The diabetes epidemic: providing the right care at each step

Our previous blog discussed some critical things about diabetes, such as what causes it and its harmful effects on the human body. The prevalence of this disease is relentlessly increasing. And with the health system’s growing challenges such as rising costs, an ageing population, increasing number and severity of chronic diseases, and fragmented care delivery, proactive early interventions in partnership with patients are essential. 

So how can patients, health care providers and specialist diabetologists get on top of this disease? How could patients with the disease take back control of their health and receive the right care at the right time and right place for them? This is where our Health Information Exchange solutions and Diabetes Clinical Pathways are making an enormous difference to the whole health and care landscape.

Fewer steps to improve care 

The Health Information Exchange (HIE) – also known as the Integrated Digital Care Record (IDCR) in the UK – is one of our fundamental solutions to address significant issues for health systems globally. It furnishes health care providers with a single view of crucial patient information, drawn from across a region and made available entirely independent of the patient’s physical location. The presented information includes patient demographics, lab results, medications, diagnoses, encounters, clinical documents and much more. Without an HIE, clinicians could only access a narrow view of information about their patients, typically restricted to the data available in their single organisation. This is an example of the now well-recognized data “silos” problem. Clinicians had to devote precious time to locating necessary patient information, reducing the time available for direct patient care activities. 

So when it comes to early prevention, how does the HIE help? 

A better view of patients using our HIE

Analysing the whole population-level data stored in an HIE, clinicians, including primary care providers, can run frequent population-level risk scores based on simple algorithms. Viewing the diabetic codes in the data, they can find anyone ever diagnosed with diabetes or find anyone in a population who has ever had a high blood sugar reading. Having ever had an elevated blood sugar is an indicator of risk for developing diabetes in the future. Clinicians typically refer to this stage as “pre-diabetes”.  By identifying pre-diabetes patients, clinicians and patients can work together to design appropriate prevention programs tailored to the need of each individual. When and if a patient with pre-diabetes moves on to develop the disease itself, management programs can assist in assuring the care of all patients is standardised, evidence-based and high quality. 

Taking a step from “viewing” to “doing.” 

The Orion Health Diabetes Pathway, built using our Health Care Pathways application, is part of the Coordinate solution suite. It enables the delivery of standardised, best-practice care to diabetic patients across a population. A noteworthy case study for the software is the Diabetes program across Northern Ireland. 

Leveraging access to comprehensive information available in the HIE facilitates the hands-on management of Diabetic patients. Manually entered data, patient-generated data, and remote patient monitoring data are other sources of information that can contribute to the patient’s journey along the Diabetes pathway.  

So how does the Pathway enable the “doing”?

At its most fundamental, any pathway consists of a set of tasks, assessments and plans that promote evidence-based best practices in the care of a diabetic patient. After identifying a cohort of suitable patients and their risk factors, the pathway tracks and recommends actions at the point of care. An example could be a patient with pre-diabetes placed on a dietary intervention programme. The dietary intervention component of the programme guides patients through the steps of seeing relevant specialists, including dieticians, nurse practitioners, exercise physiologists, etc. The result is the patient receives the right care at the right time and right place. 

A Pathway to better care 

“It’s inspiring from the perspective of what Orion Health can add to the picture of diabetes management as a whole,” says Orion Health’s Chief Medical Officer, Dr Chris Hobson. By integrating local, regional, and national data, our software has changed the face of diabetes management by making it more accessible to doctors, pharmacists, nurses, specialists and patients themselves. Orion Health’s HIE and Diabetes Pathway empower clinicians to be proactive in inpatient care and deliver a much better, streamlined experience.

Are you interested in learning more?