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DM & CKD Users Guide [pdf]
DM Users Guide [pdf]

Diabetes Standard of Care, 2015 [pdf]

PES Testing Intervals for DM and CKD, 2015 [pdf]

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About your DM & CKD Patient Query (4 minutes)



PES letters and reports

This diagram is an overview of the PES system. The right hand side of that diagram — "The Right Information at the Right Time" — refers to the letters and reports that PES prepares and delivers.

Download a two page summary of PES letters and reports here.

Letters to patients

Patients receive three different kinds of letters from PES. First is an Invitation Letter. This letter is mailed after a patient is confirmed as eligible and likely to benefit by their primary care physician. The letter explains how the system works and encourages patients to call us if they have questions. Two weeks after mailing the invitation letter patients become active. Once active, patients receive Alert Letters if some lab results are out of range, and Reminder Letters when lab tests are overdue.

Most of the letters we send to patients are reminders to obtain a lab test that is overdue. PES waits until a month after a lab test is overdue to mail the reminder, and we send individual patients only one reminder every 90 days. Therefore, the maximum number of reminder letters a patient can receive from PES is four a year. Alert letters are mailed in response to a specific lab result, for instance an LDL result greater than 130 mg/dl.

Reports to Providers

Five different kinds of reports are sent to clinic offices. We start with a New Patient Query (also see 4 minute video). This is how clinics confirm with us that they are managing the patient and that the patient is likely to benefit from the service.

Flow Sheets are sent to clinics every time an active patient has new lab tests. It looks a little like a lab report but is not the same thing. Note in the examples differences such as the inclusion of historical results for the same tests. This is to make it easy for both doctor and patient to understand trends. The PES flow sheet also includes very brief reminders that are based on clinical best practices.

Labs Due Work Lists (DM version) correlate to the reminder letter sent to patients. The standard work list is sent to clinics every Friday and includes all patients that are either 1) overdue no more than two weeks, or 2) will become due over the next two weeks. The timing is based on the expectation that clinics will successfully urge patients to have labs done before it is necessary to send a reminder letter to the patient.

Population Reports, CKD version (DM version) are typically sent quarterly. Including all you active and inactive patients, this report shows at a glance those patients that would most benefit from an intervention, especially any that otherwise might be lost to follow-up care. The first page dashboard of the report shows clinicians how their patients compare to all patients active patients and the top 10 percent of all providers. Many physicians have used this dashboard to discover opportunities for quality improvement in clinic workflow or practices.

If PES is mailing first class letters to patients the accuracy of the address is important. Patient addresses are initially obtained by either the client roster of eligible patients or the lab system. However, when patients move these sources may lag behind. When a patient letter is returned, PES staff makes every effort to correct or resolve the issue. Those times that proves impossible, we'll ask the clinic by sending our request for a Patient's Address.


Getting started with PES

PES is structured to be simple to learn and easy to incorporate into clinic workflow. Behind the scenes, PES is technologically sophisticated but for users it can be as simple as a fax machine. PES communications also integrate seamlessly with popular EHR systems, if desired.

Starting PES in a clinic includes a role for physicians, the practice manager, and practice staff. To start, PES and the physician (or clinic executive if applicable) need to agree to and sign a business associate agreement. This is the document that establishes the primacy of protecting patient health information and the HIPAA regulations that ensure it. You can read more about business associate agreements on the US Department of Health & Human Services website.

PES will then ask the practice manager to confirm the clinic's contact information, fax number, and communication preferences. The practice manager is also the person who will inform and educate clinic staff about PES.

The next step is to review the New Patient Query that PES provides. The roster lists all the patients that the data suggests are being managed by the physician. Once we receive confirmation that the physician is caring for the patient and that the disease condition exists we invite the patient to participate.

Many physicans create standing appointments and lab orders for patients that will need both on an ongoing basis.









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