Quality of Diabetes Care Influenced by Use of Electronic Health Records

In anticipation of a quality-related financial return, provisions in the Patient Protection and Affordable Care Act of 2010 include incentives for the development and meaningful use of electronic health records (EHRs). However, studies to date have not shown substantial quality-related advantages of current EHR systems compared with paper-based medical record systems. Cost-savings are projected based primarily on models with unsupported assumptions about adherence to and the effect of fully functional EHR systems. In addition to regional initiatives for quality improvement supported by Medicare and state Medicaid programs, the Robert Wood Johnson Foundation has established 16 sites nationwide in its Aligning Forces for Quality (AF4Q) programs. These programs provide an opportunity to conduct an evaluation of the effectiveness of EHRs and refinements in national payment policy. In Cleveland—1 of the 16 AF4Q sites—there are a variety of EHR-based and paper-based ambulatory practices that report publicly on the quality and outcomes of care for patients with chronic medical conditions, including diabetes. To date, achievement of diabetes-related standards has been reported 6 times in the region. Noting that the data gathered at the Cleveland site come from practices with high concentrations of priority primary care providers, allowing for a comparison of quality standards for practices with EHRs to those with paper records, researchers recently conducted an analysis to assess the independent association of the use of EHRs with achievement of quality standards for the care of patients with diabetes. Results of the analysis were reported in the New England Journal of Medicine [2011;365(9):825-833]. The analysis included data from a retrospective cohort of primary care practices of 7 healthcare organizations between July 2007 and June 2010; the data included in the report were the most recent yearlong cross-section (July 2009-June 2010) and practice-level trends across 3 years of reports. The primary practice partners of Better Health Greater Cleveland (Better Health) are responsible for the majority of medical care for patients with diabetes in Cuyahoga County in Ohio, an urban area that includes Cleveland. The Clinical Advisory Committee of Better Health established 4 standards of care for patients with diabetes and 5 standards of intermediate outcomes. The care standards include receipt of a glycated hemoglobin value, testing for urinary microalbumin or prescription of an angiotensin-converting enzyme inhibitor or an angiotensin-pneumococcal vaccination. Intermediate-outcome standards include glycated hemoglobin level <8%, blood pressure <140/80 mm Hg, low-density lipoprotein cholesterol value <100 mg/dL or documented prescription for a statin medication, body mass index <30, and nonsmoking status. In the 7 care organizations, 27,207 adults with diabetes were given care from 569 primary care providers in 46 practices. Of those patients, 24,547 were in EHR-based practices and 2660 were cared for in paper-based practices. Of the patients in EHR-based practices, 16,927 were in safety-net practices and 7620 were in non¬–safety-net practices. Overall, mean age of the patients was 57.8 years, 52.4% were female, 47.9% were nonwhite, and 79.2% were high school graduates; 35.1% were covered by Medicare, 43.9% had commercial insurance, 8.6% were Medicaid beneficiaries, and 12.5% were uninsured. Of the 46 practices, 33 utilized an EHR-based system (20 non–safety-net practices; 13 safety-net practices) and 13 utilized a paper-based system. After adjusting for covariates, achievement of composite standards for diabetes care at all EHR-based sites was 35.1 percentage points (95% confidence interval [CI], 28.3-41.9; P<.001) higher than at sites with a paper-based system; among safety-net sites, the difference was 29.8 percentage points (95% CI, 24.0-35.7; P<.001). EHR-based sites were associated with higher achievement on 8 of 9 component standards. Overall, sites with EHR-based systems achieved improvements in diabetes outcomes that were 15.2 percentage points higher than those achieved by sites with paper-based record systems (95% CI, 4.5-25.9; P=.005); for safety-net sites, the difference was 9.7 percentage points (95% CI, 3.4-16.2; P=.002). In conclusion, the researchers said, “These findings support the premise that federal policies encouraging the meaningful use of EHRs may improve the quality of care across insurance types."