The Bettering Lives Utilizing Electronic Systems (BLUES) Project: Improving Diabetes Outcomes in Mississippi with Health Information Technology (Mississippi)

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The Bettering Lives Utilizing Electronic Systems (BLUES) Project: Improving Diabetes Outcomes in Mississippi with Health Information Technology - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality through Clinician Use of Health IT (R18)
  • Grant Number: 
    R18 HS 017233
  • Project Period: 
    September 2007 - September 2011
  • AHRQ Funding Amount: 
    $1,163,573
  • PDF Version: 
    (PDF, 195.05 KB)

Summary: The Delta Health Alliance (DHA), which has sponsored the Delta Diabetes Project (DDP) over the past several years, initiated the Bettering Lives Utilizing Electronic Systems (BLUES) Project in September 2007 to determine whether utilization of health information technology (IT) in diabetes management would enhance health care delivery and improve patient's health outcomes. This pilot project examined the cost-effectiveness of using well-designed, comprehensive health IT in diabetes management practices at several ambulatory clinics in Mississippi. The research team collected measures related to process and outcomes associated with diabetes, such as those for blood pressure, HbA1c, low-density lipoprotein (LDL) and patient satisfaction. Additionally, the study looked at the impact of health IT on medication management and timeliness of care.

Four diabetes management clinics participated in this study: two in an urban setting and two in a rural setting, each clinic employing the same model of diabetes care. Two clinics implemented an electronic health record (EHR) (one urban, one rural), and two remained paper-based practices (one urban, one rural). Outcome variables were measured at baseline and at 6-month intervals for a period of 2 years, yielding a maximum of five total time points.

Overall, the results in terms of EHR versus non-EHR sites were mixed, although the LDL results were consistent with a positive effect of the EHR. The lessons learned were invaluable in demonstrating that installation of EHRs alone does not improve outcomes for chronic disease; it must include significant clinician training, support, and use of health IT tools such as clinical decision support.

Specific Aims:

  • Implement an EHR system in two existing diabetes management clinics, focusing on integration of the EHR into clinician workflows. (Achieved)
  • Evaluate the impact of the EHR system on clinical processes of care and patient outcomes. (Achieved)
  • Produce and distribute a generalizable, replicable model of care for implementing an integrated health IT system for diabetes management care throughout the United States. (Achieved)

2011 Activities: During the initial data analysis in late 2010 and early 2011, one test clinic continuously demonstrated clinically different outcomes from the others. This difference caused the project team to review the methods used in the original queries to ensure they were the same as in the other test clinic. Upon further review, the team noted that there was a technological problem with one of the servers at the University of Mississippi Medical Center from which the data was pulled. This resulted in a significant difference in the way the data was pulled between the two test sites. Therefore, activities in 2011 focused on re-running the data and correcting the data issue with this clinic.

The project team used a 12-month no-cost extension to adjust the data collection between comparison sites and complete the project aims. Meanwhile, the team was conducting the background work to prepare for the data analysis and looking at comparative research to inform any potential journal articles that could result from this study. Once the data issue was resolved, data analysis was conducted relatively quickly and manuscript development began. As last self-reported in the AHRQ Research Reporting System, project progress was on track and project budget spending was on target. The project ended in September and the study team delivered a final report to AHRQ in December.

Impact and Findings: This pilot study provided many lessons about the implementation of EHR projects as well as necessary steps for improving health care and health outcomes for diabetes patients. The project revealed some inherent difficulties in collecting data in order to evaluate the impact of obtaining and using an EHR, such as the necessity of a paper chart control group and the large number of missing lab values in the initial EHR data. It is thought that as the EHR system continues to develop, the data generated from it will most likely improve.

Findings in this study indicate that simply deploying EHRs does not improve health care for diabetic patients. However, EHRs coupled with training and appropriate tools can result in improved process-of-care measures (timely and appropriate exams and lab testing, for example), greater patient satisfaction, enhanced diabetes-related outcomes, improved provider satisfaction, better medication management, increased patient safety, and reduced care-related costs. These findings imply that the promotion of best practices for disease management and care coordination in conjunction with the implementation of health IT improve health outcomes for patients.

The data and information collected from this study will be important in designing and securing future programs that are addressing the deficiencies often seen in the Mississippi Delta. Rural clinics need technological literacy and training to implement health IT, including EHRs, and serve a disparate population in a more connected way. Future studies might focus on how to best implement training programs in clinics to speed the process of EHR implementation and clinician training.

Target Population: Adults, Chronic Care*, Diabetes, Medically Underserved, Racial or Ethnic Minorities*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

The Bettering Lives Utilizing Electronic Systems (BLUES) - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS07-006: Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health Information Technology (IQHIT)
  • Grant Number: 
    R18 HS 017233
  • Project Period: 
    September 2007 – September 2011, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,163,573
  • PDF Version: 
    (PDF, 312.82 KB)


Target Population: Adults, Chronic Care*, Diabetes

Summary: The prevalence and incidence of diabetes in the U.S. are reaching epidemic proportions, especially in Mississippi. The Delta Health Alliance (DHA), which has sponsored the Delta Diabetes Project (DDP) over the past several years, initiated the Bettering Lives Utilizing Electronic Systems (BLUES) Project in September 2007 to determine whether utilization of health information technology (IT) in diabetes management would enhance delivery of health care and improve health outcomes of patients. The project examines the cost-effectiveness of using well-designed, comprehensive health IT in diabetes management practices at several ambulatory clinics in Mississippi. Additionally, the study looks at the impact of the health IT on clinical outcomes, medication management, and timeliness of care.

The BLUES project uses the Allscripts Electronic Health Record (EHR), a system that is certified by the Certification Commission for Health Information Technology. The research and measurement module of the EHR enables users to easily query patient records to review key clinical performance indicators. Data is centralized from different databases to combine information related to patient demographics, clinical outcomes, reported laboratory values, and medication history. An important capability of the EHR for this project is the system's ability to integrate and maximize the effectiveness of third-party technologies that aid diabetic care.

Four diabetes management clinics that employ the same model of diabetes care are participating in this study: two in an urban setting and two in a rural setting. One of the sites in each setting utilizes the health IT system, while the other does not. The timeline for this project coincides with independent plans to implement EHRs at these sites, which provides an invaluable opportunity to compare similar practices of health care providers and the health outcomes of their patients with and without use of a comprehensive health IT system.

Various data analysis methods are being used to measure the progress toward attaining the project aims. For example, clinician use of the various components of the EHR are being modeled as a continuous measure (percent or proportion) rather than a strict yes or no binary measure, and a mixed model analysis of covariance will be used to analyze the measure, controlling for fixed (clinic, time) and random (patient) effects. Individual generalized estimating equations are being used to model changes over time in the proportion of patients that access various components of the Patients Interactive Module. Lastly, a multivariate model is being used to investigate and measure changes from baseline to end-of-study.

Specific Aims:
  • Implement an EHR system in two existing diabetes management clinics, focusing on integration of the EHR into clinician workflows. (Achieved)
  • Evaluate the impact of the EHR system on clinical processes of care and patient outcomes. (Ongoing)
  • Produce and distribute a generalizable, replicable model of care for implementing an integrated health IT system for diabetes management care throughout the United States. (Ongoing)

2010 Activities: The DHA continued its legal, administrative, and technical work implementing an EHR system that is integrated into clinicians’ workflow at clinics in Jackson and Greenville, Mississippi. The research team met regularly via conference call throughout the year to review chart-pull progress, preliminary results, and protocols. This ongoing communication helped identify potential protocol and/or quality issues, including the discovery that some research assistants were pulling overlapping charts at the comparison sites. This discovery prompted a more strenuous review of the data, which identified the exact number of charts each clinic needed to provide in each time period to maintain the integrity of the study. Those charts were collected by year’s end and the data were entered into the database. Subsequently, the database was reviewed by the co-investigator and the data were cleaned again.

The team began to prioritize variables to be reviewed based on the research questions that are being considered. Analysis has begun but results have not yet been compiled. Preliminary reports are being run from EHR sites and are being used to test the EHR reporting process.

Some extenuating circumstances impacted the project timeline, requiring that a no-cost extension be utilized. The Jackson Medical Mall Internal Medicine Clinic changed ownership in August 2010. Management of the clinic now falls under Jackson-Hinds Comprehensive Healthcare, rather than the University of Mississippi Medical Center. This change in ownership limited access to the charts for a short period of time, but chart abstractions resumed shortly after. As mentioned above, all chart abstractions, including abstractions to replace duplicate charts, were completed by December 31, 2010. Notification of the change in ownership also required an institutional review board amendment be made, and a related amendment to request a HIPAA waiver to review medical records without patient authorization.

Numerous presentations on the BLUES project were made throughout the year, including; 1) a poster presentation at the Agency for Healthcare Research and Quality Heath IT Grantee and Contractor Conference in June 2010; 2) a presentation of preliminary data at the American Health Information Management Association Symposium in July 2010; and 3) a presentation of updated data at DHA’s EHR-Telemedicine Summit in November 2010.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): The project was granted a 12-month no-cost extension due to delays in data collection described above. Progress is on track to achieve all the aims and milestones set forth in the project. Below-budget spending at year’s end provided the resources to maintain the project staff allocations during the extension period.

Preliminary Impact and Findings: Due to the delays in data collection with the comparison sites, analysis has begun but findings are not available at this time. Preliminary reports from the EHR sites are being used to test the EHR reporting process.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Project Details - Ended

Project Categories

Summary:

The Delta Health Alliance and the University of Mississippi Medical Center (UMMC) collaborated on the Bettering Lives Utilizing Electronic Systems (BLUES) Project to evaluate whether the use of an electronic health record (EHR) in the management of diabetes would enhance health care delivery and lead to improved outcomes in patients. Specifically the study team looked at the ability of EHRs to facilitate patient outcomes tracking, improve provider communication, reduce medical errors, and improve quality of care. Four diabetes management clinics, all using the same model for diabetes care, participated in this study. Two of the clinics were in urban settings and two were in rural settings. One clinic in each setting used an EHR, allowing the project team to compare the health outcomes of patients with and without the use of technology. There were three outcomes of interest: hemoglobin A1c (HbA1c), low density lipoprotein (LDL), and blood pressure. Both quantitative and qualitative methods were used in the study.

The main objectives of this project were to:

  • Implement an EHR system in two existing diabetes management clinics, focusing on integration of the EHR into clinician workflows.
  • Evaluate the impact of the EHR system on clinical processes of care and patient outcomes.
  • Produce and distribute a generalizable, replicable model of care for implementing an integrated health information technology (IT) system for diabetes management care throughout the United States.

Findings from the EHR versus non-EHR sites were mixed. The LDL results improved at the EHR sites, indicating a positive effect of the EHR. Substantially lower levels of LDL were seen at follow-up versus baseline in both the urban and rural EHR clinics, and slight increases in LDL were seen in both the urban and rural non-technology clinics. Regarding HbA1C levels, there were small increases from baseline to follow-up, with the exception of a decrease in HbA1c levels seen in the rural non-EHR clinic. Changes in the percent of patients with an average HbA1c level below nine were small. Lastly, changes in blood pressures were minor with the exception of a sizable increase in the percent with low overall blood pressure in the rural non-EHR clinic, and a very large drop in the percent of patients with low overall blood pressure in the rural EHR clinic.

The project team concluded that the use of EHRs in and of themselves does not improve health care in diabetics. However, these findings can be used to imply that best practices for disease management and care coordination in conjunction with the implementation of health IT do improve health outcomes for patients. EHRs combined with adequate training and tools result in improved process of care measures, such as timely and appropriate exams and lab testing; greater patient satisfaction; enhanced diabetes-related outcomes; improved provider satisfaction; better medication management; increased patient safety; and reduced costs related to care.

The Bettering Lives Utilizing Electronic Systems (BLUES) Project: Improving Diabetes Outcomes in Mississippi with Health Information Technology - Final Report

Citation:
Fox K. The Bettering Lives Utilizing Electronic Systems (BLUES) Project: Improving Diabetes Outcomes in Mississippi with Health Information Technology - Final Report. (Prepared by Delta Health Alliance, Inc under Grant No. R18 HS017233). Rockville, MD: Agency for Healthcare Research and Quality, 2011. (PDF, 210.79 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
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Medical Condition: 
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