Integris Health: Stanley Hupfeld, President & CEO

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Are patients in your hospital being placed at risk unnecessarily every time they enter your surgery suite or get admitted to your ICUs? Will they have more complications, post operative infections and returns to surgery? If your facility is like most across the United States, the answer is YES! And undiagnosed hyperglycemia may be to blame.

It is no secret that a handful of high cost/ high risk diseases account for most health care costs today. Abnormal glycemic control/diabetes either by itself or with other chronic conditions and complications is one of the greatest offenders. According to 2007 data from the Centers for Disease Control, 23.6 million people in the United States had diabetes at a cost of $174 billion in direct and indirect costs. This reflects an average increase in diabetes of more than 90 percent within the last decade.

Type 2 diabetes was once considered a disease associated with aging; now, new cases of diabetes and other metabolic disorders are being diagnosed in rising numbers in youth and young adults. This means employers are facing mounting employee health care costs and suffering from the effects of lost productivity.

Hospitals and their patients are making a significant contribution to these escalating costs of care and paying the additional price of costly co-morbidities and complications. In addition, hospitals are receiving inadequate reimbursement by not capturing the appropriate spectrum of services being provided. The culprit is unrecognized hyperglycemia with or without diagnosable diabetes. Nationally, the identification of inpatients with primary diabetes mellitus (ICD9 250) or diabetes as a secondary/concurrent condition has been relatively flat at 11 percent of the inpatient population. The medical literature has convincingly demonstrated that significant inpatient hyperglycemia (AACE consensus statement targets fasting plasma glucose > 110 mg/dl or random glucose >180) actually occurs in approximately 40 percent of the inpatient population. These patients, if unrecognized and untreated, suffer increased mortality, longer lengths of stay, higher complication rates particularly with infection, and require more subsequent nursing home care.


Recognizing this, INTEGRIS Health, an integrated health care delivery system located in Oklahoma, began an inpatient effort in 1997 at INTEGRIS Baptist Medical Center to improve the quality of care for patients with hyperglycemia. This inpatient effort was a collaboration between INTEGRIS and the ediba Diabetes Center of Excellence, a diabetes education company, with championship by endocrinologist John S. Muchmore, M.D., Ph.D. Initiative results from FY 1997 – FY 2005 were as follows:

  • Increased identification of patients with hyperglycemia/diabetes
  • Improved appropriate coding resulting in increased reimbursement
  • Decreased geometric mean length of stay for patient with diabetes
  • Reduced gap between length of stay for patients with and without diabetes
  • Decreased readmission of patients with secondary diabetes
  • Improved financial performance returning $4 for each $1 invested in the program.[i]

Though the inpatient initiative showed considerable success, it was clear that being able to maintain the gains achievable during a four to five day inpatient stay under controlled conditions is not sufficient in many cases to meaningfully impact the longer term aspects of the disease.

Diabetes doesn’t go away. Many patients, at discharge, lack a primary care physician or specialist to assume an evidence-based program for long-term management of their disease. It was obvious there was a need for an ambulatory program to reduce the incidence of diabetes co-morbidities and complications not only for INTEGRIS inpatients, but also for medical staff members and their patients as well as INTEGRIS employees and their dependents. INTEGRIS had tried several independent third party claims administrator based disease management programs during the last several years without great success.


Evident Health Services was founded to provide this ambulatory care follow-up resource to meet the need for evidence based diabetes management. It provides disease management services with a focus on prospective risk screening, evidence-based management protocols, and proactive collaboration with patients and their primary care provider.

The goal is to identify cardiovascular and/or diabetes risk and intervene early to achieve as closely as possible the outcome goals as established by the American Association of Clinical Endocrinology. A clinical entity, Evident Care Clinic, was created to enable at-risk patients to be evaluated and an individualized plan of care to be developed and implemented. A case manager provides follow-up with patients to monitor progress and support behavioral and plan of care success. An electronic health record is used to capture discrete data for objective outcome reporting.

The Evident Health Services/ Evident Care Clinic offer INTEGRIS both a resource prepared to receive discharged inpatients for ongoing evidence-based management and a resource to the entire INTEGRIS system medical staff who have difficulty referring patients with diabetes to the limited number of endocrinologists practicing in Oklahoma. The Evident model also provides a proactive and focused program to identify INTEGRIS employees and dependents with cardiovascular and/or diabetes risk. Prior disease management/diabetes programs used retrospective claims data to identify at-risk individuals and depended on telephonic case management to identify patient problems. The Evident model’s prospective process offers a potentially more robust program to identify and effectively manage individuals at risk.

Literature indicates the earlier chronic disease is identified and an effective treatment initiated, the better the clinical outcomes can be for the patient. Plus, losses due to related health care costs and lost productivity are reduced. A key advantage of the Evident model is the combination of prevention, early detection and disease status assessment as well as direct patient care. This is achieved through risk screening, lab confirmation, and administrative claims data and pharmaceutical utilization analysis. Results are factored together to find those already diagnosed, diagnosed but in poor control, undiagnosed and those with “pre-diabetes” risk factors who are likely to develop cardiovascular disease and/or diabetes at a later date. By having the evaluation and individualized plan of care developed in the Evident Care Clinic, an opportunity exists to provide busy primary care physicians with a tool to reduce the variation in application of evidence-based practice and improve their patient’s glucose control.

In 2007, risk screens were sent to a trial group of 4800 employees (a combined total of approximately 11,000 covered lives) and 782 responses were returned. Of these, 254 were found to have confirmed cardiovascular disease and/ or diabetes risk. Only five of the patients with diabetes were found to be within recommended control limits. Patients with inadequate control were referred to Evident Care Clinic where assessment and individualized plans of care were developed. The risk screen response in the first half of 2008 has been even higher. More than 1,550 screens have been received and an additional 293 at-risk individuals have been identified and are being scheduled for lab test confirmation. While individual patient results have been positive, aggregated outcome reports are pending until sufficient longitudinal data is gathered in the electronic health record to generate meaningful results.

The initial successes in inpatient management of hyperglycemia have been clear and INTEGRIS continues to improve and refine the program as it rolls it out to the other hospitals in its system. The full outpatient program through a contract with Evident Health Services began in 2007 and was limited to the employees and dependents at INTEGRIS Baptist Medical Center in Oklahoma City. In 2008, the full program was expanded to the three other Oklahoma City metro area INTEGRIS hospitals and all other employees and their dependents in the metro area.

Evidence is mounting that employers can work as partners and collaborators with health care providers to implement wellness initiatives to improve the health and well being of their employees and families. The goal of the Evident model is to demonstrate that in time INTEGRIS Health will have credible data showing improved clinical outcomes, financial improvement in health care costs and improved productivity and satisfaction from their employees. If successful, it will reinforce the idea that enlightened proactive programs, well executed and integrated, can be a win for everyone.

Charles A. Bryant, M.D., president of Evident Health Services, is a pediatrician and champion for early recognition, intervention and aggressive management of disease risk. He was vice president of Clinical Integration for INTEGRIS Health before leaving to found EHS. He worked closely with Dr. Muchmore and ediba Diabetes Center of Excellence during the development of the inpatient initiative. Dr. Muchmore is medical director of Evident Health Services. Stanley Hupfeld is the president and chief executive officer of INTEGRIS Health.

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