Electronic Medical Records and Diabetes Quality of Care: Results From a Sample of Family Medicine Practices

Crosson et al. Electronic Medical records and Diabetes Quality of Care: Results from a Sample of Family Medicine Practices, 2007, (5)3, 209- 215.

Introducing an innovative tool with a dazzling array of new functionalities into a traditional practice requires establishment of new goals and measures to define success. As medical directors for Lumetra, California’s Quality Improvement Organization, our experience shows that acquiring health information technology (HIT) is just one step in a transforming process that will lead to better quality of care, management of chronic illness, greater efficiency, and potentially greater reward under pay-for-performance programs.

We’ve provided technical assistance to more than 349 small and medium -sized physician groups since 2002 as the principal designers of the original Doctor’s Office Quality - Information Technology (DOQ-IT) pilot (with the highest physician adoption rate in the country - more than twice the national average); a special study that looked at diabetes care management with Electronic Health Records (EHRs) and now, as one of 4 states leading the Medicare Care Management Performance (MCMP) pay-for- performance demonstration project, all funded by the Centers for Medicare & Medicaid Services (CMS). From our vantage point, we respectively submit that this study attempts to measure an electronic outcome with an abacus. You don’t hand a new, innovative tool with a variety of functionalities to the same old practice and then look at the results to define success. Office systems and culture must be reviewed, evaluated, and likely re-designed.

Adoption and effective use of HIT does take some time, but even in the interim, physicians have better tools for patient care ranging from better prompts, a diabetic care flow sheet, and overall greater efficiency to improve care. For diabetic patients, a goal of using Electronic Medical Records (EMRs) is not to see patients more quickly when their A1bc is controlled; rather, it is to effectively monitor, treat, and use evidence- based guidelines for populations and see them in the office when it is not.

Effective use of EMRs support the physician, care team, and patient through individual and population management with clinical decision support, patient self-management, and effective care delivery system design. A large body of research has shown that the use of digital and accessible patient data, registries for population analyses, and embedded clinical decision support features enhance care quality. Furthermore, an effective communication portal for secure interaction between the patient and the care team will enhance diabetes care processes, treatment, and quality outcomes. We suggest that future studies use prospective, controlled research studies to determine the effects of workflow redesign and EMR technology integration, including interoperability, to advance quality diabetes indicators.

Finally, we agree with the authors that efforts to expand EMR use should focus not only on improving technology, but also on developing methods for implementing and integrating this technology into practice reality. That’s the right way to incorporate HIT and the right way to study it as we move forward.

Sincerely, James Lett, MD, CMD, Senior Medical Director, Healthcare Process Improvement, Lumetra and Joseph Scherger, MD, MPH, Consulting Medical Director, Informatics, Lumetra

Competing interests:   None declared

Crosson and colleagues expand on the existing EHR literature by examining commercially available EHRs that have been implemented in a wide variety of settings including community-based physician offices. The study used a large sample of 50 different practices. It is of further interest for its focus on diabetes mellitus, a key chronic condition.

The authors found that practices using an EHR were less likely to meet the standards for quality of care used as benchmarks for the study. A growing body of evidence and experience suggests that simply implementing an EHR may not be enough to improve quality because what matters most may be how the technology is used, not simply adopting the technology.(1, 2) The organizational change and workflow reengineering that accompany EHR adoption are critical to improving quality because this is where the capabilities of EHRs are translated into processes of care.(3)

Caution needs to be taken when interpreting the results of this study, however, due to important methodological limitations. Significant confounding between the outcome of interest and the choice to implement the intervention may account for the observed results. This study used a cross sectional cohort design and such designs can be particularly problematic in health information technology studies due to problems related to selection bias.(4) Of the 50 practices in the convenience sample, 13 used EHRs and 37 did not. It is likely that these two cohorts represent very different groups with respect to diabetes quality for a host of different factors outside EHR use.

Two very different quality-related hypotheses can be made for why practices implement an EHR. A priori, it is plausible to hypothesize that practices may choose to implement an EHR because at baseline they are either "high performers" who are committed to and able to improve quality further or are "low performers" who realize large scale changes need to be made in the care delivery process. This leads to potential confounding between the outcome of interest (diabetes quality) and the intervention (EHR use). Systematic differences in the two cohorts with respect to the outcome of interest and not only EHR adoption may account for the difference in observed performance in diabetes quality. The authors attempted to correct for practice differences statistically but such approaches cannot fully address this type of selection bias with respect to adoption of the intervention of interest - EHR adoption. In addition, the authors were only able to control for a limited number of covariates in their model.

For these reasons, some of the most important findings from this study come from corollary data that was collected regarding how the EHRs were being used. Two key finding from this study need to be highlighted: first, only 3 of the 13 EHR enabled practices had assembled a disease registry for diabetes; second, the authors report that there was no statistically significant differences in the use of clinical reminders between the EHR and non-EHR practices.

EHRs are an information management infrastructure. Their potential capacities need to be translated and integrated into the care delivery process. For complex chronic diseases, disease registries and decision support mechanism are key aspects to harnessing the potential of EHRs to improve care. If such potential capabilities either aren't part of the EHR system in question or aren't being utilized, the EHR becomes reduced to an electronic version of a paper chart rather than a tool that can enable new ways of delivering care.

Basit Chaudhry, M.D. UCLA Division of General Internal Medicine & Health Services Research

1. Hillestad R, Bigelow J, Bower A et al. Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs. Health Affairs 2005;24:1103-1117.

2. Milstein A. Health Information Technology Is A Vehicle, Not A Destination: A Conversation With David J. Brailer. Health Affairs 2007;26:236-241.

3. Miller RH, West C, Brown TM, Sim I, Ganchoff C. The Value Of Electronic Health Records In Solo Or Small Group Practices. Health Affairs 2005;24:1127-1137.

4. Garg AX, Adhikari NKJ, McDonald H et al. Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes A Systematic Review. JAMA 2005;293:1223-1238.

Competing interests:   None declared

Information systems that collect, integrate, and interpret patient data have been shown to be of value in the management of complex patients with chronic disease [1-3] but for many reasons, fewer than 25%.of primary care physicians use them. [4, 5] Crosson and colleagues examined differences in clinical care processes, treatment, and intermediate outcomes for 50 primary care practices in New Jersey and Pennsylvania, and have concluded that the promise of electronic medical records (EMRs) to improve the currently accepted standards of care continues to be the Holy Grail. [3] EMRs are not solutions in themselves, but are only one additional tool set that requires integration into the care delivery process. [2] This concept is further compounded by the unrealistic expectations of providers, health systems and policy planners, that this integration can and should occur as a result of the use of an EMR.

Additional problems with many current EMRs include: an emphasis on administrative and billing functions that require creative but often invalid use of administrative data for interpreting clinical outcomes; the requirement for expensive secondary data entry of clinical outcomes of interests (e.g. why was the study team required to do expensive chart review on a limited number of patients, when an information management system should be able to do this at a fraction of the cost and time), the lack of available real time data other than text capture; lack of common architectures and platforms between electronic systems; and a steep and long learning curve for the end user. The EMR should collect provider’s notes preferably in a structured format (to be available for analysis), integrate lab and other current and historical data for real-time access, provide decision support tools for feedback performance information to provider and patient, remind providers of routine preventive services, link to patient education materials and medication information, and facilitate prescription management monitoring for medication interactions or clerical errors.

Currently most healthcare institutions have realized the shortcomings of the lack of an integrated medical record in support of their information system, whether it is electronic or not. The key points are 1) an EMR is not an information system by itself and 2) it is appropriate for health systems and health policy planners to expect information systems to add value in improving quality of care.

1. Montori, VM, Dinneen SF, Gorman CA, Zimmerman BR, Rizza RA, Bjornsen SS, Green E, Bryant SC, et al., The Impact of Planned Care and a Diabetes Electronic Management System on Community-based Diabetes Care. The Mayo Health System Diabetes Translation Project. Diabetes Care, 2002. 25: p. 1952-1957.

2. Dinneen, SF, Bjornsen SS, Bryant SC, Zimmerman BR, Gorman CA, Knudsen JB, Rizza RA and Smith SA, Towards an optimal model for community- based diabetes care: design and basline data from the Mayo Health System Diabetes Translation Project. J Eval Clin Pract, 2000. 6: p. 421-429.

3. Montori, VM and Smith SA, Information Systems in diabetes: in search of the Holy Grail in the era of evidence-based diabetes care. Exp Clin Endocrinol Diabetes, 2001. 109: p. S358-S372.

4. Crosson, JC, Ohman-Strickland PA, Hahn KA, DiCicco-Bloom B, Shaw E, Orzano AJ and BCrabtree BF, Electronic Medical Records and Diabetes quality of Care: Results From a Sample of Family Medicine Practices. Annals of Family Medicine, 2007. 5(3).

5. Loomis, GA, Ries JS, Saywell RM, Jr. and Thakker NR, If electronic medical records are so great, why aren't family physicians using them? Journal of Family Practice., 2002. 51(7): p. 636-41.

Competing interests:   Accroding to Mayo Policy, I am one of 16 inventors of the Diabetes Electronic Management System for which any royalities that might result are to be used in support of diabetes education and research.

As someone who has seen her practice's quality improve from about the 50th percentile to the 95th for over 80 quality indicators partly because of using an EHR well, I think it is dangerous to assume from this article that EHR implementation worsens care. Along with other articles, it does show that just implementing an EHR does not improve quality. The conclusion: "The use of an EMR in primary care practices is insufficient for insuring high-quality diabetes care. Efforts to expand EMR use should focus not only on improving technology but also on developing methods for implementing and integrating this technology into practice reality."

This is right on target, but unfortunately, readers I've communicated with are not getting the punch line.

It is difficult to know how well you are meeting evidence-based practice guidelines if you have no data. It is extremely difficult to have data without an EHR. It is difficult to work on quality without data - the practitioner has no idea where the deficits are and what needs to be worked on, plus no feedback on improvement- all are critical to improvement efforts. Some EHRs have features that allow for improved health maintenance and chronic disease management. Using them well has been shown to improve quality care- see Different Paths to High-Quality Care: Three Archetypes of Top-Performing Practice Sites in this journal featuring qualities of best practices, for one.

The take home message of this article should be that without leveraging an EHR to improve care, care can decline rather than improve. It should not be that EHRs cause worsening of care. They can provide the tools for improving care dramatically. Because few EHR users measure quality or use them to improve quality, it is not likely the authors surveyed practices that were having success with quality improvement and using EHRs. EHR vendors should continue to work on improving the ease of data collection and the features that allow for health maintenance and chronic disease management. Providers with EHRs should leverage them to improve quality. This is not a passive process.

This article does provide useful information. Let's just keep it in context.

1. Ornstein SM, Nietert PJ, Jenkins RG, Wessell AM, Feifer C, Corley ST: Improving Diabetes Care through a Multi-component Quality Improvement Model in a Practice-Based Research Network. American Journal of Medical Quality, 2007, 22(1): 34-41 Website: http://ajm.sagepub.com/cgi/content/abstract/22/1/34 2. Ornstein SM, Jenkins RG, Nietert PJ, Feifer C, Roylance LF, Nemeth L, Corley S, Dickerson L, Bradford WD, Litvin, C: Multi-Method Quality Improvement Intervention to Improve Cardiovascular Care: A Cluster Randomized Trial, Annals of Internal Medicine, 2004; 141(7):523-532 http://www.annals.org/cgi/content/full/141/7/523 3. Nagykaldi, Zsolt PhD; Mold, James W. MD, MPH. The Role of Health Information Technology in the Translation of Research into Practice: An Oklahoma Physicians Resource/Research Network (OKPRN) Study. Journal of the American Board of Family Medicine. 20(2):188-195, March/April 2007. http://www.jabfm.org/cgi/content/full/20/2/188

Competing interests:   None declared