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Active Management Allows Practice to Improve Diabetes Outcomes

Deborah J. Neveleff

November 2012
Diabetes Strategy

All providers find it challenging to help diabetes patients maintain blood glucose control. But at Southeast Texas Medical Associates (SETMA), providers have designed a coordinated, multifaceted set of initiatives that have prompted a steady 10-year decline in their patients’ mean hemoglobin A1c (HbA1c). In 2001, mean HbA1c was 7.48; by 2011, it had fallen to 6.54.

SETMA has 36 providers including primary care physicians, specialists, nurse practitioners, and diabetes educators. “We have focused heavily on adopting strategies to improve our diabetes care,” says James (Larry) Holly, MD, SETMA’s CEO, adding that the practice currently treats more than 8,000 patients with diabetes. “Today, we are a Joslin Diabetes Center Affiliate, and all of our providers have earned National Committee for Quality Assurance (NCQA) recognition for excellence in diabetes care.”

Components of SETMA’s care model include using an electronic medical record (EMR) to track quality metrics and fill gaps in care; auditing care by population group; providing diabetes self-management education; ensuring that messaging stimulates patient empowerment; performing statistical analyses to identify areas for improvement; publicly reporting data by provider; and setting up a foundation to support the care of financially vulnerable patients.

Investing in Technology
The practice adopted an EMR in 1995. “We realized that the value of the EMR would not come from simply documenting patient encounters electronically, but rather would depend upon exploiting data integration and computation capacity to improve care and outcomes,” Holly says.

In 1998, the practice designed a diabetes disease management tool, which is accessed through the EMR. The tool includes a suite of templates that guide providers in providing optimal diabetes care. The first template summarizes critical information such as the patient’s vital signs, laboratory values, smoking status, and compliance with various care ....


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