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INNOVATION

Using information prescriptions in diabetes

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Diabetes UK has developed information prescriptions to give people with diabetes clear information and advice to help them improve their health outcomes

Abstract

Information prescriptions are designed to give people with diabetes the information they need to understand, engage with and improve on their health targets. The prescriptions are short, personal, easy to read and clinically accurate, and are designed to support care planning and behaviour change.

Citation: Rylance A (2015) Using information prescriptions in diabetes. Nursing Times; 111, 10, 12-13.

Author: Amy Rylance is head of healthcare professional engagement at Diabetes UK.

Introduction

The National Diabetes Audit for 2012-13 (Health and Social Care Information Centre, 2014) found that only 36% of patients with diabetes meet the National Institute for Health and Care Excellence’s recommended targets for the key outcomes: glycated haemoglobin level (HbA1c); blood pressure; and cholesterol (NICE, 2015). Failure to manage these targets increases the risk of developing complications such as kidney failure, amputations, blindness, heart disease or stroke.

Getting the clinical prescribing right is only half the battle; to help patients with diabetes live well and prevent devastating complications, we need to enable them to understand and engage with their diabetes. This needs to be done within a context of enormous pressure on primary care services, an ever-increasing number of patients with diabetes, and patients with more complex diabetes being treated in primary care.

At Diabetes UK, we spoke to diabetes nurse specialists, practice nurses, GPs and people living with diabetes about their experiences of diabetes care. One of the most striking things was how similar the concerns of professionals and patients were. Both used one particular phrase repeatedly: “tick-box exercise”. There was genuine frustration that the number of tests and time pressures meant that diabetes care was becoming purely a process of ticking boxes, with no opportunity to explore what matters to the patient or to change behaviour and therefore clinical outcomes. 

Our ambition was to create a tool that would support clinicians in making consultations engaging and personal for individual patients, while being sensitive to the immense demands on time.

Developing a new system

We developed information prescriptions, which enable a brief intervention to increase understanding, ownership and behaviour change. The prescriptions are designed to give people with diabetes the information they need to improve on their health targets. They are short (a single side of A4), personalised, easy to read and clinically accurate.

Information prescriptions need to target the patients at greatest need and give clinicians the tools to make an effective intervention in a matter of minutes. To support this, we worked closely with primary care information technology providers to integrate and embed the prescriptions into clinical IT systems.

Information prescriptions 

Information prescriptions are designed to be used in brief interventions. They may be used as part of a diabetes review or during other appointments. If a patient is outside the targets for glycated haemoglobin level (HbA1c), blood pressure and cholesterol, the IT system will generate a pop-up message informing the nurse that an information prescription is required. 

The prescription is generated and personalised with the patient’s details. The nurse and patient can then discuss the issues and agree an individualised prescription to meet the patient’s needs. This is then printed off and given to the patient; a copy is saved in the patient’s notes. 

The prescription can be used in discussions at subsequent appointments, with new information prescriptions creating an evolving record of ongoing care planning. The key characteristics of the system are summarised in Box 1. 

Box 1. Key characteristics

  • Targets those at highest risk: NICE guidelines were used to create prompt rules within the IT system. If a patient with diabetes fails to meet the NICE recommended targets for any of the three outcomes, the practitioner carrying out the review will receive a pop-up alert on opening the patient’s medical record.
  • Enables swift intervention: the pop-up links to an information prescription with the patient’s information automatically completed. 
  • Supports care planning: check boxes allow generic advice to be individualised, while the action plan box draws on the best evidence around behaviour change. 
  • Enables continuity of care: a copy of the completed information prescription is saved in the patient’s notes and can be recalled in future appointments to enable quick review of past goals; a copy is given to the patient to take home.
  • Signposts back to Diabetes UK for further support and information: during the pilot phase over 80 patients a month were visiting a unique web page given on the prescription, which offered information and guidance on diabetes. Since only three GP practices took part in the pilot, this suggests a high proportion of patients will want to seek further information.
  • Prevents pop-up fatigue: if an information prescription has been given, the system will not re-prompt clinicians for the same patient and same factor for six months.

Evaluation

Our evaluation to date has focused on the experience of using information prescriptions. Clinicians have given positive feedback on usability within the time constraints of a standard appointment. Patients report feeling more in control, and like having clear goals set out to help them improve their health. The feedback from nurses has been enthusiastic (Box 2).

Box 2. Case study: practice nurse

Sandi Kendall is a practice nurse in south London who was involved in the diabetes information prescriptions pilot scheme. 

Since I started using information prescriptions, I have noticed that my patients appear to retain more information and are much more aware about their diabetes. 

I’m sure this is because information prescriptions provide the chance to home in on and prioritise their specific problems and challenges. It gives patients the framework to understand that their lifestyle and behaviour does have an impact on their HbA1c, their blood pressure and their cholesterol. 

The format of information prescriptions has really opened my eyes about my patients’ knowledge about their diabetes, or rather the lack of it. One of my patients was drinking a large sweet shake every day and proudly told me he had made the “healthy” switch to a couple of digestive biscuits. 

Obviously, there is still work to do, but at least I feel I am having conversations with patients that shine a light on their problems. It has shown me that often we do need to go back to basics, and I shouldn’t assume someone understands diabetes just because they have had the condition for a while that just because someone has had diabetes for a while that they understand their condition.

The personalisation of the information prescriptions is what makes them so effective, especially with people from different ethnic groups. I tend to personalise them even more by talking about portion control and changing the balance of the amount of carbohydrates – which often make up a large part of African and South Asian diets. It can be hard to change behaviour when it is so culturally rooted, but information prescriptions are about the patient making changes to their behaviour that they can stick to in the long term. 

I have found that by encouraging patients to build additional exercise into their daily routines, such as walking children to school instead of taking the car, spending more time in the garden or taking the stairs instead of the lift, I am offering them solutions that don’t cost more money but they can embrace.

The fact that this is a “prescription” of advice and information seems to resonate with patients. They understand it’s not just a magic wand, but that they also have a part to play. 

It is still too early to tell whether we will see a significant improvement in numbers of patients hitting their targets, but I feel confident that, in the long term, information prescriptions will make a difference.

Following the initial launch of information prescriptions on EMIS Web in January 2015 and a subsequent launch on Vision (together, these two companies provide software to more than two-thirds of GP surgeries in the UK), our focus is on maximising their use. To activate the information prescriptions on their system, practitioners should visit their IT provider’s support centre, which will contain all the instructions. 

In the coming months, Diabetes UK will continue to evaluate the effects of information prescriptions on clinical practice. This may lead to the development of topics in addition to the original three key outcomes targets of HbA1c, blood pressure and cholesterol measurements; we have already received requests for information prescriptions on erectile dysfunction and on preventing diabetes for patients at risk.

Key points

  • Only 36% of patients with diabetes meet NICE targets for key outcomes 
  • Patients need to better understand and engage with their diabetes to improve outcomes 
  • Diabetes UK developed information prescriptions to support brief interventions to increase understanding, ownership and behaviour change
  • Information prescriptions are short, personal, easy to read and clinically accurate
  • They help to make consultations more engaging and personal 
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