Metrics for Doctors and Patients

Electronic health records can improve processes of care as well as real health outcomes for diabetic patients. However, it is critical that patients themselves are held accountable for their own health and given the tools to do so.

The ability of electronic health records (EHRs) to improve healthcare quality and safety through improvements in care coordination and reductions in medical errors and duplicative care is widely accepted. However, very few studies clearly show quality-related advantages of EHRs over traditional paper-based record systems, particularly in outpatient primary care practices. It is presumed that improvements in outpatient care of chronic diseases will have a substantial effect on health related outcomes thereby preventing inpatient admissions and their associated costs. As costs are one of the prevailing targets of the Affordable Care Act (ACA) legislation and a major driving force for change within the healthcare system, it makes sense to explore this potential effect. Thus, researchers sought to compare available diabetes-related quality data between outpatient EHRs versus paper-based records.

The study design was that of a retrospective cross-sectional cohort analysis over one year of patients and their interactions with primary care outpatient practices in the Cleveland area. The research was supported by the Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q) program. The researchers hypothesized that practices using EHRs would have higher achievement of composite standards for diabetes care and outcomes than those sites with paper-based record systems. Among the 46 primary care practices assessed, 33 practices used EHRs and 13 practices used paper-based record systems.

The practices with paper-based record systems were more likely to treat minority patients with Medicaid or uninsured patients with an overall lower median income and lower high-school graduate rate. A total of 27,207 adults with diabetes who made at least 2 visits to the same provider within the year were assessed.

The primary outcomes of the study were the composite diabetes-related process measures (measurement of HbA1c%, measurement of urine microalbumin, annual eye exam screening for diabetic retinopathy, prescriptions for angiotensin-converting-enzyme inhibitor or angiotensin-receptor blocker, receipt of pneumococcal vaccination) and the composite diabetes-related health outcomes measures (HbA1c<8%, blood pressure <140/80, LDL <100mg/dL or use of statin drug, BMI<30, nonsmoker). After factors likely to affect the quality care and health outcomes – type of insurance, ethnicity, age, sex, household income, and level of education – were adjusted, the EHR practices achieved 35.1 percentage points higher for composite diabetes process measures and 15.2 percentage points higher for composite diabetes outcomes measures. The study did not address measures of patient engagement.

Commentary

This study concludes with the suggestion that outpatient  process improvements initiated by physicians, such as those  intrinsically linked with many EHR decision support tools, lead to improved diabetes-related health outcomes. However, diabetes is a unique chronic disease in which the decisions most affecting the health and well-being of patients are made by the patients themselves. In addition to physician-oriented change, critical innovations which target patient engagement are necessary to translate actions and impact into diabetes-related health outcomes, improved quality, and decreased costs.

Mobile health technology offers metrics of patient engagement (such as the number of times patients utilize their diabetes-management app, access their mobile PHR records, or upload blood sugar values). These metrics assess the potency of diabetes care at the patient-level, and correlations can be made with diabetes-related health outcomes such as HbA1C. Physician process improvements that then create positive changes in patient engagement would be more likely to affect diabetes-related health outcomes, quality, and costs. For instance, is it more important that the physician order the HbA1C or that the physician instruct the patient to monitor their daily blood sugar?

Combined, EHR technology and mobile health provide tremendous opportunities to improve quality of care due to their ability to measure and monitor. However, such measurement and monitoring must not only occur at the physician level but also at the patient engagement level when it comes to chronic diseases such as diabetes where patient choices strongly correlate with health outcomes.

Cebul, RD, et al. Electronic Health Records and Quality of Diabetes Care. NEJM 2011; 365: 825-833.

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Jennifer Shine Dyer, MD, MPH, FAAP