Libby Owen-Jones (Austin Health) - HiNZ 2015 Conference, Christchurch

1. Diabetes Discovery Project
Using technology to support the implementation of
standardised clinical care
Libby Owen-Jones
Project Director

2. Overview
 Austin Health EMR Strategy & implementation
 Diabetes Discovery Project
 Change management and Clinical Adoption
 Outcomes

3.  Major Tertiary Health Provider in Northeast
Melbourne
 3 Campuses
- The Austin Hospital
- Heidelberg Repatriation Hospital
- Royal Talbot Rehabilitation Centre
 Major Services
- Liver and Gastro-Intestinal Transplantation
- Spinal Cord Injuries
- Oncology
- Victorian Respiratory Services
- Olivia Newton John Cancer Centre

4.  93,000 Inpatient Admissions
 900 Beds
 73,000 Emergency Attendances
 57,000 Placement
Days for Entry Level
to Practice Students
in 17 disciplines
 176,000 Outpatients
 176,000 Outpatients
(360 clinics)
 8,000 staff
 >26,000 Surgical Operations
 Large Nursing
and Medical Post Graduate
Education Program

5. Austin Health IT and EMR Strategy

6. Austin Health – Strategic Priorities
 Build Capacity in Systems Redesign to Improve Quality, Value and
Efficiency
 Provide Contemporary Clinical and Business Information Systems
that Support Excellence in Decision Making, Patient Care and
Accountability
 Continually Enhance Information Technology and Communication
Systems

7. From paper ……to mobile computing

8. EMR Journey
2011
Rad/Lab orders
ePrescribing
Disch Summary
Results
2012
E-Meds
Management
Fluid balance chart
E-Referrals
2013
E-Meds
Management
Diabetes Discovery
2014
ED - FirstNet
Physician
Handover
2015 -2016
Vital Signs & Obs
Theatres -Surginet
Oncology system
BI/Data
warehousing
Nursing
documentation
Progress notes

9. EMR Adoption Model
 EMR Adoption Model
Structure Ensures
Objectivity
 2012 Self Assessment
for Austin Health =
Stage 2
 2014 Self Assessment
for Austin Health =
Stage 5

10. Transformational Change
More than 70% of all major transformation efforts fail.
Why? Because organisations do not take a consistent,
holistic approach to changing themselves, nor do they
engage their workforce effectively.
Kotter 1995

11. Prevalence of Diabetes
Prevalence of diabetes in Australia is estimated at 7%
(AusDiab)1
23% for people older than 75 years2
40% of diabetes undiagnosed3
1 Diabetes Care 2002; 25: 829-834
2 Dunstan DW, Zimmet PZ, Welborn TA, et al. Diabetes Care 2002; 25: 829-834
3 Diabetes Care 32:287–294, 2009
.

12. Background – Inpatient hyperglycaemia
0
2
4
6
8
10
12
Known diabetes New hyperglycaemia
(FPG >7mmol/L)
Uncertain glycaemic
status (FPG, 5.6–
6.9mmol/L)
Normoglycaemia (FPG, <
5.6mmol/L)
Mortality(%)
p=0.04

13. Diabetes in the Surgical Units
• Comparison of Length of Stay data for Surgical
patients from 2009 to 2013:
– Ave LOS is 6.91 days
– Patients with a coded diagnosis of Diabetes 10.61
days
– Diabetes patients stay 53% longer
• Comparison of Readmission rates
– Diabetes patients have higher readmission rate –
but may be due to other reasons

14.  Goal: patient
safety &
consistent
practice
 Clinical System
supports Clinical
practice
 Clinician Led
 Use evidence based
protocols
BUT
Who needs the
intervention?
Diabetes Management Project

15. Diabetes Discovery Project
• Aim
– To investigate the prevalence of diabetes (diagnosed and
undiagnosed) at Austin Health via routine HbA1c testing in
inpatients using the CERNER Millennium Health IT System
– To identify inpatients with poor glycaemic control (HbA1c≥
8.5%, 69 mmol/mol)
• Hypothesis
– Information technology tools such as CERNER Millennium
aid the identification of patients with undiagnosed and
patients with poor glycaemic control

16. Diabetes management Technical build
• Early & broad identification via Hb A1c Auto ordering
• Notification of poorly controlled and New diabetes
patients via:
Medical History via Problems/Alerts & Message Centre
• Reports for division of duty of care by Hba1c ranges
• Standardised evidence based ordering –BMJ action sets
• Powerplans & BMJ subscription (initially)
• Diabetes Educator Referrals
• Communication to GP community via Discharge Summary

17. Automated ordering of HbA1c
Austin Health Admissions (July 2013 to Jan 2014)
Inclusion criteria:
≥ 54 years
Acute admissions
Austin campus
Exclusion criteria:
Day cases
Palliative care
Psychiatry

18. Automated Ordering of HbA1c
Austin Health Admissions (July 2013 to Jan 2014)
Inclusion criteria:
≥ 54 years
Acute admissions
Austin campus
Exclusion criteria:
Day cases
Palliative care
Psychiatry
Automated CERNER order for HbA1c% generated if no result within 3 months

19. Change Management
 Workflow for Medical staff
 Who sees which patients?
 How do they know who they need to see ?
Alerts and Notifications
 Tools to support Medical staff workflow
 HbA1c Results Extract Report
 Improve communication with GPs via discharge summary documentation
 Clinical Guideline translated to a PowerPlan
 Nursing Workflows
 Patient Access List : Referrals , Meds to be administered, Path to be collected
 Diabetes education team – e-referral workflows
 Task List
 Reports
 Documenting outcomes

20. Adding an Alert and notification –
automated process

21. HbA1c Results Extract

22. Clinical Guideline

23. Clinical Guideline – e referrals

24. Communication with GPs

25. Outcomes
N = 5083 patients, 6716 admissions (June 2013 to Jan 2014)
History of diabetes
HbA1c <6.5% HbA1c ≥ 6.5%
Known Diabetes
N= 1453
No history of diabetes
HbA1c <6.5%
No Diabetes
N=3359
HbA1c ≥ 6.5%
New Diabetes
N=271

26. Outcomes
63%
70%
31%
25%
6%
4%
0 1000 2000 3000 4000
Medical
Surgical
Number of patients
No Diabetes Known Diabetes New Diabetes

27. Outcomes
0
2
4
6
8
10
Medical Surgical
Days
HbA1c <6.5 HbA1c ≥ 6.5%
p=0.35
p=0.03

28. Conclusions
34% of all inpatients > 54 years have diabetes
• 5% of inpatients have undiagnosed diabetes
• 29% known diabetes
Higher HbA1c is associated with
• increased admission rates
• Longer length of stay in surgical patients
Routine inpatient HbA1c testing using CERNER addresses a currently
missed opportunity to identify patients with newly diagnosed
diabetes and poor glycaemic control.
.

29. Evolving Changes to practice
 Inclusion of Mental Health patients – with different auto
ordering criteria
 Refinement of parameters – who sees which patients
 General medicine Outpatient Clinic- follow-up of poorly
controlled patients post discharge
 Ongoing education in diabetes management to junior medical
staff
 Research in ICU – using HbA1c results – changes to protocols
 The impact of early identification and treatment of poor
glycaemic control on patient outcomes requires further study

30. Acknowledgements
Cerner Corporation
University of Melbourne – Endocrinology Unit at Austin Health
Austin Health - Clinical Systems Projects Unit & Business
Intelligence Unit
Health Shared Services
BMJ – Action Sets