Organization Structure

• University of Vermont College of Medicine – Assembled team, wrote grant, operated project.
• Physician practices – Private independent and group practices that agreed to participate.
• Laboratories – Clinical laboratories supporting area medical practices that allowed information system connections to identify participants and to feed raw lab results into system.

Partner Organizations:

• North East Community Laboratory Alliance – supported data sharing process. Association of community hospital-based laboratories; in collaboration with Mayo Medical Laboratories of Rochester, MN.
• Vermont Program for Quality in Health Care, Inc. – Supported peer-review process (Cy Jordan, MD, Medical Director). Broad-based community coalition (provider, consumer, government, and employer representatives).

Brief History:
An automated decision support system for physicians and patients was established. It was designed to support physicians and patients without sophisticated electronic information systems and is based on the general Chronic Care Model.

• Daily data feeds from labs were established on diabetes patients
• Automated test interpretation based on consensus guidelines was added to the reports
• Report formats were designed to be accessible and useful to both providers and patients
• Fax and mail were used for providers and patients not on electronic networks

Committees:
The project was operated by an informal committee of University of Vermont faculty who administered the grant, oversaw daily operations and invited representatives from other organizations as needed. They did not report as a formal body.

Educational Activity

Information Capability

Outputs to Providers: Flow sheets of trended lab results and DSS information on each patient when lab work is done. Quarterly profiles of the diabetic patient population assigned to each physician. These are sent by fax or mail when Internet connections are not available.

Outputs to Patients: Appointment reminders and alerts on out-of-guideline test results by regular mail when an Internet connection is not available.

Published Articles: Clinical Trials 2004 and the American Journal of Public Health 2006.

Research Knowledge Base: This was a funded clinical trial and the formal results will be posted by 2007. The clinical algorithms are based on the Chronic Care Model and the American Diabetes Association Clinical Practice Recommendations.

Funding

Baseline Data

Laboratory Flow Sheet
Demographic:	Age and Sex
Glycemic control:	A1c
Lipids:	Total Cholesterol HDL, LDL Triglycerides
Renal function:	Creatinine, Microalbumin: Creatinine Ratio
Physical Examination
Obesity:	Height Weight BMI
Hypertension:	BP
Heart Rate:	Pulse
Functional Health Literacy:	Brief test
Medications:	Name, dose, frequency in last month Prescription OTC Herbal Supplement preparations
Self Reported (Study Only)
Demography:	Income, education, race/ethnicity Marital status, health insurance
Health Habits:	Smoking Drinking Exercise
Functional Status:	Medical Outcomes Trust SF-12
Diabetes QoL:	Audit of Diabetes Dependant Quality of Life
Diabetes Self Care:	Summary of Diabetes Self Care Activities Measure
Health Care Utilization:	Primary Care Visits ER visits Endocrinology, ophthalmology, diabetes educator, dietician
Complication status:	Diabetes complications
Comorbidity:	Self Administered Comorbidity Questionnaire
Patient Satisfaction:	Primary Care Assessment Survey
Diabetes Utility:	Paper Standard Gamble
Depression:	Patient Health Questionnaire

Information Tools and Uses

• HIPAA Guidelines
• Vermont Guidelines
• American Diabetes Association Clinical Practice Recommendations
• American Diabetes Association Provider Recognition Program benchmarks
• Various federal, state, and professional guidelines on the treatment of human subjects
• Medical Outcomes Trust SF-12 (general health status)
• Audit of Diabetes-Dependent Quality of Life (patient-weighted assessment)
• Self-Administered Comorbidity questionnaire (patient-based version of Charlson Index)
• Patient Health questionnair-9 (questionnaire to identify depression)

Reports

• Basic Flow Sheet used by physicians to track individual metrics.
• A lab result alert from the patient's physician.
• A reminder letter to the patient, again, from their PCP.

Measures of Success
Improved patient testing measured by performance against standard and improvement in parameters compared to baseline. Final results to be published in 2007.

QI Tools and Uses

• Chronic Care Model – Wagner
• "The definition of quality and approaches to its assessment" – Donabedian

Specific Actions and "process change concepts"

• Clinical – ADA Clinical Practice Guidelines
• Disease Management – CCM
• Feedback systems – unknown
• Practice Policy – CCM

Consumer Information and Awareness Tools

Incentives

Non-financial incentives were:

• Improved office processes
• Better information on diabetic patients
• Peer comparisons (top 10% identified each quarter)

Patient Incentives
Patients were paid $20 for completing all of the various surveys.

Non-financial incentives were:

• More information about their disease and their clinical status
• Dependable reminders of appointments and lab tests