EHR Incentives Likely to Improve Quality

Healthcare is one of the last industries in the United States to universally incorporate technological advancements. While most sectors have made significant investments in information technology to improve efficiency and consumer relationships, America’s health care system is still largely paper-driven. As a result the healthcare system is plagued by inefficiency and poor quality. Delivery is slower, more prone to errors, and harder to measure and coordinate than it should be. Investments in health information technology can help improve this situation. Research published in the New England Journal of Medicine (FREE FULL TEXT) gives cause for optimism that efforts to increase adoption of electronic health records (EHRs) will provide major benefits in better patient care and health outcomes. Perhaps we can finally move away from using a dead tree medical recod system in this country.

“We were not surprised by these results,” said Randall D. Cebul, M.D., a professor of medicine at Case Western Reserve University and the study’s lead author who I was able to speak with earlier today. “They were influenced by several factors, including our public reporting on agreed-upon standards of care and the willingness of our clinical partners to share their EHR-based best practices while simultaneously competing on their execution.”

The research involved more than 500 primary care physicians in 46 practices that are partners in a region-wide collaborative known as Better Health Greater Cleveland (Better Health). This alliance of providers, businesses and other stakeholders is dedicated to enhancing the value of care for patients with chronic medical conditions in the region. Launched in 2007, the organization is one of 16 that the Robert Wood Johnson Foundation chose to support in its nationwide initiative, called Aligning Forces for Quality. This initiative is the foundation’s signature effort to lift the overall quality of health care in targeted communities as well as reduce racial and ethnic disparities and provide models that will help propel national reform. Common themes across the communities include public reporting of performance and community-wide initiatives to improve care.

As important as electronic health records are, Dr. Cebul said, their greatest value merges when used in conjunction with other approaches, such as the sharing of best practices and coaching offered through collaborations such as Better Health Greater Cleveland. "We've been doing summits twice yearly and will continue in the future so that we can identify and share best practices among providers. We also will provide ongoing coaching to practices that wish to continue to improve clinical outcomes," he said. The patient centered medical home is built on the foundation of electronic health records, and Better Health is working with employers and payers in the region to develop medical homes as well as exploring opportunities to participate in new payment models.

I asked Dr. Cebul what impact health information exchange will have on continuing improvements, particularly in the area of clinical care coordination. "I think that HIE will have a big benefit and it's value will be as much in cost reductions as it will in improving quality of care. For the smaller practices it will be very valuable in providing data from outside providers and specialists. HIE will enable us to reduce unnecessary emergency room visits and hospital readmission, as well as reducing duplicate testing. This will also accelerate the process of clinical evaluation and save money."

The authors did caution that they could not conclude that EHRs were the only explanation for quality differences. Other potential causes could be "the participation of exceptional EHR-based organizations, a nonrepresentative sample of paper-based organizations and inadequate adjustment for patient characteristics," they stated. Their study also would have provided even more compelling evidence for an advantage to EHR use if they had measured before-and-after performance for groups that had switched away from paper-based to using an EHR. But this study absolutely provides a basis for determining that digitizing medical records can have a substantial impact on quality of care.

The study involved more than 27,000 adults with diabetes and found that those in physician practices using EHRs were significantly more likely to have health care and outcomes that align with accepted standards than those where doctors rely on paper records. Improvements in care and outcomes over a three-year period also proved greater among patients in EHR practices. The study’s findings remained consistent for patients regardless of insurance type, including the uninsured as well as patients insured by Medicare, Medicaid, and commercial payers.

The data shows a staggering difference in performance among practices with EHRs as compared to those without: 51 percent of diabetes patients in EHR practices received all the care they needed as compared to only 7 percent in practices with paper records. A similar variation was also reported for diabetes patient outcomes—how well patients and their doctors were able to effectively manage their condition. For both care and outcomes, patients treated at practices with EHRs far outpaced those in paper practices across all insurance types—whether patients were on Medicare, Medicaid, a commercial plan or uninsured. Breaking the data down further shows that for practices using EHRs, the percentages of patients meeting standards for diabetes care were higher for making sure hemoglobin A1c tests were performed, kidney management was maintained, eye examinations were made than for those practices using paper records.

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