Digital Repository Doctoral Projects Fall 2021 The Implementation of a Diabetes Education Patient Tracking System in a Rural Utah Hospital Holly Hacking Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Hacking, H. (2021) The Implementation of a Diabetes Education Patient Tracking System in a Rural Utah Hospital. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. The Implementation of a Diabetes Education Patient Tracking System in a Rural Utah Hospital by Holly C. Hacking A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 12, 2021 Jessica Bartlett, DNP, CNM, RN, IBCLC__(signature) Faculty Advisor/Committee Chair (Jessica Bartlett, DNP, CNM, RN, IBCLC) Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Running head: DIABETIC TRACKING SYSTEM 1 Implementation of a Diabetes Education Patient Tracking System in a Rural Utah Hospital Holly C. Hacking Annie Taylor Dee School of Nursing Weber State University November 20, 2021 DIABETIC TRACKING SYSTEM 2 Table of Contents Abstract ............................................................................................................................... 6 Implementation of a Diabetes Education Patient Tracking System in a Rural Utah Hospital ........................................................................................................................................... 7 Problem ............................................................................................................................... 8 Search .................................................................................................................................. 8 Diabetes........................................................................................................................... 9 Diabetes treatment. ..................................................................................................... 9 Diabetes Education ........................................................................................................11 Topics. ........................................................................................................................11 Roles. ........................................................................................................................ 12 Diabetes Documentation ........................................................................................... 13 Importance of documentation and content. ............................................................... 13 Documentation and communication methods. .......................................................... 14 Care Gap Identified ....................................................................................................... 15 Population and Setting .................................................................................................. 15 Theory ........................................................................................................................... 16 Expected Outcomes and Goals ......................................................................................... 17 Project Barriers ............................................................................................................. 18 Project Implementation ..................................................................................................... 19 DIABETIC TRACKING SYSTEM 3 Planning. ................................................................................................................... 19 System analysis and requirements. ........................................................................... 20 Systems design. ......................................................................................................... 20 Development. ............................................................................................................ 21 Integration and testing............................................................................................... 21 Evaluation and Data Analysis ........................................................................................... 22 Discussion and Recommendations ................................................................................... 24 Conclusion ........................................................................................................................ 25 References ......................................................................................................................... 26 Figures............................................................................................................................... 32 Appendix A: Weber State University Institutional Review Board letter .......................... 33 Appendix B: Systems development life cycle (SDLC) ................................................... 34 Appendix C: Pre-implementation survey level of satisfaction of the implementation of a diabetes education patient tracking system ................................................................................... 35 Appendix D: Post-implementation survey level of satisfaction of the implementation of a diabetes education patient tracking system ................................................................................... 36 Appendix G: ARMC Chronicle Diabetes initial steps workflow..................................... 39 DIABETIC TRACKING SYSTEM 4 Acknowledgments There are several people that I would like to express my sincere gratitude to for assisting me through this Doctor of Nursing Practice Project. First, I would like to thank my mentor, Dr. Jessica Bartlett, for her guidance and encouragement through each of my DNP project implementation steps. I want to thank Dr. Mary Anne Reynolds, who advised me at the beginning of project development. I would also like to thank each of the professors and staff members of the Ann Taylor Dee School of Nursing at Weber State University. I have leaned on them throughout my entire nursing education, from my associate degree many years ago to this terminal Doctor of Nursing Practice degree. Next, I would like to thank the Certified Diabetes Educator at Ashely Regional Medical Center for her trust in me to seek a solution and lead this much-needed project through to the end. I would also like to thank Greg Gardiner, the Chief Clinical Officer at Ashely Regional Medical Center, for being willing to head my project and bring the idea and need to the administrative board and Ashley Regional's board of directors. I would also like to thank the Information Systems Team, Cameron Winn, HDIS, Justin Allred, IS Lead, and my dear friend Sage McMickell, CI Nurse, for their unwavering support to this project as well as my overall success through my education journey. Finally, I would like to express my gratitude to my friends and family. To my many friends who have extended support and encouragement, thank you. Thank you to my mother and father, who always taught me the value of education, dedication, and perseverance. My father who believed that nursing was my calling in life and not merely my career path. My children who have always been proud of my nursing profession and encouraged me to work and pursue further education. And there are no words for my dear husband, who has selflessly cared for me DIABETIC TRACKING SYSTEM 5 and kept me nourished over these past few years. Without every person in my life, I would not have made it to this point. I sincerely thank each and every one of you. And now, let the games begin. DIABETIC TRACKING SYSTEM 6 Abstract Diabetes self-management education and support are critical for all patients with diabetes. For diabetes education programs to be effective, they must determine patient status, track changes, provide consistent, organized education, follow up with patients, report to referring providers, and report to the accreditation body. The purpose of this Doctor of Nursing Practice (DNP) project was to replace paper documentation with an electronic diabetes education tracking system. The utilization of electronic health records improves quality patient outcomes by increasing the efficiency of documentation and retrieval of data. Chronicle Diabetes is an electronic data management system designed specifically for diabetes education. Implementation included working with the Information Technology department, introducing the program to hospital staff, and completing education with the diabetes educator. The training was completed with the diabetes educator, the clinical informatics nurse, and the medical records department. During the data collection phase of the project, thirty-one patients were entered into the Chronicle Diabetes. The project’s success was demonstrated by the diabetes educator’s increase in efficiency of 60-90 minutes per patient, improved patient outcomes noted by the average decrease in AIC’s and the increase in patient and provider communication. Implementing a diabetes patient tracking system like Chronicle Diabetes improves the consistency of diabetes self-management education and support for patients with diabetes. Well-developed electronic health systems improve user satisfaction by streamlining documentation, facilitating patient and provider communication, and enhancing quality care continuity for patients with diabetes. Keywords: Diabetes, diabetes education, patient tracking system, behavioral goals, electronic health records, documentation, accreditation. DIABETIC TRACKING SYSTEM 7 Implementation of a Diabetes Education Patient Tracking System in a Rural Utah Hospital According to America's Health Rankings 2019 diabetes annual report, (2020), diabetes is the seventh-leading cause of death in the United States, equating to more than 79,000 deaths annually. Diabetes is also a significant contributor to heart disease, the leading cause of death and stroke, which is the fifth leading cause of death. In 2017, diabetes was attributed to an estimated 327 billion dollars in direct medical costs and productivity loss. After adjusting for age and sex differences, people with diagnosed diabetes had two times higher medical expenses than people without diabetes. Utah’s Public Health Data Resources (2018) reports the prevalence of diabetes from 2017 to 2018 for adults 18 years and older in the Tri-county area was 11.1%, which is higher than the Utah average of 8.2%. Tri-county consists of Uintah, Duchesne, and Daggett counties. Uintah County is home to the Ute Indian Reservation. American Indians have a 14.7% prevalence of diabetes compared to 7.5% of non-Hispanic whites (ADA, 2018). Many health care providers throughout the country have significant concerns about the burden of diabetes, and how to best help their patients and communities care for themselves in a manner that will improve overall health and prevent comorbidities. Diabetic patient involvement, self-care management, and efficacy are critical to maintaining glycemic control — poor glycemic control results in the involvement of other body systems and chronic disease. These chronic diseases include cardiovascular disease, retinopathy, neuropathy, nephropathy, increased risk of infections, and poor wound healing. Because of these complications, diabetic patients face a higher number of hospital admissions or readmissions, greater lengths of stay, and in-hospital complications and mortality (Ostling et al. 2017). DIABETIC TRACKING SYSTEM 8 There are three main types of diabetes mellitus: type 1, type 2, and gestational diabetes mellitus. Type 1 diabetes mellitus, also referred to as insulin-dependent diabetes, occurs due to autoimmune destruction of pancreatic beta cells leading to the inability to secrete insulin. With type 2 diabetes mellitus, the pancreas still secretes insulin; but the cells developed insulin resistance, and the insulin produced is not usable, which causes more insulin to be secreted. Eventually, the beta cells wear out, and insulin production decreases. Gestational diabetes is much like type 2 diabetes; however, it occurs only during pregnancy. Effective management of all types of diabetes begins with education regarding the pathophysiology of diabetes, diet and lifestyle changes, self-management strategies, and ongoing support from knowledgeable professionals. Problem Ashley Regional Medical Center (ARMC) currently does not utilize a consistent method for the documentation of diabetes patient education, tracking of patient goals, or planned follow-up for the patients. Implementing a diabetes tracking system will enable the diabetes educator to be more effective and efficient in meeting the needs of diabetic patients within the Uintah Basin. Search A search was conducted using MEDLINE, PubMed, Sagepub, Directory of Open Access Journals, Google Scholar, and Elsevier B.V. Terms used to search included diabetes mellitus, diabetes educator tracking systems, diabetes education, type 2 diabetes and self-management, diabetes and self-management, diabetes clinic patient tracking systems, technology and diabetes management, diabetes and hospital admissions, hospital readmissions and diabetes. The limitations of this search included research published in English between 2011 and 2019. DIABETIC TRACKING SYSTEM 9 Literature Review Diabetes Prevalence. According to the Centers for Disease Control and Prevention (CDC), in 2017, the number of people with diabetes or prediabetes was over 100 million in the United States (2017). This shows a significant increase from the 2015 report, which denoted 30.3 million Americans with diabetes or prediabetes. The National Vital Statistics Report for 2017 shows diabetes in the United States is the seventh leading cause of death (Kochanek, Murphy, Xu, and Arias, 2019). The ADA reported over 200,000 people in Utah to have diabetes, and up to 54,000 Utahns may not even know they have it, which poses a severe risk to their health (n.d.). The National Health and Nutrition Examination Survey (2014), reports one out of three adults in Utah has prediabetes, which results in an estimated expenditure of 244 billion dollars per year for medical services. Because of these staggering numbers, the Utah Department of Health and the Bureau of Health Promotion implemented the Utah Diabetes Prevention Program (Utah Department of Health, 2018). The Utah Diabetes Prevention Program works in collaboration with the National Diabetes Prevention Program to spread awareness and encourage Utahn's to adopt healthy lifestyles. Changes in lifestyle that include alterations of diet and exercise have been shown in many research studies to improve health outcomes and even prevent diabetes (Utah Department of Health, 2018). Whyte & Munro (2019; 2018), wrote that with early treatment and the stabilization of the progressive b-cell deterioration, type 2 diabetes could be reversed. Diabetes treatment. Early, consistent treatment is critical for improving and maintaining optimal health for diabetic or prediabetic patients. Treatment consists of the safe use of DIABETIC TRACKING SYSTEM 10 medication, the prevention and care of hypoglycemic events, nutritional guidelines, glucose levels and the monitoring of those levels, physical activity, reducing risks, and the prevention of additional chronic ailments (Marincic et al. 2019). Furthermore, the study conducted by Ostling et al. (2017), concluded that the diabetic patients who had diabetes self-management education with follow up also had fewer hospital revisits as compared to those diabetic patients who did not participate in diabetes management services. Due to the complicated nature and the amount of information to be learned, patients with diabetes have greater glycemic control measured by HbA1c, TG, HDL, and TG-to-HDL ratio, weight, and BMI with the education and support from an education program recognized by the ADA (Marincic et al. 2019). Gaede et al. (2016) studied the potential long-term impact of an intensified, multifactorial intervention program in patients with type 2 DM and microalbuminuria. They measured years of life gained and years free from cardiovascular disease incidents. This study determined that the goal of improving diabetes and glycemic control is to reduce unwanted health risks of diabetes, including hypertension, dyslipidemia, and increased blood platelet aggregation. Moreover, uncontrolled hyperglycemia increases the risk of macro- and microvascular damage and reduced life expectancy. After the first 7.8 years, the researchers concluded that patients who received the intensive intervention had 8.1 years more time before any cardiovascular disease events occurred compared to those who received conventional therapy. Eight years is significant when talking about prolonging life as well as improving the quality of one's life. However, it takes proper treatment, education, and continual self-management strategies to improve clinical outcomes. DIABETIC TRACKING SYSTEM 11 Diabetes Education The Professional Practice Committee (PPC) of the ADA are responsible for the information found in the Standards of Medical Care in Diabetes Guidelines. The PPC comprises physicians, diabetes educators, registered dietitians, and other experts in endocrinology, epidemiology, public health, lipid research, hypertension, preconception planning, and pregnancy care. The ADA's goal is to provide the most authoritative and current guidelines for diabetes care to be used by clinicians, patients, researchers, payers, and others (ADA, 2020). According to the position statement from the ADA (2020), diabetic patients need to have diabetes self-management education and support (DSMES) at the time of diagnosis and on an as-needed basis. The objectives of DSMES are to teach patients about diabetes, how to manage their diabetes, to assist with decision-making and problem-solving, and to collaborate with the patients' health care providers to improve continuity of care and overall health outcomes. The patient's quality of life improves with the lessons learned from the DSMES program. Topics. The DSMES topic recommendations (2020) are divided into four categories: the education needed during the first year of diagnosis; the education needed annually; the changes in factors that may complicate the disease; and when a transition of care occurs. However, these topics are fluid and depend on the individual patient's needs. At diagnosis, the primary care provider (PCP) and his or her team need to: answer questions and provide emotional support, provide information on treatment and the goals of treatment, teach about emergencies and how to handle them, as well as provide diet guidelines for preventing emergencies. The PCP also should identify resources for education and support and write a referral for these services (ADA, 2020). The diabetes educator should assess the patient's health beliefs, current cognition of diagnosis, cultural influences, support system, financial status, medical history, and literacy DIABETIC TRACKING SYSTEM 12 (ADA, 2020). This assessment will assist the educator in prioritizing and determine the patient's individual educational needs. The diabetes educator will give extensive education on patient medications, including the action, titration, and administration (ADA, 2020). The patient will learn how to monitor their glucose, interpret results, and manage their medication for the specific results. The patient will learn about physical activity, nutrition, diabetes risks, prevention, and recognition of complications. The diabetes educator will provide encouragement and support by helping the patient develop self-management goals and strategies to change behavior, promote health, and discuss psychosocial concerns (Powers et al., 2017). Health care providers must not underestimate the need for support and encouragement for patients with diabetes. A study conducted by Peña-Purcell, Boggess, & Jimenez (2011) evaluated the effects of a culturally specific, empowerment-based diabetes self-management education program for Hispanic/Latino people with diabetes in two different counties near the Texas/Mexico border. The program utilized was the ¡Si, Yo Puedo Controlar Mi Diabetes! diabetes self-management education program. Translated this means, Yes, I can control my diabetes! In conclusion, the researchers found that this education program was effective in significantly reducing the HgbA1C levels in the intervention group as compared with the control group. A more recent study by Fisher, Polonsky, Hessler, and Potter (2017) concluded that the efficacy of diabetes self-management intervention education depended on the clinician's ability to support and encourage personal engagement and understand the patient's quality of motivation at a particular time. Roles. Patient involvement and confidence are paramount in their ability to self-manage diabetes. However, without the in-depth education, follow up, and support from a committed multidisciplinary team, their chances of success, are significantly reduced. A study by Whitehead DIABETIC TRACKING SYSTEM 13 et al. (2017) concluded that the implementation of daily life changes necessary for glycemic control is complicated, and ongoing support was needed to improve patient outcomes. In a similar study by Captieux, et al. (2018), agreed short-term glycemic control in patients with type 2 diabetes when a range of approaches was used to teach self-management interventions and provide support following education. The supported self-management enhanced patients' confidence and efficacy in improving their disease processes, self-reported quality of life, and glycemic control. Freeman-Hildreth, Aron, Cola, and Wang (2019) sought to understand patients' perspectives and preferences regarding their involvement in caring for their diabetes. Their research determined that improved provider communication practices resulted in improved health outcomes and adherence to treatment. Diabetes Documentation Importance of documentation and content. Documentation is the backbone of health care; it is where information regarding patient status, medications, test results, plans of care, and outcomes are recorded. The Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit are instructions to help reduce health care complexity, enhance patient understanding of health care instructions, and improve support for patients. Follow up and tracking of patient education, health status, and changes in the plan of care is a large part of improving health care literacy (Agency for Healthcare Research and Quality [AHRQ], 2019). The establishment of a reliable, simple patient tracking program can improve patient safety, quality of care, and minimize care delays or missed opportunities to improve patient outcomes (American College of Obstetricians and Gynecologists [ACOG], 2012). Improving a patient tracking and documentation system will facilitate real-time data entry, patient follow-up, DIABETIC TRACKING SYSTEM 14 goal tracking, and data extraction for reporting as necessary to the success and accreditation of a diabetes education program. Documentation and communication methods. Research conducted by Greenwood, Gee, Fatkin, and Peeples (2017) sought to provide health care organizational decision-makers with the current evidence to evaluate technology-enabled solutions for diabetes self-management education and support that addressed the standards, evolving models of care, reimbursement, and appropriate behavioral frameworks. The researchers concluded that technology-enabled self-management tools with two-way communication functionality with the health care team provided the most effective solution and significantly improved patients' HgA1cs. Diabetic patients who are lost to follow up is a significant concern. Tino et al. (2019) looked at type 2 diabetic patients over 13 years to determine the number of patients who were lost to follow up and what variables made these patients more apt to continue with participation or drop out of the diabetic clinic program. Data showed that patients with a higher risk for loss to follow up (LTFU) were male, younger than 45 years, smoked, were on dual therapy, had lower socioeconomic status, as well as more significant complications such as neuropathy or nephropathy. The reasons why patients are lost to follow up vary significantly and most are out of the control of providers. However, increasing engagement of the health care team could potentially reduce this number. A tracking system that included reminders for classes, goals, and yearly exams, could be sent to the patient and help build a relationship that may improve the diabetic education program. Wang and Siminerio (2013) concluded that a diabetic tracking program assisted diabetic educators in the education process and enhanced their ability to meet the standards of diabetes self-management education and reporting requirements of the ADA. DIABETIC TRACKING SYSTEM 15 Care Gap Identified Concerns over hospital admissions and readmission rates of patients with diabetes sparked much discussion during an interdisciplinary quality improvement meeting at ARMC. Patients with diabetes are at higher risk for acute illnesses, exacerbations, and complications due to comorbidities--all of which lead to a higher number of hospitalization and readmissions (McCoy et al., 2017). A care gap was identified during a conversation with the diabetes educator, who revealed the need for an electronic method for tracking diabetes education, behavioral goals, labs, and patient follow-up. The majority of the patient education documentation was a paper process and posed several obstacles to an efficient workflow and correspondence with patients and providers. EHRs can improve communication between patients and providers, improve clinical decision-making, reduce medication errors, reduce adverse drug events, and improve access to critical patient information by providers (Alafaireet & Hicks, 2017). Population and Setting The Tri-county, Uintah, Duchesne, and Daggett counties, prevalence of diabetes for adults from 2017 to 2018 was 11.1%, which is higher than the Utah average of 8.2%. (Utah's Public Health Data Resource, 2018). Uintah County is also home to the Ute Indian Reservation. American Indians have a 14.7% prevalence of diabetes compared to 7.5% of non-Hispanic whites (ADA, 2018). ARMC is a rural hospital owned by LifePoint Health located in the north-eastern part of Utah, known as the Uintah Basin. ARMC recently expanded to a 39-bed facility and is one of two hospitals that service approximately 35,000 people. There is one Registered Dietitian Nutritionist (RDN) who is also a Certified Diabetes Care and Education Specialist (CDCES) at DIABETIC TRACKING SYSTEM 16 ARMC. Patients are referred to her by local providers for diabetes education consultations. The CDCES educates patients and their families in her office located in the medical office building attached to the hospital. Since the Covid-19 pandemic, the CDCES has had several virtual education sessions because in person education was restricted during the National lock down. The patients who took advantage of the virtual visits found this option helpful and would like to have the option of virtual visits in the future. Medhost Enterprise is the central electronic health record (EHR) used at ARMC, and although the CDCES was able to view labs and other statistical information needed from current and past encounters, the information was scattered throughout the patient's record. Due to the limited functionality of Medhost, the diabetes education could not be outlined for consistency, ease of documentation, or patient follow-up. The diabetes educator documented a rather lengthy narrative note within the patient notes module of Medhost. The ease of retrieving specific patient data from their medical record or the diabetes educator's document was poor. Theory Lewin's Force Field Model provided a strong foundation for implementing a diabetes education tracking system for the diabetes educator at ARMC. Lewin's Force Field Model of change's primary goal is to identify an area of focus, analyze it, and adjust it depending on the restraining and driving forces (Lewin, 1947; Finkelman, 2018). Lewin's Force Field Model employs three main stages, the unfreezing stage, the moving stage, and the refreezing stage. The unfreezing stage began with identifying the lack of consistent documentation and ability to track the education rendered by the diabetes educator. Then, a list of elements or modules needed for an electronic patient tracking system was devised. Lastly, stakeholders who DIABETIC TRACKING SYSTEM 17 could contribute to attaining and implementing a patient education tracking system were identified and recruited. The moving stage ensured that the vision of the tracking system was identified and well defined. The driving forces included the desire to expand the diabetes education services, and the restraining forces were to identify a functional and affordable tracking system. An action plan was created for each force that the team had control over. Lastly, the education tracking system was implemented, the program underwent testing, and the evaluation of the program continues. The Information Systems team assisted with support and troubleshooting of issues, and adjustments were made as needed. The refreezing stage followed the implementation, adding patients to the education tracking system and hardwiring the new tracking system into the diabetes educator's workflow. The system's follow-up and reporting capacities are being utilized and updated as needed to meet regulatory compliance and accreditation with the ADA. Using Lewin's Force Field Model as a framework for change guided the quality improvement team with enriched planning, determining goals, facilitated communication, and the continued evaluation of this quality improvement project (Bozak, 2003). Expected Outcomes and Goals The overarching goal of the electronic patient tracking system at ARMC is to improve the overall health and wellbeing of patients with diabetes through much-needed education and support. It is expected that this tracking system will provide the diabetes educator with an electronic education outline to facilitate education consistency, refine the documentation practice and advance the diabetes educator’s workflow. DIABETIC TRACKING SYSTEM 18 Pertinent patient data will be organized for ease of retrieval by referring providers and all healthcare team members. The ease of retrieval will assist the diabetes educator during consultations with patients when establishing and reevaluating behavioral goals, ameliorate patient follow-up practices and patient support. An electronic patient education tracking system will innovate patient and provider communications. The ADA accreditation renewal process will no longer be a completely manual process which will increase satisfaction and streamline the reporting process. The diabetes educator, the DNP student leader, and the clinical informaticist (CI) received training on utilizing the patient tracking system. Having multiple users trained in running the CD system aided in the customization of the backend, the ongoing use of the electronic tracking system, and a safety net in case of staff turnover. Practice Change Plan Project Barriers The implementation of electronic information systems can be very costly, which is of great concern to a small, rural facility. The rural setting tends to have sporadic patient volumes and a minimal number of qualified staff to meet the fluctuating patient demands (Rutledge, Masalovich, Blacher, & Saunders, 2017). Another barrier to implementing an electronic patient tracking system is the level of information security required for the standards and regulations of hospital systems. According to the ADA, the CD documentation system is HIPAA compliant and was created using the ADA Practice Guidelines, which supports the requirements for accreditation (2020). The security specifications of CD were evaluated by the Information Security Officer and administrative support services. Upon review of the security and system requirements, it was discovered that DIABETIC TRACKING SYSTEM 19 the Business Agreement between the ADA and ARMC's diabetes education program was sufficient for ARMC to utilize Chronicle Diabetes. The DNP candidate leaders' unique skills in research, innovational intellect and change management are advantageous for successfully implementing a diabetes education tracking system. A DNP student leader has the education and knowledge to apply translational science and influence change in complex healthcare settings. Strong emphasis on patient safety, quality improvement, patient-centered care, and patient satisfaction necessitates continual growth and adaptation within health care organizations (Sherrod & Goda, 2016). Following a uniform standard project management method like the Systems Development Life Cycle (SDLC) ensures structure and improves quality outcomes of information system integrations. Before implementation, the project was proposed to the Weber State University’s Institutional Review Board, and approval was granted; see appendix A. Project Implementation The SDLC provided the foundation for the implementation of a diabetes patient tracking system at ARMC. The SDLC is a structured system development method that provides a multistep, iterative process for implementing information systems or technology (McBride, & Tietze, 2019). See appendix B for the diagram of this model, which is a graphical representation of the SDLC. Utilizing a well-established method for project management can improve the quality outcomes of information system implementations (Curry, McGregor & Tracy, 2007). Planning. The CDCES relayed the vision of a functional diabetes patient tracking program. The desired program must house and organize patient data related to their disease as outlined by the ADA DSMES program. A module for tracking behavioral goals that include follow-up capabilities is preferred. Much research was conducted on the different patient DIABETIC TRACKING SYSTEM 20 tracking systems available on the market. Collaboration with other diabetes educators and clinical informaticists within the LifePoint Health System took place to learn how other facilities document and track patient education for patients with diabetes. The costs and time involved in implementing a stand-alone predeveloped system versus building forms for diabetes education tracking within the current Medhost Enterprise electronic health record were explored. The desired timeline for implementing an electronic patient tracking system was quickly approaching, with the hospital's ADA accreditation renewal period coming to a close in October 2020. The CDCES wanted to implement the new diabetes tracking system shortly after the reporting period was completed to ensure all patient records for the next reporting period will be located in the new system to simplify reporting. The pros and cons of each system were outlined and discussed in a meeting with the stakeholders. During this meeting, it was determined that Diabetes Chronicle would be the best system for ARMC's diabetes education program. System analysis and requirements. A systems analysis meeting was conducted with the Chronicle Diabetes system specifications and local stakeholders, consisting of the IT team (the HDIS director, technicians, and CI) and the end-users (CDCES and DNP student leader). The meeting agenda included discussion on business requirements, solution requirements, functional and non-functional system requirements. The necessary costs and timeline were discussed. Adopting the Chronicle Diabetes education tracking system was found much more cost-effective than building forms and modules within the currently utilized Medhost Enterprise system. Systems design. The diabetes educators requested functionality for documenting and tracking diabetes education was compared to the ADA DSMES program requirements. The Chronicle Diabetes program met both the ADA requirements and the functionality requested by the diabetes educator. DIABETIC TRACKING SYSTEM 21 Development. The CD program endorsed by the ADA was found to be the best fit for ARMC's diabetes education tracking. The CD program was explicitly developed to document, track, and follow patients with diabetes. Multiple DSMES programs are utilizing CD throughout the United States. Local referring providers and letter templates were the only customizations needed to put CD into use at ARMC. Integration and testing. The local IT team completed the system evaluation and downloaded the necessary updates to ensure that the new diabetes education tracking system functioned properly. The backend of Chronicle Diabetes was customized for ARMC with local referring care providers and letter templates for patient reminders and follow-up notifications. Test patients were entered into the system for training and testing purposes. Chronicle Diabetes provided training materials for learning the system; the CDCES, DNP student leader, and the CI participated. The local IT team tested the software's effect on network infrastructure, optimized hardware, and assisted with troubleshooting issues experienced during integration. Once integration and testing were completed, live patient data was entered into the new electronic patient education tracking system by the CDCES and the DNP student leader. The letter generator portion of the system was utilized and found very effective for sending reminders and requesting patient histories. The CDCES, CI, Health Information Management (HIM) specialist, and the DNP student leader evaluated the snapshot document report produced by CD following the CDCES documentation. The snapshot was compared to the documentation done in Medhost before the CD implementation. The documentation is easier to conclude the patient’s health status and progress in the diabetes education program. Dual documentation was deemed unnecessary; the CDCES prints the snapshot from CD, and the HIM staff scans the document into the consultation DIABETIC TRACKING SYSTEM 22 notes module within the patient's chart. This process decreases the amount of charting done by the diabetes educator and facilitates quick retrieval of patient’s status by all healthcare team members. Operations, maintenance, and support. The CDCES entered and document pertinent patient data in the new diabetes tracking system. Following the initial setup, the CDCES has been able to maintain all patient documentation within the system. The IT team, including the CI, will continue ongoing evaluation and troubleshooting as concerns arise. IT will assist the CDCES in contacting the vendor with errors, performing updates, and assist with optimizing the system's functionality (Wong, Wen Yu, & Too, 2018). The sustainability of the diabetes education program has been enhanced with the addition of the electronic data management system. This electronic patient tracking system will decrease the amount of time required for training new staff members as all patient data and reports will be contained within one system. Evaluation and Data Analysis The CDCES completed two surveys. One was administered before the system implementation on October 22, 2020, and a second survey was administered on May 17, 2021, following the implementation; see appendix C and D, respectively. The survey consisted of ten questions that focused on the CDCES level of satisfaction with patient data organization, documentation organization, the ability to extract data, document and update behavioral goals, track patient needs and progress, ability to generate reports, and the ability to follow up with patients and improve communication with referring providers. Satisfaction level was scored on a 5-point Likert scale from strongly dissatisfied (1) to strongly satisfied (5). The CDCES’s pre-implantation survey showed 7/10 elements of being dissatisfied and 3/10 elements that she felt neutral about--neither satisfied nor dissatisfied. The post-implementation survey revealed 9/10 DIABETIC TRACKING SYSTEM 23 elements of the CDCES being strongly satisfied and 1/10 element where she felt satisfied (See Figure 1). Quantitative data was collected on the number of patients, their demographics, amount of time saved, average weight loss, average reduction of HgA1C’s, and the number of patient correspondences or follow up letters. From November 2020 to June 2021, there were 32 patients referred to ARMC diabetes education services. All 32 patients were contacted, and 31 patients were set up for an initial visit and other education sessions. One of the patients declined an appointment at that time. Out of the 31 patients, a welcome letter was emailed to them with instructions on filling out a pre-visit intake assessment. Two patients were not able to complete the assessment online, and it was done during their first appointment. Twenty-nine of the patients were able to complete the assessment online which allowed for more effective education during the first visit. The patient demographics showed that 51.6% of the participating patients were 19-44 years old, 19.4 % were 45-65 years old, and 29.0% were older than 65. Race and ethnicity showed that 96.7% were White or Caucasian, and 3.3% were Hispanic or Latino. Diabetes was categorized by type which showed 67.7% of the patients have type 2 diabetes, 29.0% have gestational diabetes and 3.2% have type 1 diabetes. Out of the 31 patients, nine are physically disabled, one is visually impaired, and five reported hearing impairment (Appendix E). There were several program outcomes of importance. First, time saved by completing the initial assessment online before the first education session freed up 60-90 minutes of class time. The second was the average HgA1C at the beginning of education was 8.2%, and by the end of this reporting period, the average post HgbA1C was 6.8%. The third program outcome noted was a decrease in the average of patients' weights. The average beginning weight was DIABETIC TRACKING SYSTEM 24 231.8, and the average ending weight was 213.9, which is a difference of almost 18 pounds (Appendix F). Lastly, the number of patient correspondences and follow-up letters was greatly enhanced. Out of 31 patients, 31 received a welcome letter, and 14 follow-up letters were sent. Follow up letters were a significant concern and a process that was not being done before the implementation of CD. The patients’ providers are receiving a printout or a "snapshot" of the patient's participation and status within the program. This form is generated from CD and has pertinent patient statistics which allows the doctor to be informed. Discussion and Recommendations The implementation of the diabetes patient education tracking system at ARMC was a success. The CDCES met the goal of entering all patients into the new tracking system for the next ADA accreditation reporting period. Learning a new system was challenging for the CDCES; through perseverance and support from stakeholders, she continued with the training and now excels at utilization. The tracking system's success is demonstrated by the significant increase in the CDCES level of satisfaction post-implantation. An unforeseen benefit of the ADA CD system is having patients create and log into their ADA account and complete their intake assessment. The patient's welcome letter contains simple instructions for creating an ADA account. Once the patient's assessment is complete, the data flows over into CD. The CDCES can access their intake assessment before the patient's first education session and formulate a personalized education plan. Before the CD implementation, the CDCES spent the first patient encounter gathering intake data, such as height, weight, blood pressure, HgA1C, home medications, behavioral goals, and education goals. Recommendations for other diabetes education programs include printing a copy of the education materials or having a dedicated screen to view the training materials while learning the DIABETIC TRACKING SYSTEM 25 system as accessing multiple windows are required. Compare the ADA CD workflow to the facility's workflow and possibly create a facility specific workflow to streamline patient access and allow for workflow optimization (Appendix G). Utilizing the system development life cycle provided the structure needed for this information systems implementation project, especially when faced with unforeseen circumstances such as the covid-19 pandemic and stakeholder turnover. Conclusion Diabetes is a highly complicated disease, and many patients struggle with the self-management strategies needed to improve their health and prevent further comorbidities. Diabetes educators can significantly impact the lives of their patients by building positive relationships, providing patient-centered education and follow-up, and conducting meaningful communication with a multidisciplinary team, which is critical for patients with all types of diabetes. A complete patient education tracking system to record the plan of care, education sessions, goals, labs, medication regimens, glucose history, vital signs, treatment outcomes, and team communication was a much-needed tool for advancing the diabetes program at Ashely Regional Medical Center. Greenwood, Gee, Fatkin, and Peeples (2017) suggest that organizations, diabetes educators, policymakers, and payers consider technology-enabled solutions in the design of diabetes education and support services. Implementing the electronic patient tracking system, Chronicle Diabetes, has provided a solid foundation for patient services going forward. DIABETIC TRACKING SYSTEM 26 References Agency for Healthcare Research and Quality [AHRQ]. (2019). AHRQ health literacy universal precautions toolkit. Rockville, MD. Retrieved from https://www.ahrq.gov /health-literacy/ quality-resources/tools/literacy-toolkit/index.html Alafaireet, P., & Hicks, L. (2017). Barriers and benefits of EHR usage in Missouri: A five-year journey. Missouri Medicine, 114(1), 70–72. American Diabetes Association [ADA]. (2020). Chronicle diabetes DSMES documentation platform. DiabetesPro. Retrieved from https://professional.diabetes.org/content /chronicle-diabetes American Diabetes Association [ADA]. (2020). 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Journal of Evaluation in Clinical Practice, 23(2), 264-271. doi:10.1111/jep.12594 DIABETIC TRACKING SYSTEM 31 Whyte, M.B., & Munro, N. (2019; 2018). Changing the care pathway for type 2 diabetes at the time of diagnosis: The role of the multidisciplinary team. Diabetic Medicine, 36(5), 653- 654. doi: 10.111/dme.13852 Wong, W. Y., Wen Yu, S., & Too, C. W. (2018). A systematic approach to software quality assurance: The relationship of project activities within project life cycle and system development life cycle. Paper presented at the 2018 IEEE Conference on Systems, Process & Control (ICSPC), Melaka, Malaysia. doi:10.1109/SPC.2018.8703978 DIABETIC TRACKING SYSTEM 32 Figures Figure 1. The certified diabetes care and education specialist’s (CDCES) level of satisfaction survey pre-implementation and post-implementation of an electronic patient tracking system for a diabetes education program in a rural hospital. DIABETIC TRACKING SYSTEM 33 Appendix A: Weber State University Institutional Review Board letter DIABETIC TRACKING SYSTEM 34 Appendix B: Systems development life cycle (SDLC) Note: Systems Development Life Cycle is from Sugiandi and Kerlooza (2018), which shows the cyclic process of a system or software development and integration projects. DIABETIC TRACKING SYSTEM 35 Appendix C: Pre-implementation survey level of satisfaction of the implementation of a diabetes education patient tracking system Note: Level of satisfaction of the diabetes tracking system before the implementation of Chronicle Diabetes patient tracking system at ARMC. Questions Strongly Dissatisfied Dissatisfied Neutral Satisfied Strongly Satisfied What is your level of satisfaction with… 1 2 3 4 5 1. The ability to organize patient records? x 2. The ability to categorize patient records? x 3. The ability to follow up with patients? x 4. The ability to document patient care follow up notifications? x 5. The ability to document patient behavioral goals? x 6. The ability to review and change behavioral goals? x 7. The ability to generate reports for ADA accreditation? x 8. The ability to generate patient data for providers? x 9. The ability to review records? x 10. The ability to view patient status? x Totals 7 (2) 3 (3) DIABETIC TRACKING SYSTEM 36 Appendix D: Post-implementation survey level of satisfaction of the implementation of a diabetes education patient tracking system Note: Level of satisfaction following the implementation of Chronicle Diabetes patient tracking system at ARMC. Question 7 rated 4 due to CDCES not being sure if she was utilizing cohorts as needed for reporting purposes. It was determined that until the total number of patients increased, it would be unnecessary to divide patients into cohorts. Further training on reports was completed and level of satisfaction for the ability to generate reports increased to a 5. Questions Strongly Dissatisfied Dissatisfied Neutral Satisfied Strongly Satisfied What is your level of satisfaction with… 1 2 3 4 5 1. The ability to organize patient records? x 2. The ability to categorize patient records? x 3. The ability to follow up with patients? x 4. The ability to document patient care follow up notifications? x 5. The ability to document patient behavioral goals? x 6. The ability to review and change behavioral goals? x 7. The ability to generate reports for ADA accreditation? x 8. The ability to generate patient data for providers? x 9. The ability to review records? x 10. The ability to view patient status? x Totals 1 (4) 9 (5) DIABETIC TRACKING SYSTEM 37 Appendix E: Diabetes self-management education patient demographics Note: Demographic report produced from ARMC’s Chronical Diabetes program from October 27, 2020 to June 30, 2021. DIABETIC TRACKING SYSTEM 38 Appendix F: ARMC’s Chonicle Diabetes program outcomes DIABETIC TRACKING SYSTEM 39 Appendix G: ARMC Chronicle Diabetes initial steps workflow ARMC CD Initial Steps – Workflow 1. Receive a referral 2. Contact patient to schedule first appointment. a. Obtain email address 3. Add patient into Chronicle a. Scan referral into chronicle (General Information) b. Create a class for patient (page 10) i. For 1:1 can stay in DSME & Follow-up ii. Complete Pre assessment in DSME & Follow-up c. Create a welcome letter d. Email welcome letter to patient 4. Patient comes into class a. Review assessment or enter assessment if needed b. Complete the initial class 5. Document: a. DSME & Follow-up: Post evaluation b. Behavioral Change Goals “Add new objective” c. Clinical and Lab Data – add lab values and d. Add patient note – Start with patients encounter number e. Add Post hospitalizations/ER visits - See page 22 6. Patient Reports for Communication to HCP a. Create - Patient Snapshot Report b. Create - DSME Record Report i. Save to desktop ii. Either email or print and deliver HIM 1. heather.barns@lpnt.net 2. fara.roberts@lpnt.net 3. francis.jackson@lpnt.net