Chronic Disease Electronic Management in Clinical Care of Diabetics

Objective:  This project incorporated an electronic tracking system to improve diabetic outcomes and patient self-management in one rural health clinic.

Methods:  Chronic Disease Electronic Management System (CDEMS) is a database application that is organized into three program modules: (1) data entry, (2) reports, and (3) data storage for individual and clinic data. In this project the CDEMS system was used for diabetic patient care by addressing four of the six essential elements of the Chronic Care Model (Bodenheimer et al.) as a concrete guide to improve practice:                                                                                                                       Ø  Delivery System – a summary progress note of the current state of diabetic care was printed upon arrival of the patient. Data from the current visit were entered into the system following the visit. Ø  Decision Support – CDEMS progress note displayed all medical conditions, medications, services, and laboratory work.  This served as a reminder for providers during the clinic visit. Ø  Self-Management – CDEMS generated a visual handout for patients showing graphs of historical trends for laboratory, physical assessment, and outcome goals. Ø  Registry – Access database generated lists of patients overdue for clinic visits, laboratory, or other services and enables the health professional to view clinic-wide reports for quality improvement.

Results: This electronic proactive approach to provide interactive care with diabetic patients yielded positive outcomes. 

Conclusion: Through use of this active database, quantifiable goals were tracked and plans were implemented to improve outcomes of diabetic patients.  Evaluation of specific outcomes will be shared.