Why?

Better care for patients with diabetes

Standardized HbA1C targets do not take into account the complexity and diversity of our patient populations. Even targets that vary by age may not be sufficiently flexible; for example, a frail elderly person should have a higher target than a relatively robust person, even if their age is the same. Developing individualized targets that treat patients as individuals with unique circumstances and needs allows us to ensure that we are delivering the right care to each patient.

Better measurement of diabetes care

Simply put, using individualized targets allows us to count how many patients are getting the right care for diabetes, not just how many are meeting an arbitrary standard. One doctor noticed that in her own practice, only 65% of her patients met the standardized target of 0.07% HbA1C. However, when the metric was applied to individualized targets, 71% of her patients were at target. Indicators based on standardized targets fail to reflect the patients who are receiving the right care, when the right care means meeting an HbA1C level that is higher than the standardized target.

How?

Several teams have been working on tools to enable the recording and tracking of individualized HbA1C in their EMRs. Some of these are available for use now, and others are still in testing.

• Denis Tsang, RD at CareFirst FHT, has developed an Encounter Assistant with two checkboxes for HbA1C targets: A1C <0.07 or A1C 0.071-0.085. Clinicians can check off either box after discussion with the physician responsible for determining the patient’s target. The individualized target is then appended to the patient’s cumulative patient profile and visible to all care providers. It is available for download from the Telus Community Portal.
• Kevin Samson, Physician IT Lead, and Hope Latam, former QIDS Specialist, East Wellington FHT, developed a diabetes-management dashboard which works directly within Telus PS EMR. It provides a summary of each patient’s diabetes management and functions as a “report card” that the doctor can share with the patient. It provides at-a-glance data for the patient’s most recent HbA1C and other diabetes care indicators (creatinine, cholesterol). When an indicator is not within the target range, it shows up in red. By default, the dashboard uses standard targets (e.g.,  07% for HbA1C), but a clinician can easily override this with an individualized value that reflects the right care for that patient. Once this is done, the form will compare the most recent HbA1C value against the individualized target to determine whether the patient is in or out of target. It is currently in testing at two FHTs and will be shared with other users of Telus Practice Solutions once complete.

Consider raising this as an issue at your EMR Community of Practice, and pressure your vendor to develop a solution. Meanwhile, clinicians can use the “notes” field to start recording individualized HbA1C targets in each patient’s chart. See if your team can agree on a consistent format for this, so any team member can recognize it easily.