Impact of Health Information Technology Implementation on Diabetes Process and Outcome Measures (Texas)

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Impact of Health Information Technology Implementation on Diabetes Process and Outcome Measures - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality Through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 020696
  • Project Period: 
    June 2011 – May 2013
  • AHRQ Funding Amount: 
    $299,985
  • PDF Version: 
    (PDF, 342.88 KB)

Summary: Diabetes is an increasingly common chronic disease that requires long-term management. Currently, the health care provided to patients with diabetes frequently falls short of the “best care” practices established in evidence-based clinical guidelines. The primary objective of this observational study is to quantify the effects of a commercially-available ambulatory electronic health record (EHR) on quality of diabetes care, as measured by compliance with recommended processes of care and patient outcome measures. The EHR includes diabetes care prompts and a diabetes management form (DMF), a condition-specific documentation tool that integrates data review, real-time evidence-based clinical decision support, order entry, and patient education.

The study was conducted in the Baylor Health Care System HealthTexas Provider Network, which implemented an EHR in a staggered fashion across its practices between 2006 and 2008. The primary aim is to test the impact of the EHR on the quality of diabetes care, as measured by the Health Partners “Optimal Diabetes Care” composite measure with retrospective chart audit data. This composite measure includes hemoglobin A1c (HbA1c), cholesterol, blood pressure, aspirin prescription (for patients age ≥40 years), and smoking status. Secondary aims include testing the impact of the EHR on these included measures separately, and on compliance with recommended processes of diabetes care. This study is also investigating the prevalence of voluntary physician use of the DMF embedded within the EHR, and determining the effect of DMF use on patient outcomes.

This study will provide important information about the potential for an EHR to improve quality of diabetes care, including insight regarding the potential of and need for disease-specific EHR components to effect improvement.

Specific Aims:

  • Estimate the impact of an EHR on diabetes outcomes, measured by the proportion of patients meeting the Health Partners Optimal Diabetes Care measure. (Achieved)
  • Estimate impact of an EHR on specific patient outcomes and compliance with recommended process of care related to diabetes. (Achieved)
  • Estimate the prevalence of physician use of the Diabetes Management Form, and the effect of the Diabetes Management Form on patient outcomes related to diabetes as measured by the Optimal Diabetes Care measure. (Achieved)

2012 Activities: In 2012, the research team focused on the analysis of the third aim, to examine the relationship between use of the DMF and patient process and outcome data. To complete this analysis, the research team had to link two separate datasets: 1) data generated over the prior 5 years that documents and populates pre-defined fields and measures focused on diabetes care; and 2) data from the DMF that is part of the EHR. Analysis for this aim was completed and a manuscript describing the results was developed and submitted to Health Services Research for an information technology-focused special issue. Preliminary results from this aim were also presented at the AHRQ Annual Meeting in September.

Dr. Ballard and his team wrote a manuscript describing the analysis of the impact of the EHR on processes and outcomes of diabetes care, The Effectiveness of Implementing an Electronic Health Record on Diabetes Care and Outcomes. This manuscript was published by Health Services Research in August and was selected by the editorial staff as the 2012 John M. Eisenberg Article-of-the-Year, an annual award established in 2003 that recognizes excellent and original research among all articles published in the journal during the year.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are completely on track, and project budget spending is on target.

Preliminary Impact and Findings: After adjusting for patient age, sex, and insulin use, patients seen in the EHR practices were significantly more likely to receive optimal care when compared with those from the non-EHR practices. Components of the optimal care bundle showing positive improvement after adjustment were systolic blood pressure <130 mmHg, diastolic blood pressure <80 mmHg, aspirin prescription, and smoking cessation. Among patients in the EHR practices, all process and outcome measures, except HbA1c and lipid control, showed significant improvement.

Target Population: Adults, Chronic Care*, Diabetes

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: Knowledge Creation

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

Impact of Health IT Implementation on Diabetes Process and Outcome Measures - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-269: Exploratory and Developmental Grant to Improve Health Care Quality through Health Information Technology (IT) (R21)
  • Grant Number: 
    R21 HS 020696
  • Project Period: 
    June 2011 - May 2013
  • AHRQ Funding Amount: 
    $299,985
  • PDF Version: 
    (PDF, 342.53 KB)

Summary: Diabetes is an increasingly common chronic disease that requires long-term management. Currently, the health care provided to patients with diabetes falls short of the "best care" practices established in evidence-based clinical guidelines. The primary objective of this observational study is to quantify the effects of a commercially-available ambulatory electronic health record (EHR) on quality of diabetes care, as measured by compliance with recommended processes of care and patient outcome measures. The EHR includes diabetes care prompts and a diabetes management form (DMF), a condition- specific documentation tool that integrates data review, real-time evidence-based clinical decision support, order entry, and patient education.

The study is being conducted in the Baylor Health Care System HealthTexas Provider Network, which staggered implementation of the EHR in practices between 2006 and 2008. The primary aim is to test the impact of the EHR on the care of diabetes patients using the Health Partners "Optimal Diabetes Care" composite measure with retrospective chart audit data. This composite measure includes hemoglobin A1c (HbA1c), cholesterol, blood pressure, patient age, and smoking status. Secondary aims include testing the impact of the EHR on patient outcomes and compliance with recommended processes of diabetes care, estimating the prevalence of voluntary physician use of the DMF embedded within the EHR, and determining the effect of DMF use on patient outcomes.

This study will provide important information about the potential for an EHR to improve quality of diabetes care, including insight regarding the potential of and need for disease-specific EHR components to effect improvement.

Specific Aims:

  • Estimate the impact of an EHR on diabetes outcomes, measured by the proportion of patients meeting the Health Partners Optimal Diabetes Care measure. (Achieved)
  • Estimate impact of an EHR on specific patient outcomes and compliance with recommended process of care related to diabetes. (Achieved)
  • Estimate the prevalence of physician use of the Diabetes Management Form, and the effect of the Diabetes Management Form on patient outcomes related to diabetes as measured by the Optimal Diabetes Care measure. (Ongoing)

2011 Activities: During the first 6 months of the project, funded in June 2011, Dr. Ballard and his team focused on evaluating the impact of the EHR on processes and outcomes of diabetes care (the first two aims). The analyses for these two aims were complete by the end of August, having benefitted from prior experience with the dataset. The dataset had been prepared and cleaned prior to the start of this project period for other purposes, including operational quality improvement work. The data were collected from the Baylor Health Care System HealthTexas Provider Network medical record (Centricity). The research team wrote a manuscript describing the results for these first two aims, titled The Effectiveness of Implementing an Electronic Health Record on Diabetes Care and Outcomes, and published by Health Services Research in January 2012.

During the second half of the year, the research team focused on the third aim, which included the development of a process for linking two separate datasets: 1) data generated over the past 5 years that documents (through review of paper and electronic text) and populates pre-defined fields and measures focused on diabetes care; and 2) data from the DMF that is part of the EHR. By the end of the year, the research team linked the two datasets and began to examine the relationship between use of the DMF and patient process and outcome data.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are completely on track and project budget spending is on target.

Preliminary Impact and Findings: After adjusting for patient age, sex, and insulin use, patients exposed to the EHR were significantly more likely to receive optimal care when compared with unexposed patients. Components of the optimal care bundle showing positive improvement after adjustment were systolic blood pressure <80 mmHg, diastolic blood pressure <130 mmHg, aspirin prescription, and smoking cessation. Among patients exposed to the EHR, all process and outcome measures except HbA1c and lipid control showed significant improvement.

Target Population: Adults, Chronic Care*, Diabetes

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: Knowledge Creation

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

Project Details - Ended

Project Categories

Summary:

Diabetes is a common chronic disease that requires long-term management. Currently, the health care provided to diabetic patients frequently falls short of the “best care” practices established in evidence-based diabetes clinical guidelines. Health information technology has the potential to improve compliance with recommended diabetes-related processes of care and outcome measures. Research has shown that having an electronic health record (EHR) is not enough to increase patient’s attainment of clinical targets: it is the specific functions within it – such as patient identification and tracking systems, problem lists, and electronic visit notes – that lead to improvements.

This project evaluated the impact of an EHR on the quality of diabetes care as measured by compliance with recommended processes of care and patient outcome measures. The EHR has an embedded Diabetes Management Form (DMF), an optional documentation tool that integrates diabetes-specific data review, passive clinical decision support (CDS) (showing recommended targets for key diabetes measures and whether recommended processes of care were due but not prompting any particular action), order entry, and coded data capture capabilities.

The specific aims of this project were to:

  • Estimate the impact of an EHR on diabetes outcomes, measured by the proportion of patients meeting the Health Partners Optimal Diabetes Care measure. 
  • Estimate impact of an EHR on specific patient outcomes and compliance with recommended process of care related to diabetes. 
  • Estimate the prevalence of physician use of the Diabetes Management Form, and the effect of the Diabetes Management Form on patient outcomes related to diabetes as measured by the Optimal Diabetes Care measure. 

The project used an observational study design with primary care practices that underwent a staggered implementation of a commercially available EHR. The primary outcome was meeting diabetes “optimal care” target measures for HbA1c, LDL-cholesterol, blood pressure, not smoking, and documented aspirin use. Compliance was compared between patients exposed and not exposed to the EHR and in a subset of EHR-exposed patients in patients for whom the DMF was used and those for whom it was not.

Patients whose providers were using an EHR were significantly more likely to achieve “optimal care” and were more likely to be in compliance with most process and outcome measures. DMF-exposed patients showed less improvement in attaining targets, but greater improvement in documentation of care. The project team hypothesized that the embedded DMF failed to achieve greater improvement in patient outcomes due to its being passive and physician-focused CDS. Because lifestyle changes are needed to alter a patient’s diabetes-related outcome measures, tools that directly assist patient self-management might be more likely to achieve improvement.

Impact of Health Information Technology Implementation on Diabetes Process and Outcome Measures - Final Report

Citation:
Ballard D. Impact of Health Information Technology Implementation on Diabetes Process and Outcome Measures - Final Report. (Prepared by Baylor Research Institute under Grant No. R21 HS020696). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 316.39 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.
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