Ideal Medical Practices

Typical Electronic Health Record Use in Primary Care Practices and the Quality of Diabetes Care: don't count your chickens

From the Annals of Family Medicine May/June 2012:

In this longitudinal observational study of primary care practices, we found that practices using an EHR for a 3-year period had a poorer quality of diabetes care at baseline, did not make more rapid quality improvements than practices using paper records, and had a poorer quality of diabetes care at the 2-year follow-up.  via www.annfammed.org

 

Count me among those hardly shocked. 

Many who advocate the expanded use of health IT appear to believe that health IT itself will catalyze improvements in care. While there may be a few narrow instances where this is the case, we believe that most current health IT systems have a long way to go before they encompass the functionality that would support robust ongoing improvement of care. Additionally, the success of health IT-enabled improvement depends critically on the skills of clinical and administrative staff in primary care settings to understand and use solid improvement methods—methods that need not rely solely on health IT to be effective. (Langley 2007)

 

Too many of the improvement plans I come across rely heavily on the oft-touted benefits of health information technologies.  "We'll use our electronic health record to find gaps in care and this will improve our chronic care outcomes."  or  "With electronic health records we will reduce duplication of services and unnecessary testing and reduce costs."

Maybe.

But the results to date are not as encouraging as some marketing materials would lead one to believe. 

In this controlled study, EMR use led to an increased number of HbA1c and LDL tests but not to better metabolic control. If EMRs are to fulfill their promise as care improvement tools, improved implementation strategies and more sophisticated clinical decision support may be needed. (O'Connor 2005)

 

As you consider interventions to improve outcomes for individuals and populations, consider carefully the strategies you will use to change work flow, who is doing what, and the very nature of the work being done.  To achieve meaningful results we must change the way we work, not merely create an electronic version of the way we have always worked.

There are some good strategies that truly support overstretched and under-resourced primary care practices and their patients, but too many intitiatives just pile on demands, drawing clinicians further away from the people who need their time. (Bodenheimer 2008)

 

L Gordon Moore

Bodenheimer T.  "Transforming Practice" N Engl J Med 2008; 359:2086-2089

Langley J, Beasley C. Health Information Technology for Improving Quality of Care in Primary Care Settings. Prepared by the Institute for Healthcare Improvement for the National Opinion Research Center under contract No. 290-04-0016. AHRQ Publication No. 07-0079-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2007.

O’Connor PJ. “Impact of an Electronic Medical Record on Diabetes Quality of Care,” The Annals of Family Medicine 3, no. 4 (July 1, 2005): 300–306.

Hospitals, Practice Administrators and Clinicians: You Gotta Learn to Love Patient Ratings – Health Affairs Blog

You are increasingly being held accountable for the outcomes of the health care you deliver. Pay for performance; shared savings in ACOs; public report cards…the list of strategies to monitor and measure the effects of your efforts is lengthening. Many of you seem dismayed by the increased weight accorded to the patient experience of care ratings embedded in most of these programs.  Here’s why you should embrace them: The care you deliver cannot improve our health outcomes or even maintain passable ones without the knowledgeable, active participation of us patients and our families.

via healthaffairs.org

There is good evidence linking patients' experience of care to important outcomes.  Here are a couple of examples: 

• Hospitalized Medicare beneficiaries who can't tell who is running the show and perceive conflicting messages from clinicians are much more likely to be readmitted within 30 days than those reporting good experiences. (Boulding 2011)
• People receiving care in practices with good access, less wasted time, and better communication are more likely to report that treatments have helped reduce problems with pain & emotions, have improved markers of chronic conditions, and reduced use of the hospital & emergency room. (Wasson 2006)

We think that if we adhere to evidence-based guidelines our patients will achieve excellent outcomes, but if we also know that if patients experience delays getting a timely appointment they are less likely to follow up for needed care (Lacy 2004), and people who experience in-office waits and delays are less likely to follow through on appropriate care recommendations (Ling 2006).

Clinician adherence to evidence-based guidelines only goes so far and all the best health information technology for disease tracking is of limited use if the health care team fails to communicate effectively with people who struggle to manage their conditions.  Before we write people off as "non-compliant" we can and should ask ourselves if we have inadvertantly created a series of hurdles and barriers that negatively impacts our patients.

These fundamental attributes of primary care are a good starting point:

1. Access:  how easy is it for people to get a timely appointment?  The ultimate answer comes from those you serve - don't just rely on administrative data.
2. Person-focused care over time:  what percent of your patients say that they can identify a 'go-to' medical person?
3. Comprehensiveness: Recognizing that people must manage their own conditions the overwhelming majority of time, what percent of those with chronic conditions report that they understand what to do and have the confidence to manage?

We showed that it is possible to implement tools to measure and address these issues even in solo independent primary care practices. (Moore 2007)

I agree with Jessie Gruman that we should embrace patient experience data as a powerful addition to our understanding of system performance as well as insight into why some people struggle with effective self-managment.

L Gordon Moore

 

Boulding W, Glickman S, Manary M, Schulman K, Staelin R.  Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days  Am J Manag Care 2011 17(1): 41-48

Lacy, N., Pullman, A. Reuter, M., Lovejoy, B. Why we don’t come: Patient perceptions on No-shows. Annals of Family Medicine 2004;2:541-545.

Ling BS, Klein WM, Dang Q.  Relationship of communication and information measures to colorectal cancer screening utilization: results from HINTS.  Journal of Health Communication. 11 Suppl 1:181-90, 2006.

Moore LG, Wasson JH.  The Ideal Medical Practice Model: Maximizing Efficiency, Quality, and the Doctor-Patient Relationship.  Family Practice Management September 2007 pp. 20-24.

Wasson, J. H., Johnson, D. J., Benjamin, R., Phillips, J., & MacKenzie, T. A. Patients report positive impacts of collaborative care. Journal of Ambulatory Care Management, July-September 2006 29(3), 199–206