Oracle Health powers data-driven interventions for high-risk diabetes patients

In the US today, there are approximately 37.3 million Americans living with diabetes; another 96 million are living with prediabetic diagnoses^[1]. These statistics call for urgent action from all medical providers to target and treat this potentially life-threatening disease. Having the right tools, technology, and data is critical to managing and monitoring risk factors and empowers patients to have greater control over their condition.

In September of 2021, Margaret Mary Health located in Batesville, Indiana, embarked on a mission to target quality improvement initiatives for diabetic populations, and specifically, those at higher risk. The organization set out to decrease the percentage of diabetes patients, cared for by our primary care provider team, with A1C poor control (> 9%) from a baseline of 36%^[2] to 27.5% by December 31, 2022.

To define the scope of the problem and to evaluate response to interventions, Margaret Mary strategized using Oracle Health technology including registries and scorecards, population health analytics, and its enterprise data warehouse. A quality improvement team was pulled together and led by Primary Care Provider and Director of Informatics Dr. Michelle Shorten. The improvement team used optimized data from these solutions to advance provider education, define existing problems, map processes, identify goals, and launch targeted interventions.

“Providers were able to use data to see how many diabetes patients they had in their care, how many had not been seen by their provider, and how many were poorly controlled with A1C levels greater than 9%,” says Director of Quality and Process Improvement Laurie Mustin. “Data also showed how individual provider performance compared to the rest of their peers.”

To reach target care goals, patients were regularly monitored under treatment plans tailored to their specific needs and condition acuity. For patients with A1C levels greater than 9% or no test completed, proactive outreach efforts were initiated for interventional appointments, testing, and treatment. The 12-month baseline data prior to the start of the project involved 1,918 type 2 diabetes patients seen across Margaret Mary providers. Of those patients, 697 presented with A1Cs over 9% or did not have A1C testing completed during the measurement period. For patients working toward treatment goals and those with stable glycemic control, testing was recommended at minimum twice annually. For those patients not meeting glycemic goals, or undergoing therapy changes, testing was recommended on a quarterly basis.

By December 31, 2022, there were 2,386 type 2 diabetes patients seen across Margaret Mary Health Primary Care Providers. Of those patients, 571 presented with an A1C over 9% or did not have A1C testing completed during the measurement period, which represented 23.9% diabetic patients at Margaret Mary Health.  This not only met the established goal for 2022 of having less than 27.5% of our diabetes patients in poor control, but surpassed it.

The team also considered external factors that could indicate when a patient was in poor control – like incomplete records, testing elsewhere, or limited accessibility. To remedy these issues. Margaret Mary reinforced staff education related to capturing external records into Oracle Health, hosted community-based diabetes clinics, and expanded point-of-care testing in primary care practices.

“We targeted several of our communities and other outlying locations. We held one day clinics for people that just focused on diabetes testing and education by clinical educators and nurses” says Mustin.

Point of care testing also helped eliminate significant gaps in care and remedy missed lab work. Instead of going to a second location for blood work before, after, or in between visits, providers at Margaret Mary Health have the option to complete testing within the practice, during the visit. After initial success, point of care testing was expanded to all primary care locations under the organization’s umbrella.

“Doing the point of care testing in offices has been helpful. If you’re seeing a patient who has a history of poor control, but they didn't get their labs, you can test them right then and there. That can help drive your plan of care for the patient on the day of the visit and prevent delays,” says Mustin.

In 2023, Margaret Mary Health seeks to achieve no more than 25% of primary care patients with an A1C over 9%. As of August 2023, 588 of our primary care patients have an A1C over 9%, out of 2,401 type 2 diabetes patients seen across Margaret Mary Health Primary Care Providers, which represents 24.5% of our patients. Part of our ongoing efforts will include close monitoring of the data and working the list of patients who have A1C poor control or who have not had A1C testing during the measurement period.

“This is an indication of positive impact on quality of care associated with very high-risk patients,” says Mustin. “It also ties into our overall population health efforts to ensure that we are providing the best care for all of our patients.”

^[1] Centers for Disease Control and Prevention. National Diabetes Statistics Report website. https://www.cdc.gov/diabetes/data/statistics-report/index.html. Accessed 10.23.23

^[2] Percentage of patients with A1C over 9% in September 2021 at the time of kickoff.