Investigators Devise EHR Workflow to Support T1D Glycemic Improvement

In an effort to improve glycemic outcomes among patients with type 1 diabetes (T1D), researchers created an electronic health record (EHR) workflow to measure self-management habits.

In a cross-sectional study researchers identified and measured 6 patient-level habits that supported quality improvement interventions among patients with type 1 diabetes (T1D). Findings were published in JAMA Network Open.

Since the publication of the Diabetes Control and Complications Trial findings in 1993, there has been a translational gap in the achievement of optimal glycemic outcomes in the subsequent 25 years, researchers explained.

“From 2016 to 2018, only 17% of children (<18 years old) and 21% of adults achieved American Diabetes Association glycemic goals of (glycated hemoglobin [A1C]) levels of less than 7.5% or 58 mmol/molfor children and less than 7.0% or 53 mmol/molfor adults,” they wrote, while racial, ethnic and socioeconomic disparities in glycemic outcomes persist.

In an effort to measure self-management habits associated with improved glycemic outcomes in this population, investigators created an electronic health record (EHR) workflow to systematically collect a series of evidence-based diabetes self-management measures during clinic visits.

The 6 self-management behavior metrics were devised and implemented at the C.S. Mott Children’s Hospital Pediatric Diabetes Program in Michigan, while study author Joyce M. Lee, MD, MPH, “created EHR flowsheet items and tools to facilitate documentation at each clinic visit by the diabetes team (diabetes educator/endocrinologist), which went live in the EHR in April 2018.”

The 6 habits included:

  • checks blood glucose (BG) at least 4 times/day if not using a continuous glucose monitor (CGM) or uses CGM
  • gives at least 3 rapid-acting insulin boluses per day
  • uses insulin pump
  • delivers boluses before meals
  • reviewed glucose data for patterns at least once since the last clinic visit
  • changed insulin doses at least once since the last clinic visit

Of the more than 1000 patients seen at the clinic in 2019, 50.3% were male, and the majority (85%) were non-Hispanic White. Patients had a mean (SD) age of 15.5 (4.5) years, and of those assessed, 654 (54%) were using a CGM, had a time in range (TIR), and were included in the study. Out of these patients, only 105 (8.7%) completed all 6 habits.

Analyses revealed:

  • Habit performance was lower among older vs younger patients, Black vs White patients, those with public vs private insurance, and those with lower vs higher parental education levels (P<.001 for all)
  • After adjustment for demographic characteristics and disease duration, for every 1-unit increase in total habit score, there was a mean (SE) 0.6% (0.05) decrease in A1C among all participants and a mean (SE) 2.86% (0.71) increase in TIR among those who used CGMs
  • Performing each habit was associated with a significantly lower A1C level
  • There were differences in A1C according to race, insurance, and parental education, but these associations were attenuated with the inclusion of the 6 habits, which had more robust associations with A1C levels than the demographic characteristics

Giving at least 3 rapid-acting insulin boluses per day was the most frequently performed habit, while reviewing data between visits and changing insulin doses between visits were the least performed habits.

“For the population of patients seen at our diabetes center, we found that the 6 habits can be efficiently and reliably collected as discrete data elements in routine clinical care and that performance of each of the habits and the total habit score are significantly associated with improved glycemic outcomes, regardless of age, race, sex, insurance status, and parental education,” researchers said.

They hope the 6 habits will help guide clinicians and patients, offering a set of 6 heuristics on which to act, and enabling them to set consistent goals aimed at improving glycemic management. Authors also acknowledge that 3 of the habits involve technology use—a factor that may not be available to all patients with T1D.

Additional unmeasured confounding variables may have impacted the adoption of the 6 habits in this study, marking a limitation. These could include household/family structure or social determinants of health.

“The associations between these habits were more robust than those between demographic characteristics and glycemic control, suggesting that adoption of the 6 habits could be a critical tool for improving disparities in glycemic outcomes,” researchers concluded.

As they continue implementing this workflow across clinics, “we anticipate that these 6 habits will become universal across diabetes centers with the goal of increasing the overall proportion of individuals who perform them and ultimately closing the racial, socioeconomic, and educational gaps in habit performance and A1C level.”


Lee JM, Rusnak A, Garrity A, et al. Feasibility of electronic health record assessment of 6 pediatric type 1 diabetes self-management habits and their association with glycemic outcomes. JAMA Netw Open. Published online October 28, 2021. doi:10.1001/jamanetworkopen.2021.31278