers should visit each insurer’s provider portal.

Direct Billing

Beyond services provided by physicians or nurse practitioners, practices may be able to bill for additional services provided.  Practices may be able to bill for dietician services delivered to Medicare patients with Diabetes if those services meet criteria for Medical Nutrition Therapy (MNT).  More information about billing for MNT can be found here.  Practice-embedded pharmacists may also be able to bill certain commercial insurers for their services, depending on the practitioner’s state and the specific insurer.  More information can be found here.

Innovators
  • Kristin Huang MD
Editors
Location

Boston, MA

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