Home Forums Discussions General Discussion Diabetes tracking

Has anyone found a useful way to look at, within the note, the last few A1c's? We use Quest (no interface yet, but I don't think that will be the answer anyway) and do some POS A1c's. When I'm looking at pt's weight (trend) BP (trend) etc, I'd really like to look at A1c too.
Also, in terms of providing data for P4P
Also, in terms of searching patients w/ DM who have not had an A1c (either Quest or POS) after a certain amount of time?
Thanks

See:

http://tinyurl.com/4tz9v9

Okay, this is something we have been talking a lot about.

Obviously, Jon is wanting to set up a Registry function for AC. That is one of the things we will be talking about in Branson.

There are also "third party" registries, and we talked about them in some detail in this thread:

http://amazingcharts.com/ub/ubbthre...ems&topic=0&Search=true#Post7164

One of them, CDEMS, is a "diabetes" registry.

Another thing you can do is set up a diabetes template, like:

Just create a template along those lines, and use it for all followups.

If you always use this form, you can do a "free text" search and find all your patients with this information, and look up their data. The "DMQ1" signifier just provides a unique search term for the free text search, as opposed to "HgbA1c" which you might use conversationally in the text of a note.

Here is a workaround which I have used at my office and it might work for you. I did fingerstick HgbA1c in my office, and I had my nurse send me an interoffice email with the result, which I saved to the chart. The title of the note was the A1c result, as in: "Fingerstick HgbA1c = 6.8"

The net effect is that when you look at their past encounters tab, the A1c is displayed as the title of the note, so you can see the old values at a glance.

Thank you, I see how that could help. but then I still feel as though I need to reference the data I'm evaluating in my note.
Do you think that the Vital Signs section might inforporate additional measures, like an A1c done during the encounter?
Anyway, re: registries We've been using PECS and are dropping it and hope to begin using i2i TRACKS. I can't quite imagine how the info (A1c, UMA, foot exam, etc etc) would be inforporated into an AC progress note, but... avoiding duplicate entry would sure be nice!

Quann, if you will post *EXACTLY* how you want it to work, it will fuel discussion at our meeting in Branson in a few weeks. Your posts and questions are very helpful in that regard.

Quann,

I don't use this often, but I am playing with it to try and help. I see what you are saying. The only thing I could come up with since AC doesn't allow you to embed hyperlinks, etc. would be to add in your data, then reference it in the note, i.e. Steve Smith's HbA1C was up today. See Excel flowsheet A6 Sheet 1. After awhile you could just abbreviate that to. Labs: A6S1, etc.
I will get my Excel guru on it. There are nice hyperlinks in Excel, they just don't see to work in AC.

If all you want to do is see the changes in any given value like A1c's that are certainly important to most docs for sure, you need to do a little work in the Admin section. I don't rememember if there is a limit on the number of tracked items but Nancy is up to like 15 and counting and we have lots of DM patients and she uses this feature all the time. So set of stuff like triglicirides, A1c's and other things you like to track in the tracked items or data section of Admin and then you can enter and track them. The values will be in the second most left tab in the chart in the summary section down at the lower left hand corner of that page.

Then after you entered some values over time and so you now have some to compare, hit edit or print button on the left and up come the numbers you have tracked for that patient and the dates they were entered. Although not graphable I believe it certainly give you the ability to enter, record and see their changes over time on any given value of any given patient... Not perfect but certainly gives you most of what you need on a patient per patient basis.

Nancy enters certain values from the labs we don't interface from as well as some things we do in house too. Must say we really like our interface and now seems like Bert's FAP is going to help with quick and easy access to our lab results as well as other reports and the like. It seems to track the major things she needs and she likes it. Hope this helps.

Well, I noticed in the newest version of AC that the recent Vital signs are displayed (& that's really helpful when you want to know how the patient's weight or BP compares over the last few visits) so I would like 1 or 2 customizable spaces in that vital signs section to track: A1c or INR or PSA or Hgb.
BUT: I don't know if this would then be available for graphing or reporting (a la P4P). I'm also not sure how this works with the lab interface.

We keep trying to reinvent the wheel. There are also certain aspects of AC, that Jon just doesn't seem to want to change. The VS area is one thing.

If you use Excel as we have talked about, the graphs one can make are incredible. I was playing around with it today, and I made a small table for HbA1Cs. Put in a patient and about ten values over a few months and inserted a graph. It was beautiful.

In FAP???

No, in Excel. When I say over a few months, I mean I put values in the Excel table which represented a few months. Many users wish to find a way to organize data and, until AC allows this, the best bet is importing an Excel file made the way one wants it. Even if AC does become capable of hosting lots of data, I doubt it will have the capabilities of Excel.

I was just being a wise@$$... Now when you say import one question, if one imports an item into AC it is not "frozen" right. So something like an Excel file, can be pulled out, data entered, and then have it put back where it came from and have it's changes now recorded and saved in it's new updated form? Right?

And just as a BTW, it seems that the pdf's that I am saving to FAP are still able to be worked with. Couldn't one take one out and put it back, or is FAP more stagnant, which makes it both a good solid record of the documents saved, but not so good at recording, updating, over and over again... Do I have this correct?

Here's a screenshot of an Excel diabetes flow sheet:



From this website, which has a ton of them. I'm still checking them all out.

http://www.familydocs.org/new-direc...s/flow-sheets-forms-signs-and-charts.php

Wow, that is so pretty man. Care to share???

I just got to thinking today that somebody had probably posted Excel medical flow sheets before -- behold the power of Google -- I found the site above.

I have not checked out all their files; downloading one of theirs would probably be easier than trying to post one here.

This is a little off-topic but as long as diabetic flow sheets are being discussed I began thinking what things I would wish to see tracked there. I guess I will have to open myself up to criticism and perhaps disclose my idiocy but, of what real use is monofilament testing in diabetes? Does it in anyway change the way one should manage a diabetic? If it is normal and the patient is asymptomatic does that mean I do not have to discuss potential foot issues with them and continue to urge them to control their sugars? Can I then ignore an elevated HgBA1C and not work as hard to normalize it? Can I stop checking their feet routinely? Would it give them a false sense of good health and assist them with the possible denial of the seriousness of their disease? If it is abnormal I suspect it might give me more ammunition to use to urge the patient to control their sugars but would I not do this anyway? What would I do for a patient whose test is positive that I would not do for one whose test is negative? I am very much open to being enlightened on this subject. I just have a need to know what I should be doing differently based on the results of this test. If I am already doing what I should, why do I need to do it? And why do I need to show 3rd party payors that I have done it?

Leslie

Leslie,
I understand where you are coming from. I still tell my diabetics the same info about foot care whether or not they have neuropathy. Odds are they will get it eventually to some degree, kind of the nature of the beast. To me, it seems more like one of those reminders for conversation. However, if I know they have it, I am more likely to really push the self care. While sharing call this weekend I got to see one very dead looking toe on a diabetic who has not been doing his foot care properly and he apparently will lose that toe and possibly more of his foot. But back to your point....it's like my old medicine attending said in school, think about what you will do with the possible answers from a given test and if it won't change your management, then why do the test in the first place.

My sentiments exactly, David.

Leslie

Would someone be willing to post or email me (drjim@drspattyandjim.com) an example of an Excel speadsheet they use for tracking of this sort of thing? I remember reading this thread several months ago about how handy this tool is. I've used Excel before but not sure I'm handy enough with it to design my own spreadsheet capable of doing this.

My recollection is that the blank spreadsheet is saved to each patient's chart and then data is filled in as it comes in, correct? Can Excel then look at entire practice data (like, "what's my practice's average hemoglobin Aic?" or "list the names of all patients currently on coumadin") by extracting data from multiple individual spreadsheets, as well as looking at trends for any individual?

Thanks,

Jim (who's going live with AC in about a month and will likely be posting here a lot as I stumble through)

Jim:

You can download some samples from the site I linked to above.

You could not look up entire practice data, unless you could somehow link all your patients to the same Excel spreadsheet (or can you?).

Leslie- While it may not impact your care for a particular patient, testing for and documenting LOPS (loss of protective sensation) may have implications for coding and Medicare reimbursement. In my paid job with Kaiser, documenting this will increase the complexity of the diabetes diagnosis and may increase reimbursement from Medicare.

Exactly, it's more about feeding the system than it is about the care of the patient and pehaps documenting for protection of oneself as well. Now I guess tracking the loss itself does have some amount of clinic relevance to you guys though.

I get paid the same for, say a 99214 encounter, with a dx of 250.00 as I do with a code of 250.60. I must either be doing something wrong or the ICD-9 code serves purely as an identifier for clinicians and epidemiologists (which I believe is why the coding system was devised in the first place.) I can document the complexity of my visit without ever mentioning whether I did the microfilament testing. If I am way out in left field, someone please educate me!!

Leslie

Leslie, I think you are right about the original intent of the ICD code systems....more for epidemiological purposes. Like you, I don't get paid more for a visit if the dx code is more complex. The procedure code is all that matters in the payment arena in private practice. I believe some employed positions are arranged to reimburse based on patient complexity though, but that depends on the employer.

Leslie- I don't think you're out in left field; I think this is important in a capitated system like Kaiser, where Medicare bases the next year's reimbursement based on diagnosis complexity.

I double checked with our billing company and she stated the ICD9s are used to support higher level codes. She asked us to document 4 whenever possible to support these codes.

Be careful Eric. The number of codes has little to do with the proper coding for an office visit. You could have all the codes in the world on there and still not qualify for a higher code if you don't have the supporting documentation. The little coding helper on AC actually does a pretty good job of summarizing what you need in your note for the various office level visits. I am becoming wary of advice from billing companies, as they don't always seem to know as much as they should and most have an incentive to bill more charges (even when there isn't real documentation to back it up)because they are paid by how much money comes back. But you will be the one paying back money with interest(and penalties and jail time if applicable) if an audit of your charts finds you have been "overbilling" the carrier. Not sure what this has to do with diabetes tracking, but didn't want you guys to get screwed by poor/incomplete advice.