Quality of Care and Electronic Medical Records: Implications of Increased Adoption and Meaningful Use.
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1 Quality of Care and Electronic Medical Records: Implications of Increased Adoption and Meaningful Use. RD Cebul 1,4, TE Love 1,4, AK Jain 2,4, CJ Hebert 3,4 MetroHealth Medical Center at Case Western Reserve University 1, Cleveland Clinic 2, Kaiser Permanente Ohio 3, Better Health Greater Cleveland 4 Supported in part by the Robert Wood Johnson Foundation
2 EMR Effects on Quality and Cost Incentives for EMR adoption anticipate a qualityrelated ROI Data are scarce re: EMR adoption among priority primary care providers (PPCPs) For whom EMR adoption is supported by HIT Regional Extension Centers (RECs) Data are mixed re: both QI and cost savings Positive results (eg, Group Health, Geisinger) w/o paper-based comparators; these/others w/o PPCPs Widely cited negative studies use inadequate and dated survey data
3 Regional Collaboratives Roles Regional collaboratives are proliferating for quality improvement, public reporting, and pilots of PCMH etc; eg, RWJF Aligning Forces for Quality (AF4Q) communities; AHRQ Chartered Value Exchanges, Beacon Communities, NRHI, other test beds to evaluate EMR effectiveness and refinements in national payment policy 1 Better Health Greater Cleveland 1 of 16 RWJF-supported AF4Q markets 1. Clancy CM, Anderson KM, White PJ. Health Aff (Millwood ) 2009;28(2):478-82
4 Fundamentals of Better Health Primary Care/QI for chronic conditions DM (27K), HBP (108K), HF (5K) Nationally endorsed, locally vetted standards Electronic Medical Records-catalyzed For measurement and twice-yearly public reporting Patient-level data stratified by insurance, race/ethnicity, language preference, and estimated household income and educational attainment Accountability Attribution at practice level
5 Objectives To compare achievement and trends in care and outcomes of EMR- and paperbased practices for adult patients with diabetes Overall, and stratified by insurance type For Composite standards for Care and Outcomes as well as individual metrics
6 Methods Setting: Cuyahoga County/Cleveland Subjects: For Achievement ( ): 27,207 diabetic patients (18-75 years old, > 2 visits) 569 PCPs in 46 practices of 7 HC systems For Trends in Achievement ( ) ~26,000 patients; 36 sites reporting all periods
7 Methods Dependent Variables: % of patients meeting composite standards for Care (4 stds: measured as all-or-none) and Outcomes (5 stds: measured as >4) Analyses: Weighted GEE within insurance strata to estimate the differences in percentages of EMR vs. paper-based systems meeting standards Adjusting for age, sex, race/ethnicity, income, education, and language preference, accounting for clustering Trend models include baseline value as a covariate, omit language preference Secondary analysis restricted to safety net practices only: more likely to consist of Priority Primary Care Providers
8 Baseline Comparisons of EMR, Paper Sites Overall: EMR site patients more likely to be: older (58.3 vs years) white (56.1 vs. 15.2%) insured by Medicare (36.7 vs. 20.2%) or commercial insurers (47.6 vs. 9.9%) wealthier ($42K vs. $28K) and more educated (80 vs. 72% HS graduation rates); English language preferrers Safety Net Practices (SNP): 10,280 patients (37.8%) were cared for in SNPs, including: 7620 EMR sites, 2660 from paper-based sites. Patients from SNP EMR sites were much more similar to patients from SNP Paper sites
9 EMR Effect is Large, Larger in Care than Outcomes, and Similar in SNP Sample EHR - Paper Difference (adjusted) Care Composite Outcome Composite All Patients Safety Net All Patients Safety Net
10 Patients in EMR Sites Achieve Better Across All Payers ( ) EHR - Paper Difference in (adjusted) Care Composite Outcome Composite Medicare Commercial Medicaid Uninsured Medicare Commercial Medicaid Uninsured
11 40 EMR Sites Achieve Better on 8 of 9 Quality Standards EHR - Paper Difference in (adjusted) A1c Done Care Standards Kidney Mgmt Eye Exam Pn Vax A1c < 8 BP < 140/80 Outcome Standards LDL < 100 or Statin BMI < Not Smoking
12 EMR Sites Also Improve Faster: Differences in Improvement/Year by Payer EHR - Paper Difference in Trend (adjusted) Care Composite Outcome Composite
13 Summary EMRs were associated with: Better achievement Faster improvement Across payers Across all care standards and most outcome standards For adults with diabetes In the context of a Regional Health Improvement Collaborative
14 Our Results Differ from Some Others: Potential Explanations 1. Better Health is a region-wide collaborative with common metrics, a QI Learning Collaborative, sharing of EMR Best Practices, public reporting LC highlights meaningful use of EMRs (registries, CDS, pop mgmnt, PHRs) for agreed-upon conditions and metrics
15 Our Results Differ from Some Others: Potential Explanations 2. Better Health s EMR sites are sophisticated users with generally more advantaged patients - all paper sites are safety net practices Possible inadequate adjustment for patient, provider, site, or organization factors But results are virtually identical when sample is restricted to only safety net systems; systems more likely to include Priority Primary Care Providers
16 Comments 1. This report raises cause for optimism that incentives for EMR adoption and Meaningful Use, at least in the context of a Regional Health Improvement Collaborative, can improve quality. 2. This investigation does not: Address cost reductions Demonstrate year-over-year changes in the same organizations After EMRs have been adopted and used meaningfully
17 Thank you
18 Sharing the experience of new adoption
19 Accelerating Improvement, Reducing Disparities In Diabetic Eye Exams 70 All Other Organizations 63 % of Diabetes Patients with Eye Examination FQHCs 59 FQHCs Transition to EMRs Better Health Reporting Period
20 Learning Collaborative Summit March 5, 2010
21 Individual & Composite Standards
22 EMR vs Paper Achievement: ,000 patients 109,000 patients
23
Electronic Health Records and Quality of Diabetes Care
SPECIAL article Electronic Health Records and Quality of Diabetes Care Randall D. Cebul, M.D., Thomas E. Love, Ph.D., Anil K. Jain, M.D., and Christopher J. Hebert, M.D. A bs tr ac t Background Available
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