Impact of Dedicated Nurse Time on Electronic Health Record (EHR)-Based Diabetes Quality Measures: A Pre–Post Observational Study

Background and objective: Despite major advances in diabetes therapies, only about 60% of U.S. patients achieve recommended glycemic targets in primary care. Inconsistent electronic health records (EHR) complicate diabetes care delivery and highlight the need for strategies that support accurate documentation and patient engagement. The objective of this project is to have 50% of patients with diabetes meet six quality measures: hemoglobin A1c, blood pressure, statin use, aspirin use, tobacco status, and urine microalbumin. Methods: In April 2019, a registered nurse (RN) was tasked with overseeing these six diabetes quality measures among 477 patients with diabetes. Using electronic health record (EHR) reports, the RN identified patients not meeting measures and implemented interventions, including patient outreach, laboratory coordination, medication reconciliation, and documentation updates. The primary outcome was the proportion of patients meeting all six measures (“all-or-none compliance”). The clinic transitioned its electronic health record (EHR) from Cerner to Epic in October 2018, which affected quality reporting during the study period. Results: All-or-none compliance was 40.0% during the pre-EHR transition phase, declined to 24.6% after EHR implementation (pre-RN phase), and increased to 40.6% during the RN intervention phase. At the start of the RN intervention, mean compliance was 35% and improved by an average of 45.7 patients (1.2%) per month through December 2019. RN review identified multiple deficiencies related to EHR documentation, including unreconciled medications, outdated tobacco status, missing external laboratory results, and patients no longer affiliated with the practice. Addressing these issues improved the accuracy of quality reporting and completion of required measures. Conclusion: Diabetes often carries a complex care plan, initiated and managed in most primary care settings. It requires a multidisciplinary approach with EHR facilitating quality measurement. Dedicating an RN to oversee the quality of measures of patients with diabetes may improve the accuracy and completeness of EHRs.