Electronic Documentation of Lifestyle Counseling and Glycemic Control in Patients with Diabetes

1Brigham and Women’s Hospital, 2Massachusetts General Hospital 3Harvard Medical School, 4Harvard Clinical Research Institute

Naoshi Hosomura, DDS, DMSc1, Saveli I Goldberg, PhD2, Mary Zhang, MA1, Maria Shubina, ScD1, Alexander Turchin, MD, MS, FACMI1,3,4

June 16, 2015

Background

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• The Meaningful Use incentive of electronic medical record (EMR) technology has introduced a wide array of electronic measures (eMeasures) of quality of care.

• Most studies on EMR use and quality of care focused on structured EMR data.

• Very little is known about how characteristics of narrative electronic documentation may reflect the quality of care.

Background

• Lifestyle counseling has been shown to be strongly associated with faster achievement of HbA1c control in patients with diabetes (e.g. Morrison et al., 2012).

• Most of the proposed eMeasures of lifestyle counseling focus on the presence or absence of counseling rather than counseling quality or effectiveness.

Background

• To establish quantitative characteristics of lifestyle counseling documentation that are associated with improved glycemic control in patients with diabetes

Objectives

• Copy-paste documentation of lifestyle counseling, unlike original records, is not associated with faster achievement of target A1c level (Turchin et al., 2011).

• More heterogeneous documentation of lifestyle counseling is associated with faster achievement of HbA1c control.

Context

Hypothesis

• More intensive lifestyle counseling where patients are given detailed instructions on diet and exercise is more effective than less intensive methods (e.g. Greaves et al., 2011).

• More intensive documentation of lifestyle counseling is associated with faster achievement of HbA1c control.

Hypothesis

Context

• We developed two metrics of narrative documentation: documentation heterogeneity and documentation intensity.

• We utilized Natural Language Processing (NLP) system to abstract sentences documenting lifestyle counseling from narrative provider notes.

Approach

Materials & Methods

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Study Design• Retrospective cohort study

Study Cohort• Adult patients with diabetes:

a. followed for 2+ years at the primary care practices affiliated with BWH/MGH between 2000-2010

b. at least one annual encounter with a PCP during the hyperglycemic period (defined on the next slide)

Materials and Methods

Unit of Analysis• Hyperglycemic period – a single period of continuous HgbA1c >

targetA1c

Time

End of study

Hyperglycemic Period 1 Hyperglycemic Period 2

Target

Outcome variable• Time to A1c < 7.0% = length of the hyperglycemic period

Materials and Methods

Exclusion criteria• No Zip code information (to adjust for median household income)• 2+ encounters with an endocrinologist• No medication records• Suspected HbA1c measurement errors (rate of HbA1c change >3SD

from the mean)• Transient elevations of HbA1c (a single elevated measurement

followed by a fall below the target at the next measurement with no interceding medication intensification)

Materials and Methods

Confounder variables• Age • Gender• Race/ethnicity• Primary language• Income • Health insurance• On insulin vs. not on insulin• Obesity (BMI > 30)• Charlson comorbidity index• Starting HbA1c level • Frequency of HbA1c testing• Frequency of documented lifestyle counseling • Frequency of anti-hyperglycemic medication intensification

Materials and Methods

1. Documentation Heterogeneity

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Predictor Variables

• Documentation heterogeneity: the normalized Levenshtein distance between lifestyle counsling sentences between consecutive notes.

• The Levenshtein distance between two strings is the minimum number of editing operations needed to transform one into the other.– Insertion of a character– Deletion of a character– Substitution of a character by another character

Levenshtein DistanceDocumentation Heterogeneity

Example 1

Example 2

Levenshtein Distance = 9

Levenshtein Distance = 5

• The Levenshtein distance divided by the length of the longer string

Levenshtein distance = 5Normalized Levenshtein distance = 5/11 = 0.45

11 characters

8 characters

Normalized Levenshtein Distance

Sentence length threshold • ≤100 characters per sentence; to exclude sentences composed of multiple

sentences without separating punctuations

Documentation heterogeneity calculability• Only 1 note with documented lifestyle counseling (i.e. documentation

heterogeneity incalculable)

Copy/paste notes• Lifestyle counseling documentation consisted entirely of copied/duplicate

sentences (zero documentation heterogeneity).

Additional Exclusion Criteria

Predictor Variables

2. Documentation Intensity

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…Assessment / Plan:

1. DiabetesA1c remains elevated- advised the patient to avoid food with high glycemic index (>40)- encouraged the patient to lower fat content in their diet- recommended a low fat diet, portion/calorie controlled meal such as Jenny Craig

2. HypercholesterolemiaLDL-C 125 mg/dL- increase simvastatin from 20 to 40 mg daily

John Jones, MD

…Assessment / Plan:

1. Diabetes: - A1c remains elevated.- advised weight loss- explained importance of replacing regular sodas with diet sodas for glucose control- recommended monitoring carbohydrate intake using experience-based estimation- discussed a referral to the diabetic education center for advice on diet

2. HypercholesterolemiaLDL-C on target- continue simvastatin 40 mg daily

John Jones, MD

…Assessment / Plan:

1. DiabetesA1c remains elevated- increase metformin from 500 to 1000 mg daily - patient was encouraged to get regular exercise- reviewed with the patient the importance of a low fat diet- recommended a higher consumption of fruits, vegetables, fiber, and lean meats

2. HypertensionUnder good control- continue current management

John Jones, MD

…Assessment / Plan:

1. Diabetes: - A1c remains elevated.- increased metformin from 1000 to 1500 mg daily- strongly encouraged the patient to follow a low fat, carbohydrate restricted diet- discussed a referral to the diabetic education center for advice on diet

2. HypertensionUnder good control- continue current management

John Jones, MD

Documentation Intensity: the mean number of characters per note dedicated to documenting lifestyle counseling

NOTE 1NOTE 2 NOTE 3 NOTE 4

153 characters 182 characters 141 characters 120 characters

Calculation of Documentation Intensity

14

(153 + 182 + 141 + 120) = 149

NoteID Sentence

0001 Extensive counseling on DASH diet, diabetes, and exercise interventions

0001 Counseled on diet and need for more vigorous daily exercise and caloric restriction

0002 DASH diet reviewed again

0003 Ongoing struggle father reports with dietary compliance

0003 Extensive counseling regarding diabetes mellitus including diet

0003 Recommended referral to nutritionist based on post visit labs

NoteID Sentence

0004 pt advised about weight loss

0005 pt advised about weight loss

0006 Has gained about 5 lbs since last visit

0006 pt advised about weight loss

Hyperglycemic Period 1

Hyperglycemic Period 2

Documentation Heterogeneity*

Documentation Intensity (characters/note)

Hyperglycemic Period 1 0.82 119Hyperglycemic Period 2 0.31 22.3

*Documentation heterogeneity represented by the normalized Levenshtein distance.

Sample Data

• Log-rank test to compare Kaplan-Meier curves for time to HbA1c target between tertiles by documentation heterogeneity and intensity.

• Marginal Cox proportional hazards models to estimate the association between time to HbA1c control and documentation characteristics while adjusting for covariates and accounting for clustering within individual patients

• P values adjusted for multiple hypothesis testing using the Simes-Hochberg method

Statistical Analyses

Results

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• 13,594 hyperglycemic periods included in the analyses.• 10,870 patients contributed to the hyperglycemic periods.• The NLP software identified 183,611 sentences from 92,671

provider notes.

Results

Patient Characteristics

Hyperglycemic Period Characteristics

*Documentation heterogeneity represented by the normalized Levenshtein distance.

Documentation heterogeneity and time to HbA1c control

Documentation heterogeneity*

Median time to HbA1c control

≥0.77 26 months0.71-0.77 36 months

< 0.71 39 months

Documentation intensity and time to HbA1c control

Documentation intensity†

Median time to HbA1c control

≥100 24 months68.7-100 38 months

< 68.7 39 months

†Number of characters per note

Values are hazard ratios for reaching a HbA1c < 7.0%. bP values <0.001 are significant after Simes-Hochberg correction.

Hazard ratios for associations between documentation characteristics and time to HbA1c control

Discussion & Conclusions

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• In this large, long-term retrospective study, we identified novel quantitative characteristics of electronic documentation of lifestyle counseling associated with improved glycemic control.

• This is the first study to describe an association between metrics of documentation characteristics and patient outcomes.

Discussion

• Documentation intensity may reflect the extent of the counseling provided. – e.g. More time spent on counseling, more detailed

instructions

• Documentation heterogeneity may reflect the variety of advice or the amount of new information content. – e.g. Trying a different diet or exercise approach after the

previous one did not work

Discussion

• Excluded ~ 1/2 of the patients meeting the initial inclusion criteria

• Documentation heterogeneity not applicable when <2 notes• Type 1 vs. type 2 diabetes• Notes by PCPs vs. notes by non-physician clinicians.• The accuracy of the NLP software • Retrospective study

Limitations

• Higher heterogeneity and higher intensity of lifestyle counseling documentation in narrative provider notes are associated with better glycemic control in patients with diabetes.

• Further studies involving direct observation of patient care are needed to establish the nature of the relationship between documentation characteristics and patient outcomes.

Conclusions

Dr. Anna Rumshisky, PhD• Assistant Professor of Computer Science,

UMass Lowell

Acknowledgments

Questions?

Naoshi Hosomura, DDS, DMScnhosomura@partners.org