Vulcan Medicine: How Better Records Led to Better Diabetes Care
Why should medical staff follow similar formats when filling in electronic health records? (Here's my recent post on why some doctors resist this.)
For one, it can lead to better patient care. This is what Dr. Randall D. Cebul at the Center for Health Care Research and Policy at Case Western Reserve University found in a study published in 2011 in the New England Journal of Medicine. Cebul and colleagues at Case Western, the Cleveland Clinic, and Ohio Permanente Medical Group took on the thankless task of combing health records for patterns in diabetes care and outcomes. They wrote:
We analyzed data from a retrospective cohort of primary care practices of seven diverse health care organizations that publicly reported achievement of quality standards for adults with diabetes between July 2007 and June 2010. Data reported here include the most recent yearlong cross section (July 2009 through June 2010) as well as practice-level trends across three years of reports. … From July 2009 through June 2010, a total of 27,207 adults with diabetes received care from 569 primary care providers in 46 practices of 7 care organizations.
That’s a decent slice of data to analyze. What Cebul wanted to find out was the percentage of those patients who received care that met clinical standards set by Better Health Greater Cleveland, the umbrella organization for health care providers in northern Ohio focused on using electronic health records and other tools to improve care. (Because electronic records are part of Better Health’s reason for being, one could argue that the results of this study need to be viewed with that potential bias in mind.)
Better Health’s care standards include four basic things that serve as indicators of whether the full care experience was high quality:
1. Whether a patient was given a blood sugar (glycated hemoglobin to be precise) value
2. Whether a patient was tested for kidney damage by checking urinary microalbumin levels or whether a patient was prescribed a drug that would help with high blood pressure (an angiotensin-converting–enzyme inhibitor or an angiotensin-receptor blocker)
3. Whether a patient was screened for vision loss caused by diabetic retinopathy
4. Whether a patient was given pneumococcal vaccination.
The first pass at the data showed that the health care facilities using electronic health records were much more likely to hit all of these quality scores.
In unadjusted analyses, between July 2009 and June 2010, 50.9% of patients at EHR sites, as compared with 6.6% of patients at paper-based sites, received care for diabetes that met all four standards, representing a difference of 44.3 percentage points. … These findings were similar but somewhat blunted in analyses that adjusted for insurance type, age, sex, race or ethnic group, language preference, estimated household income, and educational level.
If you’d like to read more about the statistical models they used to arrive at these conclusions, you can dive into the study’s appendix.
But what about patient outcomes? They may have received better care, but did they fare better overall? They wrote:
As in other studies, the association was stronger for 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.
Taking a look at the outcome standards, you can see why. Nearly all of them require longer term follow-through and significant patient buy-in:
1. Glycated hemoglobin value below 8%
2. Blood pressure below 140/80 mm Hg
3. Low-density lipoprotein (LDL) cholesterol below 100 mg per deciliter or documented prescription for a statin medication
4. Body-mass index (the weight in kilograms divided by the square of the height in meters) below 30
5. Nonsmoking status.
Still, the study found a big advantage in the electronic health record group.
For diabetes outcomes, 43.7% of patients at EHR sites and 15.7% of those at paper-based sites had outcomes that met at least four of the five standards, a difference of 28.0 percentage points.
The idea is that EHRs can improve care and outcomes by enabling physicians to coordinate care with other doctors and ultimately help them formulate treatment. Here’s what Cebul wrote in a guest column for the Cleveland Plain Dealer at the time of his study:
Tools in the EHR alert me to order tests that are recommended for my patients' conditions and offer on-the-spot information to guide treatment that reflects current laboratory information, allergies and immunization history. Results of tests recently ordered by my colleagues are available to me, just as the results of tests that I've ordered are available to them.
He also encouraged patients to get involved:
Ask your physician if she uses an EHR. If she doesn't, ask what she is doing to move in that direction. There are a lot of local resources to help her take the leap. If she already uses an EHR, ask how you can help improve your care. Most patients I know want better communication with their doctors and among their doctors. Most doctors want patients to get more involved in understanding and improving their health. The EHR provides valuable information to better help patients and doctors set and check up on their goals.
I’ll write more about the evidence supporting (and critiquing) electronic health records in future posts. If you have thoughts of your own, send them to askantidote [at] gmail [dot] com. Or write on Twitter @wheisel.
Image by Life Mental Health via Flickr