Table 1.

Using your EMR for proactive chronic disease management

Search for patients who have the condition of interest (eg, diabetes)Search for 1 or more of ...
  • a billing code for diabetes (ICD-9-CM starting with 250)

  • a problem list entry for diabetes

  • medications that lower blood glucose level (eg, metformin, insulin)

  • an HbA1c test result > 6.5%

Consider the role of coding your patient diagnoses for common conditions to improve search results. Make sure you know how diabetes is entered into the billing section or problem list (eg, ICD-9 or ICD-10, free text)
Identify patients who might benefit from reassessmentSearch for ...
  • the date of the most recent HbA1c test result

  • the date of most recent BP measurement

  • patients with a prescription for insulin or sulfonylureas aged > 80 y

Consider saving the search strategy so you can rerun it a few times each year
Ensure patients are aware of their statusIn many cases, office staff can assist in reminding patients to do tests and arrange appointmentsConsider whether your EMR has the capacity to send bulk messages or tasks, send batch e-mail or text messages, or create labels for mailings
  • BP—blood pressure, EMR—electronic medical record, HbA1c—hemoglobin A1c.