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Health IT Success Stories

Dr. Margot Savoy Uses Health IT to Improve Care Coordination for Patients with Diabetes

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Dr. Margot Savoy is Medical Director at Christiana Care Family Medicine Centers (FMC). FMC consists of two family medicine practices in Wilmington, Delaware – one practice in North Wilmington and another in downtown Wilmington. Together, the practices serve approximately 12,000 patients, ranging from newborns to the elderly. As Medical Director at FMC, Dr. Savoy is using FMC’s electronic health record (EHR) system to improve care coordination for FMC’s patients with diabetes.

Health IT Helps FMC Better Understand its Patient Population

In 2011, FMC became one of the first primary care practices in Delaware to be certified as a National Committee for Quality Assurance Patient-Centered Medical Home. In the process of redesigning the practice’s workflows and examining EHR data about FMC’s patient population, Dr. Savoy discovered some troubling statistics. Approximately 10% percent of FMC’s patients were diabetic. Among the North Wilmington practice’s patients with diabetes, 33% had uncontrolled hemoglobin A1c levels, and, among the downtown Wilmington practice’s patients with diabetes, 50% had uncontrolled hemoglobin A1c levels.

Dr. Savoy and her colleagues knew it was time to act. “We saw this as an opportunity to rethink how we care for our patients with diabetes,” explained Dr. Savoy. “Health IT helped us understand the problem and start improving health care quality.”

A New Approach to Diabetes Care

After establishing a baseline to work from, Dr. Savoy and her colleagues began using Health IT to improve health care quality for their patients with diabetes. With the EHR system, Dr. Savoy and her colleagues were able to generate lists of patients with diabetes and begin targeting patients for health care quality improvement. “We could see which of our patients with diabetes had uncontrolled hemoglobin A1c levels and which of our patients with diabetes had not come in for an appointment in the past three years,” said Dr. Savoy. “Being able to quickly see which patients needed follow-up care enabled us to formulate new strategies for improving diabetes care.”

Next, FMC hired a care coordinator, who used patient lists generated by the EHR system to proactively reach out to patients to schedule appointments. The care coordinator also helped to link patients with other important resources, such as referring patients to FMC’s diabetes education classes or connecting patients with specialists for eye exams. “With Health IT, we have the data we need to engage the entire care team in diabetes care,” said Dr. Savoy. “This process is improving care coordination and health care quality for our patients with diabetes.”

Improved Outcomes for Patients with Diabetes

Since FMC began using its EHR system to improve diabetes care, Dr. Savoy and FMC have seen significant improvements in patient outcomes. In the North Wilmington practice and the downtown Wilmington practice the percent of patients with uncontrolled hemoglobin A1c levels dropped from 36% to 27% and from 43% to 35%, respectively. Furthermore, Dr. Savoy believes the increasing number of new patients with diabetes coming to FMC is also a good indicator of FMC’s success. “EHRs and Health IT have helped us improve health care quality for our patients with diabetes,” explained Dr. Savoy. “Through word of mouth, we are attracting more patients to FMC who hear about our high-quality diabetes care.”

As for next steps, Dr. Savoy plans to continue using Health IT to improve diabetes care at FMC. FMC is collaborating with the American Medical Association and YMCA on a diabetes prevention program. Additionally, as Clinical Co-Chair of Million Hearts Delaware, Dr. Savoy is looking forward to using Health IT to improve cardiovascular health in her practice and across the state of Delaware.