Family physicians who have been waiting for confirmation that the money they invest in an electronic health record, or EHR, will help improve patient care now have some firm data to consider. A recently published study found that medical practices that used EHRs provided higher-quality care to patients with diabetes than did paper-based practices.
The article "Electronic Health Records and Quality of Diabetes Care,(www.nejm.org)" which was published in the Sept. 1 issue of The New England Journal of Medicine, details the results of a study conducted by Cleveland-based researchers.
Practices participating in the study were measured based on four care standards for patients with diabetes:
- receipt of glycated hemoglobin value,
- testing for urinary microalbumin or prescription of an ACE inhibitor or an angiotensin-receptor blocker,
- provision of an eye examination to screen for diabetic retinopathy, and
- administration of a pneumococcal vaccination.
Researchers reported that in unadjusted analyses, 50.9 percent of patients at medical sites using EHRs received diabetes care that met all four standards compared with 6.6 percent of patients seen at sites using paper-based records.
Practices also were measured based on five standards for intermediate outcomes for patients with diabetes:
- glycated hemoglobin value below 8 percent,
- blood pressure below 140/80 mm Hg,
- LDL cholesterol below 100 mg per deciliter or documented prescription for a statin medication,
- body mass index below 30, and
- nonsmoking status.
- A new study finds that medical practices using electronic health records provide better diabetes care with better patient outcomes than do paper-based practices.
- Nearly 60 percent of patients at EHR sites received care that met all four care standards measured in the study.
- Just 6.6 percent of patients at paper-based sites met all four care standards.
- An AAFP expert on EHRs notes that the functionality of an EHR plus a practice's commitment to quality improvement are necessary components for good patient outcomes.
Study results showed that 43.7 percent of patients at sites using EHRs and 15.7 percent of patients at sites using paper-based records met at least four of the five intermediate outcome standards.
The study looked at a data for 27,207 adults with diabetes seen at 46 practices and cared for by 569 health care professionals, including family physicians, internists, pediatricians, nurse practitioners and other clinicians with prescription-writing privileges.
The study, conducted from July 2009 through June 2010, included data on patients with diabetes who were 18-75 years of age and who made at least two visits to the same primary care practice during each yearlong measurement interval.
Data from participating primary care practices -- many of which qualified as safety-net primary care practices -- were measured on nine quality standards for diabetes that were approved by the clinical advisory committee of a regional quality collaborative organization known as Better Health Greater Cleveland. All participating practices belonged to Better Health and publicly reported their performance.
Researchers adjusted for covariates including patients' insurance type -- Medicare, Medicaid, private or uninsured -- race and ethnicity, age, gender, estimated household income, and level of education. They noted that, "Across all insurance types, EHR sites were associated with significantly higher achievement of care and outcome standards and greater improvement in diabetes care."
Furthermore, the researchers noted, "as in other studies, the association was stronger for (medical) care -- which is largely under the direction of providers -- than for outcomes, which also require supportive home and neighborhood environments, active patient engagement, and other resources that foster adherence to prescribed regimens."
Study researchers also pointed out that their study results were in sharp contrast with those of other recent studies and concluded that their findings "support the premise that federal policies encouraging the meaningful use of EHRs may improve the quality of care across insurance types."
Neil Siegel, M.D., of Silver Spring, Md., is the medical director of ambulatory clinical informatics at the University of Maryland Medical System in Baltimore. He told AAFP News Now that the study was well done and the results encouraging.
However, he added, there's more work to be done.
Siegel, who also is clinical assistant professor of family and community medicine at the University of Maryland School of Medicine, said it was disappointing -- at least from a quality improvement standpoint -- to read that the EHR practices in the study achieved only 51 percent of recommended care measures per patient overall and 43 percent of the desired outcomes overall.
"And those were the better results; the paper-based practices did significantly worse than that," said Siegel. "It still means that about half of patients are not getting all of the highest-quality care they need even in practices using an EHR.
"It supports the point that we in the quality and the EHR world often make: that just using an EHR doesn't make you a quality doctor -- you really have to pay attention to the quality measures consistently," said Siegel.
Steven Waldren, M.D., director of the AAFP's Center for Health IT, agreed. "I'm not surprised that researchers in this study were able to demonstrate a higher quality of care with EHRs," said Waldren. "But an EHR as just a piece of technology is insufficient. It's the functionality of the EHR plus a practice's commitment to quality improvement that work together to achieve the desired patient outcomes."
Waldren told AAFP News Now that he would like to have had more information about the functionality of the EHRs that were used in the 46 practices that participated in the study.
He referenced a previous AAFP survey conducted for internal use in which EHR users were asked a series of questions about what functions their EHR systems supported and which of those functions were being used. "We found that those functions that drive quality were not used as often as some other functions of the system," said Waldren.
Certain functions, a point-of-care registry, for example, allow physicians to easily identify their patients with a chronic disease, such as diabetes, and give medical practices the ability to quickly access critical patient data, such as a hemoglobin A1c level or the date of the patient's last eye exam.
Siegel said disease registries are a popular EHR tool at the University of Maryland. "If we know every diabetic patient needs a flu shot starting in September, we can pull up one list of all diabetic patients and contact them," said Siegel. It can be done by mass mailing, automated telephone calls or, for patients who have signed up with a patient portal, via a message sent to patients' home computers reminding them they need to come in for a flu shot.
Siegel noted that all of the primary care physicians in each of the university's three community primary care sites had achieved recognition from the National Committee for Quality Assurance, or NCQA, for providing excellent quality diabetes care.
That significant achievement was accomplished, said Siegel, through physicians' use of EHR tools in clinical care as well as the use of EHR reporting tools "to document and show (NCQA) that we were providing that care," said Siegel.
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