About 17.9 million U.S. residents were diagnosed with diabetes in 2007. The total cost for this diabetes-related medical spending was about $174 billion. The Center for Disease Control (CDC) has estimated the lifetime risk of developing diabetes for individuals born in the United States in 2000 to be 32.8 percent for men and 38.5 percent for women (Narayan et al. 2003). By 2034, the number of U.S. residents with diagnosed or undiagnosed diabetes is projected to increase to 44.1 million, accompanied by $336 billion in annual diabetes-related medical spending (Huang et al. 2009). New strategies are required, both for diabetes screening and prevention (Gilmer and O’Connor 2010). Billions of dollars have been invested by various medical groups into electronic medical records, but there have not been sufficient studies that have determined the cost-effectiveness of EMR-based clinical decision support. Integrated CDS systems have the potential to improve the clinical care as well as reducing the costs associated with treating the millions of patients that are enrolled in health plans that have deployed EMRs.
EMRs can be programmed to include sophisticated algorithms that exploit current and past clinical information to provide detailed recommendations at the time of a clinical encounter (Von Korff et al. 1997). One of the biggest challenges in diabetes care in patients that have not yet attained the recommended clinical goals is the lack of timely intensification of pharmacotherapy. Medication non-adherence and other competing demands at the time of the visit may be some of the reasons for this. Some of the attempts that have been made to improve this include telephone-based management, team-based case management as well as information technology-based interventions.
EMR-based CDS treatment has been tried, though unsuccessfully, in the treatment of diabetes and some other chronic conditions such as congestive heart failure (CHF), hypertension and asthma.
Some of the reasons as to why the use of EMR-based CDS care initially failed include:
- CDS displays were availed late and were often not viewed or skipped by the primary care physician as opposed to being employed during visit planning.
- Most of the CDS did not include detailed drug-specific advice but was reduced to general prompts and reminders.
- Introduction of CDS service was not fully maximized as it was not accompanied by other changes in the clinic workflow and other staff responsibilities.
To address these concerns, an improved model of EMR-based CDS was employed. It addressed these concerns by:
- Reorganizing the workflow so as to include guidance into visits-planning activities.
- Giving treatment recommendations that included detailed and personalized drug-specific advice.
A study of the cost-effectiveness of the EMR-based CDS system in the treatment of diabetes was carried out in Midwestern health plan, and it revealed that EMR-based CDS health care is not only cost-effective in the acceptable standards, but it was also valuable in the sensitivity analyses. This summed up the importance it can have in health care. The observed clinical impact is comparable to that achieved by many disease management or patient education programs that are more expensive (Norris et al. 2002). As a matter of fact, a major appeal in the use of EMR-based CDS interventions in clinical care is in its potential to be deployed over a large population at a very affordable cost.
The adoption of these tools will, however, require incentives for provider participation and some changes in provider behavior. In the Midwestern health research study, the intervention was carried out on a research basis, but if the approach is established and adopted widely, such incentives to providers may become less important.