Diabetes Measures in EHRs Linked to
Improved Care
Omar A. Contreras, MPH
Diabetes Prevention and Control Program
Arizona Department of Health Services
June 27, 2014
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What does
medicine do?
Saves lives one at a time
What does
public health do?
Saves lives millions at a time
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Essential Services of Public Health





Monitor health status
Diagnose and investigate
Inform, educate, and empower
Mobilize community
partnerships
Develop policies and plans





Enforce laws and regulations
Link people to needed
services/assure care
Assure a competent
workforce
Evaluate health services
Research
Source of Ten Essential Public
Health Services: Core Public
Health Functions Steering
Committee, 1994
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Framework for Improving
the Performance of Public Health
Health
Department
+
PH System
+
Community
Partners
+
Workforce
Builds
Operational
Capacity
Every
Community
Program and
Public Health
Activity
Impacts
(Infrastructure)
(Chronic Disease,
Inf. Disease, EH)
Investments here
Better Health
Which
Outcomes
leads
Reduced
to
Disparities
Better
Preparedness
Pay big dividends here
Source: D. Lenaway. Centers for Disease Control and Prevention, Office of Chief of Public Health Practice. 2009
(unpublished)
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Governmental Public Health
State and Local Health Departments
Retain the primary responsibility for health under the US Constitution
State and the
District of
Columbia
Health
Departments
Tribal Health
Departments
Local Health
Departments
Territorial
Health
Departments
* Number based on 2010 National Profile of Local Health Departments (NACCHO, 2011)
** Numbers cited from ASTHO, Profile of State Public Health, Volume Two, 2011
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State and the
District of
Columbia
Health
Departments
Territorial
Health
Departments
Federally
Qualified
Health Centers
Tribal Health
Departments
Local Health
Departments
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Outline
• Arizona Department of Health Services/Arizona
Diabetes Program
– Diabetes in Arizona
– Epidemiology and Surveillance
– Trends and Cost Analyses
•
•
•
•
The Arizona Diabetes Coalition
Diabetes measures and systems change
Public Health in Action Grant
EHR and non-physician team base approach to
diabetes care
• Summary
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Arizona Department of Health Services
Hierarchy
Arizona Department of Health
Services
Agency
Director
Division of Public Health
Prevention Services
Assistant
Director
Bureau of Tobacco and Chronic
Diseases
Bureau
Chief
Office of Chronic Disease
Programs
Diabetes
Heart Disease
and Stroke
Healthy
Aging
CPR
Arizona Diabetes
Coalition and Leadership
Council
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CHW
Arizona Diabetes Program
What we do and what we provide?
• Ongoing technical assistance to internal and
external partners
• Information and guidance on funding resources
• Develop diabetes specific strategies and public
health interventions at a systematic, policy, and
environmental levels
• Supports and oversees the activities Arizona
Diabetes Coalition and Leadership Council
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Diabetes in Arizona
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Leading causes of death in the
United States for 2011
Leading Death
Source: National Center for
Health Statistics,
www.cdc.gov/nchs.
Death rate per 100,000
1. Heart disease
191.4
2. Cancers
184.6
3. Chronic lung diseases
46.0
4. Strokes
41.4
5. Accidents
39.4
6. Alzheimer’s disease
27.2
7. Diabetes mellitus
23.5
8. Pneumonia and influenza
17.2
9. Kidney diseases
14.7
10. Suicides
12.3
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Diabetes in Arizona
• 1/9 Arizonans have diabetes
• 1/3 of those who have diabetes in Arizona are
unaware that they have it
• Diabetes is the leading cause of new cases of
blindness and kidney failure
• Known risk factors
– Obesity
– Physical inactivity or increase in sedentary lifestyle
– Built environment
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How do rate by county?
County*
Apache
Cochise
Coconino
Gila
Graham
Greenlee
La Paz
Maricopa
Mohave
Navajo
Pima
Pinal
Santa Cruz
Yavapai
Yuma
Diabetes
8.0%
15.7%
13.3%
15.6%
17.0%
15.9%
16.0%
10.0%
14.6%
12.1%
12.2%
14.4%
10.3%
10.6%
11.8%
Arizona
10.6%
10.6%
10.6%
10.6%
10.6%
10.6%
10.6%
10.6%
10.6%
10.6%
10.6%
10.6%
10.6%
10.6%
10.6%
Hypertension**
17.5%
44.4%
17.2%
28.8%
27.5%
27.0%
34.8%
26.5%
38.2%
34.8%
25.6%
35.7%
34.5%
38.5%
40.8%
Arizona
28.1%
28.1%
28.1%
28.1%
28.1%
28.1%
28.1%
28.1%
28.1%
28.1%
28.1%
28.1%
28.1%
28.1%
28.1%
Obesity
25.1%
27.4%
22.3%
25.1%
34.5%
34.3%
32.0%
26.0%
29.4%
31.1%
23.5%
25.7%
33.7%
33.8%
28.6%
*Source: Arizona Behavioral Risk Factor Surveillance System, (AZ-BRFSS, 2013)
** 2011 Numbers shown as 2012 data not available
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Arizona
26.0%
26.0%
26.0%
26.0%
26.0%
26.0%
26.0%
26.0%
26.0%
26.0%
26.0%
26.0%
26.0%
26.0%
26.0%
Arizona Adults with Diabetes by
Race/Ethnicity, 2012
16.0%
14.7%
14.0%
12.5%
Prevalence (%)
12.0%
10.6%
10.0%
9.9%
9.4%
Other
White
8.0%
6.0%
4.0%
2.0%
Source: AZ Health
Matters (2012),
AZ BRFSS
0.0%
Black
Hispanic
Overall
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Arizona Age-adjusted Death Rate due
to Diabetes, by Gender (2012)
35
29.2
Rate per 100,000 population
30
25
20
23.5
18.6
15
10
5
0
Female
Male
Overall
Source: AZ Health
Matters (2012),
AZ BRFSS
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Arizona Age-adjusted Death Rate due
to Diabetes, by Race/Ethnicity (2012)
90
Rate per 100,000 population
80.2
80
70
60
49.4
50
40.8
40
30
27.6
23.5
18.3
20
10
0
Source: AZ Health
Matters (2012),
AZ BRFSS
American
Asian/Pacific Islander
Indian/Alaska Native
Black/African
American
Hispanic/Latino
White, Non-Hispanic
Overall
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Estimated costs
Estimated Costs of Diabetes, 2007
Estimated Costs of Diabetes, 2012
Total
$174 billion
Total
$245 billion
Direct medical
costs
$116 billion
Direct medical
costs
$176 billion
Indirect medical
costs
$58 billion
Indirect medical
costs
$69 billion
Source: http://www.diabetes.org/advocate/resources/cost-of-diabetes.html, retrieved 11/25/2013
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Estimated costs AZ, cont.
Parameter
Treated
Population
Cost per
Person
All Payers
416,200
$5,420
MEDICAID
81,800
$3,750
$307,000,000
$327,980,000
MEDICARE
168,100
$3,580
$602,000,000
$643,140,000
Private Insurers
236,500
$2,580
$610,000,000
$651,680,000
2011 Arizona Hospital Discharge Data indicated a
total of 7,065 discharges related to diabetes and
chronic conditions.
Total Costs
(2010)
Adjusted to
2013
$2,258,000,000 $2,412,300,000
$167,815,464
Arizona Diabetes Cost Data (2010) – CDC Chronic Disease Cost Calculator
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Arizona Diabetes Coalition
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Vision
A state without diabetes
Mission
To reduce the health, social, and economic
burden of diabetes in Arizona
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How are the Coalition and Council structured?
Arizona Diabetes
Program and
ADHS
Arizona Diabetes
Leadership
Council
Chair: Sandra Leal
Arizona Diabetes
Coalition
Electronic Health
Records
Chair: Sandra Leal
Pre-Diabetes
Advocacy
Tribal
DSMT/E
SALUD
(Supporting
Action for Latinos
Against Diabetes)
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Arizona Diabetes Leadership Council
• Reorganized Fall 2006
• >18-21 member leadership council
– Representation from academia, health plans, government,
private companies, non-profit organizations, etc.
• Meet 6 times a year as a council and quarterly with the
coalition
• Each Coalition workgroup chair is represented in the
Leadership Council.
• Ex-Officio members
• Well established by-laws: www.azdiabetes.gov
• Constant communication between leadership body and ADHS
Diabetes Program
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Diabetes Measures and Systems
Change
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Health Care Flowchart
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Pillars of Health Care Reform
Cost
Access Coverage
Quality
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Quality and access to Care
There are thousands of new doctors and nurses in communities around the country
and millions more patients getting care.
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Improving Quality
• Increase the utilization of EHR in multiple
healthcare systems
• Encourage completion of NQF standard measures
for diabetes and hypertension
• Require reporting and accountability for health
plans
 Coordinate care and medical home models
 Improve patient safety, reduce medical errors,
promote health and wellness
• Capacity development for FQHCs and other
health systems
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National Quality Forum (NQF)
Measures (Diabetes)
Measure
Recommended Measure Title
0055
Eye Exam (no evidence of retinopathy)
0056
Foot Exam
0059
HbA1c Poor Control (HbA1c >9%)
0061
Blood Pressure Management
0062
Urine Screening
0064
LDL Management and Control
0575
HbA1c Control (<8%)
0018
Controlling High Blood Pressure
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Role of EHR systems in FQHCs
• Advocate for your patients
• Referral mechanism for DSME and prevention
programs
• Provision of preventative care for chronic care
patients
• EHRs can help avoid re-admission rates and
improve and adherence to self-management
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Public Health in Actions Grant
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What is the Public Health in Actions
Grant?
• 5 year collaborative grant
• Focuses on policy, system, and environmental
change
• 32 states funded
– Basic and Enhanced components
• Year 1 has been completed
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Implementation of EHR system change
and performance measures
• Proportion of health care systems reporting
on NQF measures 18 and 59
• Proportion of health care systems with EHRs
appropriate for treating patients with high
blood pressure and diabetes
• Increase the institutionalization and
monitoring of aggregated/standardized quality
measures at the provider and systems level
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System level changes and
non-physician team based care in
Federally Qualified Health Centers
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Summary
• Diabetes remains a prevalent disease in Arizona,
specifically in rural areas
• Diabetes NQF measures offers the ability to detect care
when the recommended care was given or when
recommended care was not received.
• Non-physician staff will continue to be on high demand
and integration into a team base approach to diabetes
health should be warranted
• Health systems changes via the utilization of electronic
health records show positive trends in the
improvement of diabetes care
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Looking into the future
• Establish a data sharing agreement between
ADHS and FQHCs and/or the Alliance for
Community Health Centers
• Ability to generate standardize reports on
patients with diabetes and hypertension
• Reducing the gaps and inconsistencies
resulting in lack of data within the EHR
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Our ever changing public health system
Police
FQHCS
Churches
MCDPH
ADHS
EMS
Home Health
Laboratory
Facilities
Parks
Schools
Doctors
Elected Officials
Nursing Homes Mass Transit
Hospitals
Philanthropist
Environmental
Health
Civic Groups
Fire
Tribal Health
Drug
Treatment
Corrections
Mental Health
Employers
Economic
Development
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Urban
Planners
Questions?
Contact Information
Omar A. Contreras, MPH
Diabetes Prevention and Control
Program Manager
Arizona Department of Health Services
omar.contreras@azdhs.gov
(602) 542-2758
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