A health systems approach to systematic identification and referral of patients at-risk for diabetes

Approximately 466,000 West Virginians, or about 25% of the state population, have pre-diabetes and are at high-risk for developing type 2 diabetes. Appropriate lifestyle intervention using the National Diabetes Prevention Program can prevent or delay onset of type 2 diabetes if those at-risk are identified and treated early. Community-level screenings to identify this high-risk group are often ineffective in that they are time and resource intensive and fail to link positively identified individuals to care. In response, the West Virginia Diabetes Prevention and Control Program and the West Virginia University Office of Health Services Research are developing a systematic approach to diabetes prevention within primary care centers. By importing electronic health record (EHR) data into a patient registry, patients at-risk for pre-diabetes are systematically identified and channeled to care. Preliminary analysis from pilot centers reveals that among 94,283 patients who do not have a documented diagnosis of diabetes or pre-diabetes, 10,673 (11.3%) meet one or more risk criteria. In-depth support is currently being provided to four primary care centers. Current lessons learned indicate that EHR data can be repurposed into a searchable patient registry to efficiently and systematically identify patients in need of screening or intervention. Further, this innovative use of EHR data supports primary care centers in achieving meaningful use of EHR data, fulfilling Patient-Centered Medical Home efforts, and reducing barriers in improving patient care thru enhanced data management.